Friday, December 14, 2012

Important information about why your OT is eyebrow deep in paperwork

How would you like to wake up one morning and find out that there are new rules you need to know in order to get your paycheck at the end of the week?  Those of us who work in private practice understand that the rules for reimbursement change and shift constantly, but imagine wading through hundreds of pages in the hopes of trying to find the tidbits that actually apply to what you are supposed to be doing.  Enjoy this link for some light reading: Medicare Physician Fee Schedule Final Rule CY 2013 .  These requirements were just recently published and significantly change the coding requirements for Medicare reimbursement.  Again.

Other changes that we have this week are more wonderful rules to contend with - this time having to do with complex requirements for what a physician's referral has to say in order for a school district to bill related services under the Medicaid program.  This NYS Medicaid rule set is not as long as the CMS rules but only covers a very small component of service (what MD scripts have to say) - but it is just as confusing.  I like to think that I am at the least a moderately well educated person and in addition to my doctoral education I also have some measure of common sense - so why is it so challenging to wade through and try to understand these arbitrary rules?  Here are the new NYS Medicaid requirements for scripts.

As you can see in the new Medicaid rules they initially tolerated certain language in scripts, then they expressly prohibited that language, and now they are back to accepting that language again (I think).  These are small issues, actually, and have to do with whether or not a physician can write 'PER THE IEP' on a script or whether or not frequency, duration, and other factors need to be separately noted.

What is most frustrating is that with every rule change comes the accompanying threat (generally not even covert) that if you fail to follow the rules that you are committing Medicaid fraud.  The friendly State reminds us in the memo:

18 NYCRR 515.2(b)(1)(c), Unacceptable practices under the medical assistance program, states that an unacceptable practice is conduct which constitutes fraud or abuse and includes submitting, or causing to be submitted, a claim or claims for medical care, services or supplies provided at a frequency or in an amount not medically necessary.


Now no one who is trying to figure out the new rules is purposely trying to commit fraud - but here is a case where there are two conflicting demands.  Medicaid will not pay for a service that is beyond what is written on the script, but at the same time the State Education Department demands that all missed services be 'made up.'  In fact, parents are legally entitled to compensatory services when absences or other events prevent a child from receiving the services on any given day.  So, 'making up' services might cause you to try to see a child in a way that is not listed on the script because it might not be realistic to make up those services within the same week that they were missed.  BOOM!  Medicaid fraud - because as it stands now the reporting forms that we use to track service delivery are not separated and if the district attempts to bill for something that is different than the physician's script then you are now considered guilty of Medicaid fraud.  It is truly a rock and a hard place.

The reason why this matters is because none of it has anything to do with the care that children receive - at least not in any direct sense.  The rules are arbitrary, and they change, and they distract care providers from the important tasks that they SHOULD be focusing on. 

So-called concierge models of care eliminate insurance companies and return relationships back to a normalized interaction between providers and the people who are seeking services.  The legitimate criticism is that this model creates access barriers for people who do not have enough money to pay for services privately.  Many medical practices are experimenting with hybrid models to address that criticism.  When there are constant rule changes and complexities that create barriers to care these concierge models start to look very appealing, even though they have limitations.

Parents need to be aware of these kind of issues, which although might be superficially boring really do have an impact on the mindset of how care is provided within municipal systems and through complex health insurance rules.  In my opinion there are probably less complex methods for solving these problems, but as we hand more and more control over health care to our government we can expect increasing points of arbitrary decision making, convoluted and conflicting recommendations, and in the end this will all create more barriers to quality care.  As I tell my staff, be prepared for a bumpy ride.

Tuesday, December 11, 2012

Who co-opted my interventions???

This will be a brief entry to serve as placemarker for a larger discussion, if it ends up being warranted.  I have blogged before about my basic understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings.  Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. As Bruner has pointed out, words reflect our beliefs that frame our narratives and support our culture.

Today I was being interviewed by a media person and they were confused about my use of the word 'intervention'  when I was talking about 'occupational therapy interventions.'  This was surprising to me.  My message to them was focused on the friendly context of my clinic and the services we offer, and their understanding of the word 'intervention' was related to a reality television show entitled Intervention.  That was not so good.  The interviewer mentioned that when they think of interventions that they don't think of a friendly process that helps children.  It was one of these moments:



So now I am kind of wondering about my words.  Maybe I need to go back to treatment planning and forget this intervention business.  Has anyone else run into this problem?

Monday, December 10, 2012

The most important part of occupational therapy assessment

This morning my OCC 471 class is taking their final examination as I write this entry.  The class content was focused on occupational therapy assessment in pediatric settings and I am aware that the students are nervous as I sit at the front of the room.  I wish that I had a way to make them feel better.

This blog is generally about my practice and not about my teaching - even though there are many logical points of intersection.  The whole point of teaching is to prepare people FOR practice and I know that all these students spent the weekend trying to answer the same question, "How will I know when I know enough??"

As I was walking toward the college this morning I watched birds flying around the bell tower of Ball Hall.  My immediate thoughts were related to wondering why birds choose the highest spot on campus to congregate.  I figured that there were probably a few possibilities:

  • the like the view of the lake
  • the perch has geographic proximity to nesting
  • their leader went there and others followed
  • high altitude perching is a survival behavior because predators can't get that high
There are probably some reasons that I can't think of.

I am not really sure why the birds were up there, so I decided that maybe they just had lofty aspirations - and I just didn't have enough wisdom to understand their motive.

It is a safe position to take, and it actually leaves open the oppportunity to respect the behavior.  I think that is important.

I mention all this because I wanted to write such a question on the examination but it was hard to put into a multiple choice format.  So while these students learned all about early intervention and school therapy and standardized vs. non-standardized assessments I hope they also learned a little about respecting things where they were - especially when they don't have the wisdom  yet to fully understand a situation.

We run face-first into this as a practice issue every day.  My first encounter with the concept was in a decidedly non-pediatric context.  I was consulting to a nursing home and I was very inexperienced - I often wodered if I knew enough to do a proper job.  Thankfully the COTA was highly competent but more importantly the residents themselves were also highly competent even though they were the ones 'receiving services.'

Of course this pre-dated the current models that drive nursing home reimbursement but at that time occupational therapy served an important maintenance function for those residents.  Many of them had long term and chronic disability but each day the residents made sure that they got to the OT room to do their "work."  Some chose to do craftwork, some participated in cooking groups, some wrote letters (for themselves and others) and some even put pegs into pegboards.  At that time my instincts bristled against that activity choice and I wanted to change their tasks to something that I perceived as being more occupationally and developmentally appropriate.  However, those residents took the initiative to make a sign and they placed it on the door to the OT room.  The sign read something like

Let no one call another man's work insignificant.


That is a really powerful statement, even though my 21 year old mind couldn't really comprehend it at the time.  That was over 25 years ago, and in these intervening years I have taken a deep dive into the source philosophy of Martin Luther regarding Faith and the meaning of Work - and perhaps I am now beginning to understand the aspirations of those residents a little.

They were very wise people.

Anyway this is a recurrent theme when you are gifted with a professional license to provide care.  I believe that we need to be cognizant of the power differentials between caregivers and 'patients' and how we develop understandings of their 'conditions' - like when we do our occupational therapy evaluations!  We also need to be mindful of  how we dispense advice through our interventions.  I think that we might be lucky if we happen to have any wisdom - and even if we do have it then we have to be sure that we don't wield it stupidly.

So do my students know enough???  Do they know if their assessments will lead them to the best interventions???  I just hope that when they see birds flying around bell towers that they will empty their minds of prejudice.  I hope that they will be willing to wait for the wisdom to come to them if they look deeply enough and wait patiently enough for the understanding.

If that happens, I will have served my purpose to them.

Friday, December 07, 2012

Environmental sustainability and occupational therapy practice

I like ideas.  I even like big ideas.  That would include big ideas that are created simply for academic purposes.  However, as my bio indicates, I am a pragmatic guy who is sometimes at odds with his transcendent training.  Or something like that.

So in other words, I thought I liked ideas.  Maybe sometimes I don't.  I am starting to wonder.

