ABC Therapeutics Occupational Therapy Weblog

This is a topic that is probably long overdue - it is something that I have observed in my geographic area for a long period of time. Based on conversations I have with therapists around the country I know that it is not exclusive to my area. Increasing demands on therapist time, decreasing reimbursements, and dependence on a non-centralized workforce that is not subject to an intense quality improvement process has contributed to significant changes in how occupational therapy 'evaluations' are completed. Our agency made attempts to impact this system while contracted to complete some evaluations, but 'contractor status' did not place us into a position to make broad system changes. Now it seems that the entire community is stuck into a cycle of low expectations based on long history. Unfortunately, there is no centralized service delivery system or 'top-down' method of assuring quality control - so I think the only way this can change is for the stakeholder...

The State Early Intervention Coordinating Council held a meeting on June 14 (yesterday) to accept or reject the new regulations regarding issues including the 15 minute increment billing and adjusted early intervention rate calculations. I just finished speaking with Holly Kennedy from the EIP and she confirmed that the current rulemaking was rejected and that there will be a new rulemaking (look for the new Rules proposals in the Register around the end of June). There will be another 45 day comment period (but no public hearings). Ms. Kennedy stated that some alternate proposals may appear in the rulemaking but she was not free to be specific about those at this time. I have some initial information about those proposals but won't publish my information until I can verify and source it. Finally, I was told that any current service plans will continue in effect past any new rules - and will be revised on an individual basis during the regular review period. When I get details ab...

There are a couple important stories in the news today that everyone needs to watch. In this first story we see an absolute lack of understanding in how a governmental agency responded to an adult who was trying to board a plane with his family: Dr. David Mandy: Special Needs Son Harassed by TSA at Detroit Metropolitan Airport: MyFoxDETROIT.com In the second story we see people completely disrespecting and interfering with a Special Olympics activity. It is certainly within their rights to express their displeasure about whatever they want, but sane people would choose a time and place that is appropriate for such a protest: Lastly, and most tragically, is the continued failure of NYS - all these years after Willowbrook we thought it would never happen again: It is very clear to me that as a society we still have a very long road to travel.

Sometimes when children progress from preschool to school it is determined that they still need to be classified and receive special education services. Sometimes it is determined that they should be declassified. There is a defined process that is supposed to be followed. Patrick is a preschooler who has disabilities and if he enrolled in kindergarten last year he would have either continued his classification and received services OR continued his occupational therapy services in the school under a declassification plan for one year. Given his severity of delay he would have also been a likely participant in a summer readiness program designed to help support children's performance when they are struggling with key developmental skills. The goalposts have been moved again this year. Now there is no summer readiness program and there is no declassification plan. Part 200 regulations governing the special education program in NY State have not changed, and clearly state: (iii)...

Cost accounting is boring, I understand, but I hope providers and families read this so that they can empower themselves to push back against the systematic dismantling of the NYS Early Intervention program. As previously blogged, NYS is engaging in a cost reporting process for the early intervention program. Cost accounting is a valid tool used by a business to establish actual cost for delivering goods or services. Unfortunately, the NYS government is going about this process in a backwards direction. Generally, the results of cost accounting projects are used to inform stakeholders about costs so that appropriate reimbursement rates can be set. However, in NYS, the rates to providers have ALREADY been cut 15% in the last year and an additional functional cut of 33% is proposed to begin on July 1 by back-door manipulation of the billing and coding system. Why then, is the NYS Department of Health engaging in an exercise of cost accounting when reimbursement cuts have already been ...

"I love you," Kimmie's grandfather said, while gently releasing her hand and carefully pulling up the bedsheets around her thin shoulders. "Well I love your eyes," she said back, and planted a kiss squarely on his jaw. The grandfather gave her a wink, got up, and tipped his hat to me as he left the room. I felt a little awkward and concerned that I stepped into a personal moment, but Kimmie didn't say anything about it so we just quickly got to the business of therapy. Kimmie was a nineteen year old young adult who had cystic fibrosis and spent many long weeks in the hospital. I got to know her pretty well because she was admitted to the hospital several times each year. She landed on my caseload after her first hospitalization and the way we divided workload kept 'repeat' patients like her with the same therapist each time. She talked a lot about tranferring to an adult hospital but she knew her pulmonologist so well (and vice versa)that her...