The latest barrage of ideas that I got hit with this week has to do with sustainability and its application to occupational therapy.  I have some opinions about this that are probably a logical extension of these ideas that I blogged about in 2009 that relate to developing lexicon related to social or occupational justice constructs.  Please go read that information first if this is a topic that interests you.

OK so this week I saw a student spam posting the OT Connections site trying to get people to answer some survey about the role of occupational therapy with sustainability.  I normally just ignore spam posting but I went to the survey anyway simply out of academic curiosity on the topic - mostly because in my wildest imaginings I could not understand why this would be a legitimate domain of inquiry for an occupational therapist.  The survey was interesting but chock-full of assumptions that I didn't necessarily agree with.  I started answering the questions and then decided to scrap my answers because I didn't have anything constructive to add to the survey, and also because I thought this would be a more effective format for exercising my thoughts on the topic.

For a day or so I just shelved my puzzlement about why someone would think that OT had a role in sustainability but then the barrage of ideas continued.  First there was a message thread passing around the faculty where I teach about the concept of sustainability and how the college should make some movements toward more responsible efforts regarding the environment.  On its surface I don't mind when people promote recycling efforts and turn off lights and consider ways to be more efficient and environmentally mindful but then I started to get a little uncomfortable when there was a call for endowment divestment from big energy companies.  I expressed some concern about conflating methodologies for local sustainability initiatives with methodologies for "sustainability" of an endowment.  I don't know how many academics have had fiduciary responsibility for a large endowment or reserve fund like that so who knows if my cautionary opinions resonate in those halls.  Oh well.

Then a colleague sent me an opinion piece that appeared in the British Journal of Occupational Therapy in September (Whittaker, 2012).  And then someone else sent me a link to the WFOT website and they also have a position paper on environmental sustainability and sustainable practice within occupational therapy.  So there was a barrage of information about this topic this week and I guess I want to talk about it.

I don't want to have a global warming or global cooling or any kind of climate debate.  That would be boring and people are stuck in camps on the issue.  Instead I want to focus on the WFOT call for occupational therapists to "use their expertise and knowledge about occupations and occupational performance to participate in the resolution of these global problems."  According to the WFOT position paper the global problems include human driven global climate change, overuse of finite natural resources, decreasing biodiversity, overpopulation, and inequitable wealth distribution.  That is a pretty big list of problems to address in my little occupational therapy intervention plans here at ABC Therapeutics.  Still, I like to think that I am a cutting-edge kind of guy, so I figured I might have some work in front of me.

I needed some ideas, and since there is no one on the continuing education circuit peddling sustainable occupational therapy I figured I could just read some journal articles.  Whittaker talks about exploring cooking in more sustainable forms by having clients reflect on ecological context and cooking mindfully - which in turn might deepen the meaning of the cooking experience for the client.  His article goes on to explain that livestock farming accounts for 80% of greenhouse gas emissions from all food production.  This got me thinking.  Maybe we are supposed to promote "green" cooking by making peanut butter and jelly sandwiches instead of a ham sandwich during our ADL assessments.  If we stop eating meat and dairy then there will be fewer pigs and cows and chickens expelling their methane into the atmosphere.  I guess.

In the middle of these very deep thoughts I realized that my 8:30am appointment had arrived.  I started thinking that it really wasn't fair of me to even see this family because they have private insurance and are seeking private therapy to address some gross motor delays that their 8 month old daughter is experiencing.  The income inequality allows them to stay away from the municipal early intervention system which is seismically shifting and changing because of constricted funding.  Maybe it isn't fair to see people outside of the municipal system.  Based on these things that I am reading I am now considering the possibility that I am crushing the planet by reinforcing medical consumerism and wasteful spending in an unequal fashion.  Interesting.  Somehow I am not that certain that the parent looks at it all this way.  I wonder if they will mind if I just discharge them and tell them to call for County services?

After the appointment was over I decided to pick up my phone messages.  I thought I was saving some money by managing my own messages and cutting down on support staff but now I am thinking that I should reconsider my profit motive in the interest of more equitable wealth distribution on the planet.  Anyway, there was a message from a mom who was crying.  Her child has severe behavioral feeding difficulties and she was experiencing some moments of concern, crisis, and even depression about the whole situation.  Her child has made incredible improvements, and the mom has also made incredible improvements - but the whole situation remains extraordinarily acute.  I tried to call the mom back but only got to leave her a message.  I tried my best to be upbeat and positive and supportive and helpful.  I hope it will be enough until I get to see them again.

As I hung up from leaving the message I started thinking about sustainability again.  Maybe I could tell the family that chicken nuggets and hot dogs are not part of a sustainable diet.  Constricted food choices is a real problem for this child but maybe if I approach if from the angle that he can save the planet by eating more veggies that I can make a dent in his behaviors.  Maybe this is the kind of reflection that Whittaker was suggesting.  Just think: my counseling about the evils of chicken nuggets and hot dogs might enable this family to experience a deeper meaning about their mealtime routines.  I started getting excited about these new intervention strategies!!

Then I thought that maybe I could change his food-throwing behaviors by pointing out that there are hungry children in the world and that it is not sustainable to waste food when there is such an inequitable distribution of nutrition around the globe.

He is only three though.  I don't know if he will understand. 

I guess I am still struggling with how to apply these ideas about sustainability.  Maybe I will get better at it with a little practice.  I really don't want to be small-minded and I want to be an informed and globally connected practitioner.


I would like to see some of the sustainability promoters out on the lecture circuit telling us street-level practitioners how to make this happen.  I would like them to tell us all their real life case studies.  Is there a CPT code that we should be using for 'ecological occupational therapy??'  Can we reduce our carbon footprint by going back to the days of low tech craft work - and then our patients can take their tile trivets home and actually use them!  But should we only do handwork and should we avoid using a kiln?  Kilns consume an awful lot of electricity.  Maybe we can do more leather work as we pare down our farm animal populations?  There are so many exciting possibilities here on how we can be sustainable!!

We all have tremendous responsibility for stewardship.  I actually agree that we should be environmentally mindful.  I think we also have a tremendous responsibility for stewardship of our profession's scope of practice and what actually constitutes occupational therapy.

The halting and sobbing between words in that mom's message today keeps snapping me back to reality.

I think it is the pragmatic voice inside my head.  Maybe this is all just nonsense. 



References:

Whittaker, B. (2012). Sustainable global wellbeing: A proposed expansion of the occupational therapy paradigm.  British Journal of Occupational Therapy, 75(9), 436-439.

Tuesday, November 20, 2012

Letter to a prospective occupational therapy student

I think program directors and faculty can tune in to this as well so they are more aware of what goes on...

Dear Prospective Occupational Therapy Student:

Thank you for contacting me and asking about volunteer opportunities at my facility.  As a part-time occupational therapy educator I understand that most programs have some component of volunteerism associated with application to a program.

I had to complete a similar level of volunteer experience when I applied to my occupational therapy program as well, and I fondly remember my volunteer experiences.  I began those experiences a full year prior to submitting my application, probably because I read the admission requirements and saw that it was something valuable that would help me begin to make choices about a possible occupational therapy career.

My first volunteer experience was exciting and frightening.  I assisted in a crafts group that was run at a long-term institutional setting for veterans who had severe mental health difficulties.  I was so young and it was fascinating to me that combat stress could cause such long term debilitation.  I was frightened a lot of the time.  I also remember that there was another large component to the hospital that had to do with physical rehabilitation, but I committed to the psychiatric program so I never got to see the other OTs.

That made me interested in physical medicine, so when I went back to school the next semester I pursued another volunteer experience at the County hospital on the spinal cord unit.  I did not spend time with the OTs, but instead I visited with the patients, helped with trays, re-filled water containers, and similar tasks.  So many of the patients were angry, and I spent a lot of time listening to people's stories.  It was emotionally draining, and I had absolutely nothing to offer other than re-filling someone's water.  Ugh.  This experience made me really wish I had some OT skills.

When I went back home for the next summer I volunteered some more at a sheltered workshop.  I really can't remember why because I completed all my hours.  It was a different setting - for adults who had developmental difficulties - and there were no OTs there.  I helped set up workstations and for the whole time I was there I wondered where the OTs were.  I really enjoyed the setting and getting to work with all the clients there.

Anyway, when I went on my interview for the OT program I recall talking about these three settings and all the hours I put in.  I remember feeling that perhaps my preparation was not as strong as other people because some of my settings did not have OTs in them, but that didn't seem to matter much to the person interviewing me.  She was genuinely happy that I sought out a number of different places and got to see very different people who had very different needs.

This all makes me think that volunteering is a good thing and I really love having volunteers around.

Unfortunately, when you called me you said, "I am a student at XXXX and I need to get my volunteer hours in so I can apply to the OT program."  There are a few things incorrect about this approach that I want you to be aware of:

1. If you refer to volunteer hours as 'my' volunteer hours then you might be a little confused about what volunteerism is and why is it valuable.

2. If you are trying to fit all of 'your' hours in within a constricted time frame because (a) that is how much time you have off of school or (b) the deadline for getting the application in is two weeks away or (c) because you don't want to commit to a facility for any lengthened period of time then that probably should cause you to pause and not call me.  Just a heads up.

3. If you tell me that the reason why you waited until the last minute is because (a) you tried a nursing home and you left because you 'couldn't stand the possibility of being around old people who might die' or if you have some other similar line of reasoning you might also not want to bother calling me.

I wouldn't normally complain, but I am just getting a little bored with the number of students calling me at the last minute thinking that it is my responsibility to solve their problems so they can 'get their hours in.'  If it was one or two students I would chalk it up the fact that there are silly people on the planet but in truth I get around 15-20 of these calls each time the application deadline approaches and I am just kind of bored with these calls.

So if you want to volunteer here, please consider planning it out well in advance of your deadlines.  Then you could be here on a regular basis, we could actually get to know you, the kids and families could actually get to know you, and who knows - YOU MIGHT EVEN DO SOMETHING GOOD AND WORTHWHILE FOR SOMEONE.

I would love to have some volunteers like that, actually.

Wednesday, November 14, 2012

Health insurance policy and indirect methodologies for cost control


Last week the Centers for Medicare and Medicaid Services (CMS) released the final rule for the 2013 Home Health Prospective Payment System. The rule includes rate reductions as well as complex new requirements for re-assessment and coding.

It is only a 298 page document that requires accountants, lawyers, and politicians to interpret but don't worry.

It has been interesting in the last week to read email and press releases from therapy staffing agencies who are struggling to process the changes associated with the new CMS rules in addition to the realities of aspects of the Affordable Care Act which has impact on health benefits they need to offer to their own employees.  These staffing agencies took a double hit this past week so if you know anyone who owns one of these agencies or functions as a manager of these services I strongly suggest you offer them Advil, a shoulder to cry on, or perhaps a long vacation.

Normally I am not a big fan of 'travel' therapy or temporary therapy staffing agencies, but even I am moved to sympathy for these organizations.  Yesterday I received a press release from a staffing company (who will not be named, because it is NOT their fault) and they announced that new hires will be subject to contracts that are less than 30 hours per week as well as reduction in reimbursements.  I called them to ask what their motivation was for the 30 hours per week limitation and the poor person who answered the phone danced and spun in circles trying to explain how they hope to have a more 'flexible' workforce and if a new hire wants more than 30 hours they will have to do it in more than one facility and that may require additional travelling.  Also, if they want those health care benefits they will need to be more 'flexible' with their scheduling and go to multiple facilities.  Now this really confused me because last I knew the Affordable Care Act was going to mean people could keep their health insurance and that it was going to create 400,000 jobs immediately and 4 million jobs in total...

or something like that. Oh well.

Maybe they didn't mean for health care providers?  Maybe they meant jobs for people who write 298 page rules??  And the wizards we all need to hire to interpret the rules???

Anyway, I am thinking that the best answer to all this is for therapists and health care agencies to begin altering their expectations for reimbursement in a broad sense.  After seeing the 298 page document from CMS that tells me how much money I can bill for and what hoops I need to jump through in order to obtain that reimbursement, I am thinking that it will be more profitable to just see people who have Medicare for free.  That way I will avoid the costs with trying to read, understand, and comply with ever-increasing bureaucratic demands and it will leave me free to watch C-Span so I can listen to politicians tell me  how good my life is going to be.

Anyone with me on this???

Wednesday, October 31, 2012

More on proprioception


 A couple posts back I blogged about a new tool that has been in development called the Comprehensive Observations of Proprioception.  I was a little surprised about the editorial decision to publish an article about performance on the tool without publishing about the tool itself.  Now we have a paper on the tool itself - so the ordering of publication is a question for AJOT editors - not the authors of the paper.

The authors describe the tool as an observational measure that is criterion referenced.  The test includes 18 items that purportedly represent some aspects of proprioceptive function and they use literature review as one tool to substantiate the content validity of the items.  As I mentioned in the original post on this matter I am concerned that some of these items might represent some aspect or measure of proprioception but then again they also might not.  Fully 25%+ of the items are behavioral measures like 'overactive' and 'enjoyment when being pulled' that are very unclear to me if these are functional and discriminatory measures of a proprioception construct.

Use of content experts to establish validity is a well-established mechanism in item development.  However, the authors report disregarding the content experts on some items because even though the ratings of experts did not achieve a degree of criticality the authors believed that the items should be included because they are represented in the literature.

Some items that the experts excluded were curious.  They excluded 'Muscle tone is hypotonic' but they included 'Decreased muscle tone.'  This is very difficult to understand without having the benefit of operational definitions of all these items.  A Likert scale was reportedly used to rate item performance from (1) typical performance to (5) most severe form of proprioceptive processing difficulties.  If this is a criterion referenced scale, I was left wondering what the cutoffs are on these measures and how they operationally defined mild or moderate forms of proprioceptive processing difficulties, particularly on the 18 items listed.  The authors report that the test can be taught to a therapist with a minimum of two years of experience after receiving a brief training.  I am struggling to understand if there are operational definitions for this Likert scale establishing discrimination between ratings for these very vague behavioral observations - and if there are - how would it only take a brief training to reliably rate a child on this tool?  It seems that if there were true criterion points that this could be very complicated.

This leads into a significant limitation in this tool that has to do with relying on a constricted set of therapists who are working in a common clinic or set of clinics.  This is nothing new - I talked about this in 2009:  " It is a pertinent issue - you can't talk about broad validity of constructs when you only include people who are all drinking the same Kool Aid, so to speak."  This is the criticism that you will receive when you use convenience sampling, which the paper rightly identifies, but it still underscores a really big problem.

Additionally, the tool would be strengthened considerably if an evaluator was blinded to diagnostic condition before running comparison analysis between children with known problems and typically developing children. 

It would also be strengthened if it didn't use parent report measures as a measure of criterion validity.  For example, is there any surprise when this test correlates with the Body Awareness section of the Sensory Processing Measure?  If one test asks a parent to comment on "Bumps or pushes other children" and the other test includes observations of "Crashing/Falling/Running" then what else would we expect? 

Finally, the test also relies on the Kinesthesia subtest of the SIPT - and this is a major flaw because the value of any factor analysis is only as good as the data going into the analysis.  Everyone knows that the KIN subtest is weak and unreliable - so why even use it as a point of criterion validity?  There are items on the SIPT which would seem to be arguably stronger measure points of proprioceptive processing, such as the eyes closed measures on the SWB subtest, or maybe even including Oral Praxis.  Why include the weakest proprioceptive measure on the SIPT?  I am generically aware of some work done by graduate students at Brenau University last year about pilot revision of the Kinesthesia test but I don't think they published yet (??).  What I am saying here is that I know I am not the only person on the planet to think that the KIN test is pretty flawed.  Garbage in, garbage out - so they say.  Makes it hard to know what to do with this factor analysis that relies on the weakest of all the SIPT subtests.