Proposed rule changes for EI rates were published yesterday. The main issue for practitioners to be aware of is that you will no longer bill for a 'basic visit' which in most cases consists of a 30 minute visit. Instead you will bill in 15 minute increments - but what is important to understand is that the rate you were previously paid will now apply to a base visit length of 45 minutes. That means that if you are continuing with your standard 30 minute visits that you will experience an additional 33% rate cut. Whenever rule changes are proposed there needs to be impact statements - and NYS rulemakers have decided that cutting EI rates an additional 33% will result in increased job opportunities: The proposed rule change for home and community services to full 15 minute billing increments may result in a minimal increase of employment opportunities as providers will have to align time spent delivering services with the time assumptions used to establish the rates. It may als...

The March/April issue of AJOT has two articles on sensory integration that are worth discussing. The first is Verification and clarification of patterns of sensory integrative dysfunction (Mailloux, Mulligan, Smith Roley, et.al.). This article is another factor analysis study that has to be considered in the context of a number of other studies including Ayres (1989) original cluster and factor analyses that went into SIPT standardization, Mulligan's 1998 and 2000 cluster and factor analyses, and the critically appraised topic written by Davies and Tucker (2008). I'm not sure how many street level practitioners read cluster and factor analysis studies but I don't think that most people put this on top of their reading list. I think this is because we don't spend a lot of time educating practitioners on these methods and what they mean. I personally think that these statistical models are interesting but I also understand that they have a serious fundamental flaw in that...

I want to encourage people who are interested in updates on EI and other issues to follow our Facebook page at http://www.facebook.com/ABC.Therapeutics I'll be posting brief updates there more often than I update the blog - which I generally reserve for longer rants or conversations. Blog traffic has spiked the last couple days so I know there are a lot of people out there looking for information. The best information that I have available currently is that Senator Ranzenhofer's office confirmed to me that the EI rates have been cut 5%. In brief Facebook exchanges with NYSOTA they are also reporting the same information. A digital news service that covers NYC news is also reporting similar information. I spoke with people in the NYSDOH and EI programs specifically and they are keeping their lips sealed for now. A 5% cut is better than the originally proposed 10% cut, but it will still create additional challenges for providers who are still accommodating to the 10% cut tha...

I encourage everyone to open up the current American Journal of Occupational Therapy and read 'Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder.' This is a fantastic article that looks at the issue of whether or not seat cushions were effective at promoting 'in seat' and 'on task' behavior. I think this is a fantastic study because it take a very common OT intervention and puts it to the test. For many years OTs have been dispensing seat cushions to children in classrooms based on the thought that the seats provided sensory stimulation that busy children were 'seeking' or that the seats would demand a postural reaction that would promote attention and erect sitting. This has been done for so many years in so many settings that it becomes a common request from teachers who don't know what to do with fidgety children. How many OTs hear the request "Can we try to see if sitting on a seat cushion will ...

If the number of hits to this blog regarding early intervention and the NYS budget are any indication - this is a MAJOR point of concern for therapists. Our traffic has been influenced heavily by this issue in the last month. Also, it is not just NY traffic - people around the country have been watching the proposed budget cuts to the NYS Early Intervention Program. This week the Senate and the Assembly each put forward their own modifications to the budget and the budget reconciliation process begins. Click on the links to get to the respective budget proposals. These documents don't always contain all the actual legislative language so it is sometimes difficult to precisely understand where specific budget lines are reflected. It appears that in the Senate version they are 'concerned' about the EI cuts and they are waiting on information about fund availability to see how they can 'minimize the impact of the Executive Proposal.' The Assembly version is more...

For those who are not aware, IEP Direct is a proprietary Internet-based software package that many school districts use for IEP writing. One value of this kind of tool is that there is more uniformity and subsequent adherence to regulation when IEPs are created in this format. However, a serious negative is that therapists often over-rely on the canned goals that are part of the drop down menus in the software. I am not sure who writes/approves the canned goals in IEP Direct but some of them are rather silly. Being a former full time educator myself I know that academic programs spend quite a bit of time teaching students how to write appropriate goals that are both functional and measurable. Something seems to happen between the classroom and practice because the quality of many goals that I see written for children in school settings is very poor. This is not new but is a perennial rant because the situation does not ever change. Programs like IEP Direct have now compounded the p...