So there is my blunt analysis - and I am attempting to be as constructive as possible because when researchers go and do things they probably would benefit from end-users who read their work and are trying to see how to use it.  Is proprioceptive processing an important construct?  It sure is.  Do kids who have difficulties sometimes have difficulties with proprioceptive processing?  I believe they do. 

But to me I think this tool is too weak.  Maybe I would feel differently if I saw operational definitions for these items... and operational definitions for the Likert Scale and some understanding how how cutoffs were determined.  I would also like to see evaluators blinded when they are looking at discriminatory item analysis - and I would like to know that content experts were broadly represented so there was no danger of everyone thinking with a regional mindset. 

I look forward to more, so we can continue to move these kinds of ideas forward.

References:

Blanche, E.I., Bodison, S., Chang, M. & Reinoso, G., (2012).  Development of the Comprehensive Observations of Proprioception (COP): Validity, reliability, and factor analysis, American Journal of Occupational Therapy, 66, 691-698.

Thursday, October 18, 2012

Support regulations to remove potential conflicts of interest in the New York State Early Intervention Program

More regulatory mumbo-jumbo, while I am on a roll:

The New York State Department of Health has proposed an amendment to Subpart 69-4 of Title 10 of the New York Codes, Rules and Regulations, the Early Intervention Program. The public comment period ends October 22, 2012.  The new regulations create a requirement for arms-length relationships to tamp down conflict of interest that may be contributing to over-utilization and cost over runs.

An arms-length requirement between evaluators and providers is reasonable given the evidence of inappropriate utilization and significant cost over runs in these programs.  Although not all inappropriate utilization can be attributed to this factor, it is ethically correct for providers to remove any possibilities of conflicts.  Existing rules and regulations, whether in professional practice acts or the EI regs themselves, have not controlled this problem

Here is a pertinent part of the regulation: 

 (ii)(a) For children referred to the early intervention program on or after December 1, 2012, or for children referred to the early intervention program prior to December 1, 2012 for whom an additional evaluation or partial evaluation is requested on or after December 1, 2012 for the purpose of adding a new service, neither the evaluator which conducts an evaluation of a child, an approved agency which employs or contracts with the evaluator, nor a relative or business associate of the evaluator, shall provide early intervention services to such child unless authorized by the commissioner, after consultation with the early intervention official, due to special circumstances related to the evaluator’s qualifications or availability or other extraordinary circumstances in which there is a clear showing that the child will not be able to access needed services absent such authorization.

(c) If the commissioner finds there is a shortage of evaluators or approved providers in certain disciplines in a particular region of the state, the commissioner may issue a standing authorization, on such terms or conditions as he or she deems appropriate, which shall remain in effect in such region until such time as the commissioner determines that such shortage no longer exists. 

Studies completed by VESID clearly demonstrate a pattern of self-referral conflict of interest when the same therapist does evaluations and intervention (not just for  OT, but all professions). This is most notable in NYC in transition from EI to CPSE. In a 2007 study of the statewide preschool cohort, the numbers of children identified as needing services during transition from EI to CPSE were 73% in NYC; 41% in Large Four; and 34% in other districts. NYC has the largest percentage of conflicting incidences, which is why it was named specifically in the regulations as having the greatest impact in that area.

Certainly there are other 'big city' factors that might lead to greater 'identification' when transitioning to CPSE but you still can't escape the face validity to the concern that a potential conflict of interest may exist. Ethical practitioners should not be concerned about this requirement. Exceptions are allowed in the regulations when staffing or other barriers make it difficult to avoid the conflict - but the value itself to respect the potential of a conflict of interest is valid.

Many therapists are upset about this proposed regulation; the New York State Occupational Therapy Association and other groups have written letters opposing the regulation.  However, there is a long term game to consider in all this and in NY specifically our tax-supported care systems are strained to an absolute maximum. Our ability to engage people who need our services through municipal systems is already threatened by ever-changing Medicaid rule complexities, constricted staffing requirements, bureaucratic inefficiencies that fail to capture reimbursements, and many other factors. If the programs are going to survive then we should be at the table and we should be making honest attempts to promote quality and to control costs in those areas where legitimate concerns are presented. That doesn't mean we are promoting governmental interference; rather, we should be at that table and helping to shape that policy so that we can actually fix these broken systems.
 

 The need to reform our systems is obvious.  Therapists are losing jobs, reimbursements are decreasing, caseloads are increasing, and requirements for documentation become more burdensome each day.  We will not positively contribute to reform if we refuse to accept reasonable regulations like this one.

Or we can just go kicking and screaming into the night, refusing to budge and refusing to compromise. This system has to change - and it will change whether people participate productively or if they simply attempt to obstruct. 
There is no harm done by a regulation to promote an ideal of removing all potential conflicts of interest when we are working within municipal/tax-funded systems of care.  I see no problem whatsoever with this new requirement.  Quite frankly, I find it embarrassing to see the state associations and other professional groups opposing this.

You have until 10/22/12 to register your comments to the State: 

Katherine Ceroalo
New York State Department of Health
Bureau of House Counsel, Regulatory Affairs Unit
Corning Tower Building, Rm 2438
Empire State Plaza
Albany, NY 12237
(518) 473-7488
(518) 473-2019 (FAX)
REGSQNA@health.state.ny.us



References:

A longitudinal study of preschool special education: Final report. (September 6, 2007).  Retrieved from http://www.p12.nysed.gov/specialed/preschool/study/

Proposed regulations: NYS Department of Health.  Retrieved from http://w3.health.state.ny.us/dbspace/propregs.nsf/4ac9558781006774852569bd00512fda/9cbdd5b7692c1c9c85257a6a0054f4fd?OpenDocument 

Wednesday, October 17, 2012

Different perspectives on concerns with CPSE services in NYC


The following material was copied from the NYSOTA Facebook page.  A fan of the page (George Nickel) posted a general "calling out" to NYSOTA which prompted my response.  This might be lengthy, but I believe that it is instructive.


Post from George Nickel on Facebook:


Okay, I am calling you out. We have received written support from The New York State Speech Hearing and Language Association and the Regional Physical Therapy Association but none from the OT regarding the issue of the Related Services Tier System of The NYC Department of Education. Is it not an important issue that children with special needs and their families need you to join with the other organizations to advocate for not just them but for your profession?

Christopher Alterio responds:

George, this sounds like a local RFP that you lost and not a professional problem. if you have some more detailed information to share I would be interested in seeing it. I looked at various Facebook pages that are linked off of your page and I also reviewed the information on the United EI Providers site about CPSE services. From what I can tell there was an RFP process. Some people won and some people lost. It seems that the transition is bumpy and some kids are allegedly not getting services. There is no way to confirm these allegations and the DOE has not issued a response that I can find.

Why should a state association meddle in a local RFP process? When I bid on contracts sometimes I get them and sometimes I don't. Transitions between agency providers is sometimes rocky, both when starting a contract and sometimes when ending the contract. I never considered calling on the state association to intervene on behalf of a local RFP process just because I lost. That is just business - and it is up to people to be competitive or to re-tool themselves if they want to continue.

There is no doubt that the system is over-stressed and that is precisely why you are seeing competitive bidding for service provision. That is also why you see parents just bailing on the system and getting services privately.

So I am just your counterpart on the other side of the state, and I don't ever hear providers around here ask NYSOTA to save them when contracts are competitively awarded and service providers are changed. Help me understand more if there is some larger issue at play. Why should a state association be involved in this if it is a local RFP and some people lost??

George Nickel responds:

Chris you have assumed a great deal but missed the important facts.First, there are children not receiving services and the primary agencies are not sending children through the tier system in a timely manner. Secondly, many of your organizations members fees are being brought down by agencies bidding for lower fees.Further, most agencies are not taking the same percent it cuts but passing it directly to therapists.Thirdly,when a system promotes "too big too fail"/monopolies and small private practices to close that is not business as usual. Lastly, I asked you to join in advocacy for the children and their families, however by your response you seemed to have targeted the wrong issue. What is that about? And you checked my links,what is that about? Why didn't you call some of your members and find out from them directly what is going on?


Christopher Alterio responds:

 George, just to be clear (and to also ease NYSOTA's liability concerns!) I am not a NYSOTA member and I don't represent NYSOTA's position. I am just an OT who will probably become a member in the near future based on some good progress that I understand NYSOTA is making on some previously identified concerns - all beside the point.

Anyway, you are asking for support and I am always interested in professional issues so I am asking for details. I looked at your links, on some blogs, and at the United EI Provider site because these are just about the only place I could find any information on this topic. Not surprisingly, there is no information to be found on the NYC DOE website or on some of the websites of large agencies that were listed in some of the blog posts I found. I actually was going to call the NYC DOE for information but their website is a maze and there is no place to call!

If children are not receiving services then of course that is a problem but like I said previously - transitioning and service coordination when contracts change can be a nightmare, and I can only imagine how complex the problem is in a system as large as NYC. So is this a structural problem where NYC DOE is purposely denying services? There are remedies for that, obviously via due process proceedings. If there is evidence that there is purposeful structural manipulation to deny care then of course that would seem to be a large issue for a professional member association to weigh in on. I am just asking for the evidence.

Instead of evidence that this is a purposeful structural manipulation most of what I can find online are concerns like yours - that small providers have lost contracts and are out of work because of a competitive RFP process. If rates are cut because someone in the marketplace is able to provide the care at that rate then I suggest that is just the free market at work. Now if over time that care provided at a lower rate does not meet standards or needs then the free market will correct itself.

I just don't understand the outrage. These are municipal funds being used to pay for these services and the municipality has a fiscal responsibility to be judicious caretakers of funds. As was noted by a blog commenter on this topic - the municipality is responsible for providing FAPE and appropriate care is not the same as 'Cadillac' care. The legal system has been trying to find a line on what is 'appropriate' for a long time and the push and pull between cost and value is an old old debate. This is nothing new.

So this does not get a knee jerk response of support from me. As many people in our community know I am generally the last person to stand up and believe that the municipalities are blameless. However, if you are looking for support, how about some more information and evidence??

Just to reiterate, I don't represent NYSOTA and this is my own opinion. It sounds like people are asking for a membership organization to solve concerns that some people have about a local NYC RFP where there were winners and losers. That almost sounds like a call for a quasi-Union - and I will be following this rather closely because I am not of the opinion that a state association should be trying to function as a Union and to restrict competition in a free market where many therapists (self employed OR in large agencies) are all supposed to be on a level playing field. If the NYC DOE is doing something structurally incorrect then that is fine. But if NYSOTA is supposed to support one group of therapists over another just because someone lost in a fair bidding process then I don't agree at all.

George Nickel responds:

Sorry, but I thought you were a NYSOTA Board Member weighing in, thanks for your input. Perhaps you need to do more research on the issue. You are welcome to join conversations at SI Parents Therapists Unite on FaceBook and perhaps one of your colleagues would respond to your questions. As far as free market, again there are dangers when individual private practices are threatened to join large agencies or face losing work or their practices. This is even more important in today's economy and our country relies on small businesses. I am in favor of those agencies having their roots in our community and not being from out of state or country. I am against greed and as one of my mentors has thought me, "take enough for yourself and leave the rest for others". Not such a bad practice, now is it? In a health related field we should be networking more and competing less that is what would work best for the individuals we provide our services to in our community. Further, We educate and advocate for our professionals and those we provide our services for in our communities.

Christopher Alterio responds:

Research = reading everything to be found on the Internet including Facebook pages, websites, blog posts; scanning news services for articles on this topic, engaging in online discussion forums, and asking for those concerned to provide more details. Is there anything I am missing?

What are the 'dangers' you are talking about? Unless NYC has some different ruleset that I can't locate, municipalities the size of NYC are required to keep a list of approved service providers and the municipalities are responsible for determining the appropriate rate for those services.

Where is the 'greed' if an agency can provide a service at a lower cost or if labor supply and the economy dictates that the reimbursement point is lower than you might like? Are these large agencies greedy just because they won a competitive bidding process? I don't understand.

Lack of competition breeds inefficiency. Inefficiency contributes to waste. According to the US House of Representative Committee on Oversight and Governmental Reform in a report earlier this year, "these school based (Medicaid) services, which cost taxpayers $800 million annually and account for 44% of national Medicaid spending of this type, have created a Medicaid monster in New York schools. A number of audits in recent years indicate that 86% of Medicaid claims paid to New York City schools from 1993 to 2001 either lacked any explanation as to why the services had been ordered or violated some other regulation or requirement."

All of us as school based providers are acutely aware of the State Plan Amendment and the tremendous pressures everyone is under because of the lack of fiscal responsibility and in fact the outright fraud in these programs. I don't know about anyone else but I would like to see school based services available far into the future - but if we close our eyes and fail to acknowledge the HUGE problems in front of us we will serve our short term interests about our own salaries but fail to appreciate the long game and whether or not we are contributing to a real solution.

I am a small private practitioner. I have won and lost contracts. I also saw the Medicaid train wreck and before it hit I re-tooled my practice and oriented it toward direct access and private insurance. I still participate with municipal contracting and still recognize that we all need to be more fiscally sensitive and contribute to a long term solution. I don't see how attempts to quasi-unionize the workforce and eliminate competitive bidding brings us any closer to solving the large problems.

Then again maybe I just don't know much and need to keep researching. But I don't think so.

Follow the fun on the NYSOTA Facebook page:  http://www.facebook.com/MyNYSOTA

Tuesday, September 25, 2012

On piano tops and proprioception

OK so I haven't let my inner R. Buckminster Fuller out for a walk lately so I think it is time to address a problem that I perceive with some aspects of clinical problem solving in occupational therapy.

Here is some background first:

In this month's AJOT there is an article on Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities (Blanche, Reinoso, Chang, & Bodison, 2012).  It is an interesting article that demonstrates differences in test performance on an observational measure of proprioception between children who have disabilities and their typically developing peers.

The authors correctly point out that we only have limited means to actually measure proprioception.  The Standing and Walking Balance subtest of the SIPT is a good measure, but like other measures of balance it is confounded by proprioceptive processing, labyrinthine righting, and optical righting.  It is difficult to really know how much proprioception actually contributes to balance because we are measuring other functions at the same time.  Measurement with eyes closed removes an optical righting component but still does not bring us to a particularly 'clean' measure of proprioception.  So, this subtest is limited as a measure of proprioception.  The Kinesthesia subtest has known test-retest reliability problems (Ayres, 1989) and itself is not a good measure of proprioception.  These difficulties with measuring proprioception are well-established and probably not really disputed in the field.

The idea of a functional observational measure of proprioception is interesting.  However, it is really confusing as to why the AJOT editors would choose to publish this article demonstrating differences between groups on an observational measure BEFORE they publish the observational measure itself!! (Blanche, Bodison, Chang, Reinoso, in press).  It makes it a little difficult to interpret a research study on a test that has never before been published.  I don't understand this editorial choice.

The assessment tool includes observation of categories like 'Decreased muscle tone' and 'Joint Hypermobility.'  Of course we don't have the actual assessment for detailed analysis of these categories but a question in my mind relates to the fact that children may have low tone and joint laxity for many reasons that are not related at all to altered proprioceptive processing. For example, low muscle tone may be theoretically caused by poor registration of proprioceptive inputs at the local level, dysfunctional cerebellar processing at the central level, or even something entirely different like a collagen or fascial or connective tissue defect - or even a muscular dystrophy or other condition for that matter.  The point is that we don't know from observation that low tone and hypermobility are necessarily proprioceptive problems.

Additionally, there are behavioral measures on this assessment like 'Enjoyment when being pulled' and 'Tendency to lean on others.'  There are literally thousands of possible reasons why children may engage in these behaviors and they most certainly are not all related to proprioceptive processing.

These are just big questions I have about this assessment and I hope AJOT publishes it soon so that I can make better sense out of these categories.  I am hopeful that we don't have another 'Sensory Profile' type of report or assessment that includes a multitude of observed and recorded behaviors that could possibly be attributed to many different problems. 