Melissa is a happy three year old. She smiled brightly as she played with the 20 year old bead and wire toy in my waiting room. I am amazed at the durability of this toy that was originally a favorite of my oldest daughter. It has been played with by thousands of children over many years. Melissa talked quietly to herself as she slid the beads along their paths. Some of those paths are rather uniform and follow a predictable and simple geometric trajectory. Other paths twist, turn, climb and dip unexpectedly. All of them begin on one side of the toy and end on the other side of the toy. Melissa's grandmother usually brings her to occupational therapy but her thirty-something year old father also began coming to therapy sessions. He was recently released from prison and a mandatory rehabilitation program. He has a long and repetitive history of substance abuse and criminal behavior. No one knows where the mother is. Based on conversations we have had, Melissa's grandm...

I have recently blogged about the State Plan Amendment that involved a $540 million settlement paid from NY State to the federal government because of Medicaid fraud. In the wake of the settlement, the Office of the Medicaid Inspector General has developed guidelines that municipalities are trying to understand, and in turn these guidelines are trying to be followed by local school districts and providers. The current street level problem is that documentation requirements for services are being applied retroactively - and that causes even greater amounts of ineligible billing. In a mad rush to understand and comply with new requirements (I am hesitant to call them rules or guidelines) the locals are desperately looking for guidance on how they are supposed to provide services, document services, and bill for services. Inspired people (like me) went to more than one training session and were shocked to find out that there were inconsistencies between the information that was prese...

I don't frequently blog about my interest in pediatric injury prevention because our Facebook page is a much more convenient way to share information and messages about that topic. Today I thought I would tell a quick story about one of the driving events that got me thinking about injury prevention. The thought was prompted by a story on one of my favorite websites, www.safekids.org. They have a feature on furniture tipovers that reminded me of an incident that happened to my son when I was a brand new parent over 20 years ago. My son was nearly three years old and a very active toddler. I was watching him play in the fenced in back yard and he had his little toys, the family dog, and a toddler sized slide to keep him busy. It was a safe environment, I thought. He managed to fall off the toddler slide and immediately began crying that his leg was broken. Knowing that toddlers are frequently right when they use this language, I splinted his lower leg and rushed him to the hosp...

I read an article the other day that gave a lot of statistics about how teenagers who have autism spectrum disorders receive significantly less case management services, therapy, and medical care after they leave high school. That does not surprise me. Then earlier today a colleague was asking about interpretive phenomenology. That made me think I should write down this story. It gives a different perspective on the problem that moves a little beyond the statistics in the article referenced below. ___________________________________ Cindy's mom called the other day, and I was pretty certain she was calling about concerns with her young preschooler - who is 4 years old and has PDD-NOS. I evaluated Cindy about a year ago and helped the family engage their local school system for services. Instead she was calling about Emily - and I recalled that she told me about an older daughter who also has an autism spectrum diagnosis. Her older daughter graduated from high school last yea...

Here is information from Governor Cuomo's 2011-2012 proposed budget. You can find supporting documents and presentation at http://publications.budget.state.ny.us/eBudget1112/fy1112littlebook/index.html I have BOLDED the proposed budget information and italicized my own comments: Several changes are suggested for the early intervention program that provides services to children aged 0-3 who have qualifying conditions or developmental delays. • Recalibrate Early Intervention Rates. To make the cost of Early Intervention more affordable, a variety of changes will be made to payments for Early Intervention providers. These include the following: - Rate Reductions of 10 percent for Early Intervention. A 10 percent across the board rate reduction will be applied to all Early Intervention service rates. (2011-12 Value: $11.1 million; 2012-13 Value: $24.3 million) n.b. a 10% rate cut was enacted LAST YEAR. It will be interesting to see if the lower reimbursement rate drives providers...

I was impressed with the good attendance at the public hearing and the attendees represented a Who's Who of Health Care and Human Service Providers in WNY. There were CEOs from most major hospitals, directors of community service programs, community activists, and consumers. Their interests ranged from emergency room care, medicaid transportation, primary care providers, hospital and nursing home care, residential programs for people who have developmental disabilities, mental health agencies, substance abuse agencies, and so many more. I was deeply saddened that I was the only person there who talked about Medicaid in education and early intervention. These comments were hashed together from old blog posts and other rantings: My name is Christopher Alterio and I am a pediatric occupational therapist. Thank you for the opportunity to provide information from a street-level provider's perspective on the Medicaid program and funding for early intervention, preschool, and sc...