This is R. Buckminster Fuller talking now - because in occupational therapy we have this tendency to want to solve the problem by constricting our interpretation of observed behavior so that it fits neatly in with our preconceived notions and existing models.  We may have an idea in our minds about proprioceptive processing because it is part and parcel of our theory base related to sensory processing disorders. 

Fuller stated,

I am enthusiastic over humanity’s extraordinary and sometimes very timely ingenuities. If you are in a shipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday’s fortuitous contrivings as constituting the only means for solving a given problem. Our brains deal exclusively with special-case experiences. Only our minds are able to discover the generalized principles operating without exception in each and every special-experience case which if detected and mastered will give knowledgeable advantage in all instances. 


Even though we have ideas, we have to be careful not to fall into the trap of attribution or correspondence bias when we make observations.  It is possible that disordered or disorganized behavior like 'Tendency to lean on others' may be somehow related to a sensory seeking strategy associated with inefficient processing of proprioceptive afferents - but it might also be something else entirely.  We have to stop making automatic assumptions about these behaviors just because that is how we make sense out of the information when we constrict our thinking to a specific model.

Anyway, publishing the darn assessment FIRST might have prevented some of this gear spinning!

There are other issues to look at in the article though - one that caught my attention specifically is that the group of 32 children included in the study who were diagnosed with ASD reportedly did NOT have any additional motor difficulties.  That does not make any sense to me.  I understand that motor delays are not part of the diagnostic criteria for ASD but in my clinical practice I don't know that I have ever seen a child who has ASD that HAS NOT had an accompanying developmental motor delay.  Research indicates that these motor delays are quite common in this population (Provost, Lopez, Heimerl, 2007).  I am kind of wondering if the article meant to convey that they don't have an organic motor disorder?  That is really a little unclear because the study says "without any additional motor difficulties."  Very confusing.

I am hopeful that I can update some of these observations when the assessment itself is published.   Stay tuned.



 References:


Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles: Western Psychological Services.

Blanche, E.I., Reinoso, G., Chang, M. & Bodison, S. (2012).  Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities, American Journal of Occupational Therapy, 66, 621-624.

Blanche, E.I., Bodison, S., Chang, M. & Reinoso, G. (in press).  Development of the Comprehensive Observations of Proprioception: Validity, reliability and factor analysis, American Journal of Occupational Therapy. 

Fuller, R.B. (1968). Operating manual for Spaceship Earth, Carbondale: Southern Illinois University Press.    

Provost, B., Lopez, B.R., Heimerl, S. (2007).  A comparison of motor delays in young children: autism spectrum disorder, developmental delay, and developmental concerns. Journal of Autism and Developmental Disorders,  37(2), 321-328.
 

Wednesday, September 19, 2012

When it is not in your job description...

Well I am sleeping better tonight knowing that the Chicago teacher strike is over!!!  All of the really important things like making sure raises stayed in place and health care contributions stayed low got the immediate attention they required.  Muscling out charter schools got a lot of good attention also and of course that is good because we don't want to have competition against a failed school system.  The less important issues like teacher evaluation systems got pushed off into the future.

I don't even live near Chicago and I have no skin in that game directly but I just wanted to express how happy I was that those Union efforts will continue to work in favor of students - just like I saw them working in my own community recently.

You see there was a four year old child who has a physical disability - doesn't even matter what the disability is exactly so I will leave that detail out - and he was happy and excited to start his school year.  All summer long his COTA worked with him and the family to teach him how to use the toilet.  He made great progress and by the end of the summer he was able to access the toilet in his home independently.  He was READY for school!!

The COTA contacted the district and let them know what they would need to do so that their facilities would be accessible for the child.  Sadly, on the first day of school those accommodations were not in place.  The little four year old child who has a physical disability was not able to use the toilet in school.  The facilities are different, he was not confident with his new skills, just going to school for the first time is a big challenge itself, and so he was not able to use the bathroom.  So he had an 'accident' and had to go to the nurse so she could help him with clean up.

Well the COTA quickly addressed the situation and was meeting with the classroom teacher, the classroom aides, the nurse, and even the school principal to solve the problem immediately.  There was a lot of lip service about 'doing whatever was necessary to make the environment accessible' and 'doing whatever was necessary to make accommodations'  but there was a little bit of a disconnect between the words and the actions.

I jumped into the situation to see if I could help out the COTA.  The classroom staff stated that they would not be able to help a four year old who has a physical disability in the bathroom.  It wasn't in their job descriptions, they told us.  In fact, it was in the job descriptions of a personal care aide, and not a teacher or a teacher aide.  Therefore, Union rules prohibited them from performing the essential job functions of the personal care aide position.

"Even if that means that a four year old child urinates in his clothing - just because you don't want to provide a supporting hand as he practices getting onto and off of an unfamiliar toilet?  Even if he will only need that help for a little while until he gets his confidence up in this new setting??" I asked.

The deadpan response was, "Our Union Steward told us not to do it, so we won't.  It is not our job.  We can help adjust his pants if they are askew when he comes out of the bathroom but that is all."

 I will stipulate that job descriptions are specific for a purpose and I appreciate the sentiment of following rules because generically that is a good thing to do.  However, this child only has a very minor need for temporary support to make sure he is safe getting on and off the toilet until he translates his skill into the new context.  Besides, he is just four years old and all he needs is a supporting hand.

Sometimes when you encounter really nonsensical systemic barriers you might think that you have finally reached the pinnacle of human stupidity and there is just no more to be seen - but I am always disappointed that there seems to be another mountain of stupidity on the horizon.

So I fired off a letter to the CSE advising them that the child was at increased risk of injury if no one was willing to help him with toileting.  I also suggested that there was a need for more OT consultation to make sure that the environment would be safe and accessible.  That got their attention apparently, because in lightning quick fashion a meeting was scheduled.  In advance of the meeting, I have been informed that the system will now provide a personal care aide because that personal care aide is somehow uniquely qualified to hold the hand of a four year old child who needs a little assistance to get onto the toilet.

I will make the assumption that the personal care aide position pays Union dues.  I don't know that factually, but it seems like a fair assumption.

Anyway, this all makes me really happy that the Chicago teacher strike is over, because goodness knows we need these teachers and their Union back in the classroom as soon as possible.

I anticipate that this kind of blog post can generate some hate mail, so I will state in advance that if someone wants me to be sensitive to Union concerns ever again, they will first need to explain to me why it is OK to let a four year old child urinate in his clothing because helping is not in your job description.

Thursday, August 30, 2012

More discussion re: the AAP Policy Statement on sensory integration

This was written in response to Dr. Clark's letter to Pediatrics regarding the AAP Policy Statement: Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.  

++++++++++++++

Dr. Clark's response included some important points which were good to read, including recognition that single modality interventions tend to be ineffective; I am hopeful that her statements will help to move occupational therapy practice away from these interventions.

I was also glad to see mention of the neurobiological literature as theoretical backing for some interventions.  This is important literature that we should all keep in mind when trying to understand apparent processing difficulties.

Finally I was glad to see mention that occupational therapists use a wide variety of interventions with sensory processing interventions among them but not representing them solely.  I think we need to remind or medical colleagues of this fact lest we become associated with only a single intervention strategy.

I would like to encourage AOTA leaders and my occupational therapy colleagues to carefully consider the comments of Dr. William Carey, located online at http://pediatrics.aappublications.org/content/129/6/1186/reply#pediatrics_el_54252

I believe that Dr. Carey expresses an important point when he states

"Where normal variations leave off and abnormal degrees supposedly begin has not been clearly defined. Clinical problems probably occur most often when the particular level of sensitivity or reactivity makes a poor fit with the demands and expectations of the environment. That dissonance may lead to stress and to some form of dysfunction in the child. In these cases it is helpful to assist the child and parents in finding ways to get along better and reduce the impact of the mismatch. But this does not mean that the child has a disorder." 

I think that occupational therapists have done an incomplete job of making distinctions between truly pathological levels of dysfunction vs. identifying traits and tendencies regarding processing differences.  In part this has been facilitated by over-reliance on parental report measures and the an apparent desire to get this labeled as a disorder first and to develop valid and reliable client factor assessments second.

Occupational therapists remain well positioned, and I would even argue best positioned, to still provide important interventions to children and families where sensory processing differences are causing stress, anxiety, and even performance difficulties.  However, when we take the opportunity to consider that this is not always a primary disorder but sometimes a complex and dynamic relational point of dysfunction between the child and their contextual environment, then suddenly we have a whole different set of tools available to us in addition to the process and structural components that are currently being suggested as preconditions for any kind of effective intervention.

So why do we need to re-frame this so that we are not restricted to calling it a disorder and thinking that we need special equipment and 6 months of therapy (ideally)????  Because of pragmatics and the real world.

Dr. Clark talks about real world applications and so here we need to acknowledge the real world.  Insurance companies do not pay for months and months of therapy - nor should we expect that in this current health care environment.  What good do we do when we state that the only proper studies to consider are those that include a frequency and intensity of therapy that is not reimbursed?  Do we restrict this intervention only to the wealthy who are able to go to private clinics and pay these fees out of pocket?

Ultimately, I believe that the model of sensory integration therapy that calls for specific structural and process elements that are not found in the majority of intervention settings will not serve the public and will be discarded.  The model of sensory integration therapy that calls for high dosage requirements that are not reimbursed anywhere in the country will not serve the public and will also be discarded.  This high intensity and high dose strategy is not a model that will position us to help children and families who experience these difficulties.  

We need to consider the words of Dr. Carey carefully.  His words do not de-legitimize the role of occupational therapy; rather, his words are a clarion call to provide occupational therapy in a way that is more congruent with actual child/family needs and more congruent with a responsible and conservative intervention strategy.

Wednesday, August 29, 2012

How to solve children's complex feeding difficulties.

Physics tells us that energy and mass can't be created or destroyed; rather they are transformed from one form to another, at least in closed systems.  My brain can't handle much past Minkowski space so I get a little fuzzy if I try to understand conservation principles in expanding space-time volumes, but then again I am no physicist and I am certainly no mathematician.

I've been thinking a lot lately about energy and where it goes when variables are introduced into a system.  A parent began presenting me with a complex pathway of what-if scenarios regarding her child's eating skills - what would happen if this occurred, and what would happen if that occurred - and she had the entire child's trajectory imagined before a single bite of food made it past the child's lips.  There was no pause along the trajectory to map out the potential energy within the system (that might subsequently be transformed to a different kinetic pathway) because the parent already had the whole sequence pre-mapped.

I attempted to introduce some brakes into the parent's thinking system, and as her what-ifs were removed the kinetic energy of her perception of the child's trajectory got transformed into stress.  So, the parent became upset, the child stopped eating, and progress stopped.  Energy was definitely conserved within the system, but definitely not into a direction that was going to serve the child's needs.

So what do you do when the energy within a system can only be expressed in a variable that is negative, and if you try to change the negative energy it just gets transformed into a deeper but different expression of negativity?  That's a real problem.

Feeding difficulties are very challenging and some days I have no answers.

In my last blog post I talked a little about caring for caregivers.  This is all just an extension of that same conversation.

Anyway, the question of the evening is "Where can you find the energy within a closed system to move an object off of its seemingly predetermined path?"

The ancient Greeks solved these dilemmas by introducing a deus ex machina into the plot of their tragedies.  I don't have these mechanisms at my disposal.  I can't be certain that people really like those solutions anyway.

Martha Graham said "There is a vitality, a life force, a quickening that is translated through you into action, and there is only one of you in all time, this expression is unique, and if you block it, it will never exist through any other medium; and be lost."  I wish it was so easy - that you could just direct families to tap into that energy somehow and find ways to make changes.

I think that Martha Graham has an interesting perspective on potential energy but it isn't entirely consistent with the conservation theory.  Can it really become lost?

On Facebook today one of my relatives posted a picture of my grandmother who died seven years ago.  When people are alive they are an expressed vector of directed energy - but where does it go when they die?  Does that energy get lost?  I think that I can tap into my grandmother's energy at any time, invoking her memory to move my children into action.  It is a highly effective technique.  So maybe there is energy out there to be grabbed and directed - but we just have to find it.

As I sit here and think about it I am moved to consider that my grandmother could probably solve any child's eating difficulties.  Boy could she cook, and she loved to nurture other people with her cooking.  She also didn't suffer any nonsense.  She would have done well as an occupational therapist working with feeding difficulties.

If you knew my grandmother you would understand how true this is.  Maybe I can find a way to tap into this somehow.

Tuesday, August 21, 2012

I have no title for this

I was reading the Medscape Oncology pages today.  I received an email notification about a series of articles on palliative care and most of them were quite good.  There was a particularly interesting perspective on DNR choices and showing patients (who have terminal disease) CPR videos and how this impacted their choices for end of life care.

I started thinking that this was good information.  Then I started thinking that it is information that could be bureaucratically abused.  It worries me when I start seeing people use the word 'economics' next to 'end of life care.'  I think if we focus on quality issues and as long as we are honestly looking at quality issues then it is all ok.

Anyway, I started clicking around and then I stumbled across an older article and video about how doctors need to understand the needs of care providers.    I thought that it was a kind message and in watching the video portion I was thinking that Dr. Marshall seemed like a very kind doctor. 

He talked about how some care providers might secretly wish that they could just move forward and perhaps that is true.  I think that when a patient has been very sick for very long that this could be a very common feeling that a caregiver could have, even though it might be a conflicted and complicated and very painful feeling.  So I think he is correct in saying that medical people need to care for the caregivers.

I personally never had the kind of feeling that Dr. Marshall was referring to.  When my Dad died it was a process that took maybe a year and a half from diagnosis to his death.  I remember reading journal articles about his particular type of cancer, the relatively grim prognosis, the conversations I had with my Dad about the prognosis, the discussions that we had with his oncologist and how she told us not to read articles (!!) and on and on.  I think his oncologist also had a good heart.  Her card is still in my wallet, next to my Dad's funeral card.  I haven't quite figured out how to move either out of my wallet yet.

So I am not in the 'let's get by this process' camp.  I am more in the 'how in the world do I get by this' camp.  It has been two plus years now and when I saw Dr. Marshall's article it kind of came rushing back.  Grief is like that, I guess.  You never really can understand the pull of that riptide until you stop and understand how big that ocean is.  Oh well.

So the message from Dr. Marshall is correct.  Medical folk (and I am one) have to care for the care providers.  Everyone processes this stuff a little different.  Everyone will need a different kind of care.  Boy is this a tough issue.  Even when you are a medical person.

Friday, August 10, 2012

I believe that small things matter

I've been reflecting today on my belief that small things matter.

This first came to mind when our current OT student intern jokingly commented that we almost lost another puzzle piece - which is justification for disaster alert at ABC Therapeutics because I kind of have an unhealthy obsession a value for keeping puzzles complete... We recently had a celebration when we finally found the beloved monkey that was missing from a puzzle for so many months.

So anyway I am glad that we don't have that many missing puzzle pieces because even though it is a small thing I have the belief that it matters. 


The concept was reinforced when our OT student intern was able to open the door today - she has struggled with the 'child safety cover' on the door handle for her entire fieldwork experience.  This afternoon she opened up the door on the first try and at the same time we both cheered, "HOORAY!"  Again, it is a small thing that matters.



I have also been thinking about one of my little friends who while swinging upside down made the side comment that the swing 'made his pee pee hurt.'  Well that was an odd thing for a child to say, but it was a single small comment that I thought mattered.  So, I replicated the condition when he made the statement so that he was hanging upside down from the bolster and I watched him frown and wince slightly while he struggled to maintain the supine flexion position.  I told the mom to have the MD check for an inguinal hernia and sure enough he will have that repaired in a couple weeks.

My point is that small things matter and I think we do our best jobs when we are tuned in to those details.

So then I was walking outside to get my mail and one part of the black-eyed susans were leaning horizontal to the rest of the group of flowers.  It was different, I thought, and perhaps warranted rearranging.  The difference was small.  If I 'fixed' it then that might be representational of what we try to accomplish here on a daily basis.  If I left it alone then even though it was growing horizontally it was still just fine the way it was and could be celebrated.  So I thought better of it and decided to let the difference remain the way it was. It was a small thing, but it made me feel ready to start the weekend.

So off I now go...

Wednesday, August 08, 2012

Occupational therapy private practice: A day in the life


I received an email yesterday from an anonymous commenter who wanted to know what one of my actual days looked like as a private practitioner.  So here goes a listing of what happened today, which seems as representative as any other day :D :

4:30am Wake up.  Read email, respond to email.  Check local and national headlines, reading 1-2 articles of interest.  Check Internet forums, respond to messages.  Look at clock and sigh.

5:15am Go back to sleep. 

7:15am Wake up, again.  While having breakfast read email, respond to email.  Complete a journal and focused medical news scan, reading 1-2 articles of interest. Check Internet forums, respond to messages.  Look at clock and sigh.

8:30am  Wonder why children are still sleeping, pay attention to the cat and dog, leave for the office.

8:50am Arrive at office.  Meet with parents in the waiting room while their children are in for therapy.  Banter, advise, support.  Repeat as needed.  Schedule meetings to resolve lingering issues with marketing consultant and accountant.

9:30am Sit at office computer, load up email program, Twitter, Facebook, and news readers.  They are now prepared for scanning throughout the day.

Write reports.  Schedule incoming appointments with new families.  See children.  Talk to more parents.  Supervise and monitor Level II student.  Meet with staff.  See more children.  Talk to even more parents.  Respond to emails.  Ruminate, generate questions, and research morning issues including:

1. What are all the possible reasons why a child who has dual diagnosis of Down Syndrome and Autism would have neurodegenerative regression during the preschool years.

2. What are appropriate (sensory tolerable) calorie enhancers to suggest to a parent whose child has a constricted diet.

3. Is inappropriate use of social media a problem in itself or does it represent a foundational ethical problem with maintaining appropriate professional boundaries.

Act on information obtained following rumination and research.  Direct staff, advise parents, rant on professional forums.

12:45pm Look at clock and sigh.  Eat lunch rabidly.

1:00pm Complete evaluation of a new child with Level II student.  Make decisions.  Consult with family.

3:30pm Read email, respond to email.  Check Internet forums, respond to messages.  Look at clock and sigh.  Consult with COTA about caseload issues.  Try to return phone calls and wish that more people worked later in the afternoon. Start some letters, but only finish the marketing one to the cardiologist about the recent study in Circulation re: neurodevelopmental problems in children following complex cardiac procedures. 

4:30pm Worry about personnel shortages in rural areas.  Commiserate with colleagues about shortages.  Call another colleague and commiserate about the child/family who is having feeding difficulties.  Ruminate, plan, coordinate.

5:00pm Tell student to go home.  Tell staff to go home.  See more children with COTA.  Meet with parents to discuss MD plans to add Metformin to an Abilify regimen.  Discuss activity level, changes in routine, and difficulty with measuring behavioral effects when overall routine is disrupted by summer schedule.  Worry about how to give MD the best information to understand effects.

5:30pm Worry more.  Research cardioprotective value of Metformin.  Try to find articles related to use in children who have autism.  Tell COTA to go home.  Look at clock and sigh.

6:00pm Look at what didn't get done today.  Didn't address billing today.  Didn't pay bills today.  Didn't finish letter thanking someone for interviewing.  Didn't receive payment from  some vendors that owe some money.  Be thankful that payroll is NEXT week.

6:15pm  Write pointless blog post outlining my day.

6:30pm Leave office.

Monday, August 06, 2012

Special interests drive language changes to OT Assistant laws in NY State

As I blogged about earlier this year, there were some problems with the changes to the NY State occupational therapy law that placed significant barriers to non traditional fieldwork settings.  OTA fieldwork educators in New York State and NYSOTA saw these problems and there was a last minute rush to file a technical amendment to the law so that they would not have to operate under such restrictive conditions.

It is true that the way the law was written could have contributed to a decreased pool of practitioners able to accept fieldwork students; OTA students would have had to compete with OT students for licensed occupational therapy supervisors.  Fieldwork educators already struggle to find 'slots' for their students and the law certainly did not help by imposing restrictive limits on WHO could supervise a student.

However, restrictions are in place for a reason - namely to protect the public - and both Medicare and Medicaid have rather severe restrictions that functionally supersede the State law because if an agency wants to get reimbursed then they will have to be rather cautious with the way that students are involved in their agencies.

So now the law has been amended so that OTA students can be supervised by OTAs, as long as the OTA is in turn supervised by an OT.  However, the requirement is no longer for "direct supervision" but it calls for "direction and supervision."  I find this to be a wordsmithing change that completely alters the intent of the original legislation - and the educators who met in a private pow-wow with NYSOTA representatives at the national conference to come up with changes have to know that they fundamentally altered the original intent.

I understand that the original language was less than optimal.  Actually it might have been detrimental.  I also understand that there was a time crunch to get the technical amendment introduced.  Still, the idea that such a dramatic turnaround in intent and language could be engineered by such a small contingent of people that represents a focal point of interest in extraordinarily unhealthy for our profession.

What are we left with?  Well OTA students still can't operate in schools or nursing homes (that are seeking Medicare and Medicaid reimbursement) unless they are under the direct line of sight or continuous attendance of the licensed professional.  However, with the way that the law is now written fieldwork educators can place students in non-traditional placements (in other words, places that are not so tightly regulated) and provide them with this generic level of "direction and supervision."

Now that is a win for the fieldwork educators who suddenly have a lot more latitude for student placements.  But there is a problem:  According to Practice Analysis studies nearly 80% of all COTAs work in skilled nursing facilities, rehabilitation facilities, or schools - all of which function under those more restrictive Medicare and Medicaid guidelines that actually require direct supervision.  Since NY State law also now mandates that OTAs pass a certification examination (which by the way happens to be based on a practice analysis and not on impromptu pow-wows) that means that OTA students may be legally placed in these non-traditional settings where they will receive "direction and supervision" but they sure will have a difficult time passing the certification examination that asks questions about the traditional work settings.

Here are the takeaways for all this:

1. If you are an OTA student in NY State, just because you are legally allowed to complete fieldwork in non-traditional settings under "direction and supervision" that does not mean that those experiences will necessarily prepare you adequately for passing the certification examination and subsequent entry level practice.  So being an OTA for the soup kitchen or domestic violence shelter might be cool, or being an OTA for the private community agency that provides dance and karate lessons to children who have disabilities might sound like fun - but just be ready to know that most entry level practice does not occur in these settings.

2. If you are an employer who is now hiring OTAs who are operating under limited permits (until they pass their exam) then you might want to screen a little closer to make sure that the students had adequate fieldwork experience.  There are a lot of employers out there (myself included) who had to struggle with students/new therapists who previously were not required to pass a certification examination.  Have these changes really ensured that these students will be prepared for the new requirement of examination and for practice?

Alternately, if you are an employer who operates under the fast food industry's theory of a never ending supply of unskilled labor you might like hiring these marginally prepared students and just dumping them after a year when it is apparent that they won't be passing their certification examination.  NY State allows nursing homes and hospitals and schools to do this with impunity, but you won't find these candidates operating anywhere near a private practice because the law doesn't allow it. 

3. If you are a health care consumer in NY State you should be aware that this is the way that practice laws are getting written.  That should concern you.

3. If you are a NY State politician then you might want to drink an extra cup of coffee during these last minute legislative marathons so you can notice that there is a world of difference between "direct supervision" and "direction and supervision."

4.  If you are a blogger (like me), make sure you write enough disclaimers so that people know you are not anti-progress, or anti-non traditional fieldwork.  Instead, make a lot of statements so that people reading this will know that these concerns are generated based on the belief that achieving expansion into emerging areas should not come by potentially sacrificing the quality in our educational programs.  It should also not come at the price of public safety and by negligence of our duty to prepare students appropriately to serve the public.