ABC Therapeutics Occupational Therapy Weblog

I am writing this entry in the hope that it will be referenced as well as my other pages on "Adult Sensory Processing Disorder." Look here for more information. As I have discussed in the past, I advocate a conservative approach to understanding these difficulties that people report. Unfortunately, there are some rather unscrupulous people in the world who have set up websites where you pay money to take a test and then they will tell you if you have "Sensory Processing Disorder." I won't link to those sites because I don't want to drive any traffic to them. People who are having difficulties may be easily fooled by this kind of scam. It is a free world and if people want to pay money for Internet tests then I suppose that is their business - but I am also free to state that in my opinion sending money to get this "diagnosis" is a colossal waste of money and may actually divert people from seeking appropriate care from their doctors. If the pe...

The players: Yorick: The No Child Left Behind Act (NCLB) Horatio: Education Secretary Arne Duncan Hamlet: President Obama The plot: After overwhelming bipartisan support for education reform and an honest but failed attempt at tackling a problem, partisan hacks run for the hills and blame a former President for his education policy. Background reading here. ______________ Obama: Alas, poor NCLB! I knew him, Arnie Duncan; a policy of infinite bipartisan support, of most excellent intentions: it hath borne us on its back a thousand times, and now, how abhorred in my imagination it is. Here hung those standards of which I have praised I know not how oft. Where be your requirements now? Your purpose? Your promise of school choice? Your flashes of expectations, that were wont to set the teacher's unions on a roar? Not one, now, to praise your own objectives. Quite chap-fallen? Now get you to my Cabinet's chambers, free from Congressional oversight, and have them paint an inch t...

Bullying is not just a part of growing up. Just because something happens does not mean that it is normal or should be tolerated. I am aware that many people 'live through' their bullying and think that it is enculturated into childhood - but that opinion only holds up in the mind of someone who was victimized and then grows past the problem. Not all children are so resilient - particularly those who already have differences from the 'social norm' that are causing them to be targeted. The need for a different level of bullying intervention is brought to a tragic light for us locally in Western NY because of the apparent suicide of a high school student over this weekend . Perhaps I don't have much to say, or maybe I just feel like anything I was going to say feels like it rings a little hollow in context of the real story. Please go read about Jamey Rodemeyer. He perceived himself as different and perhaps was victimized because of these differences. Sometimes t...

Proposed changes to early intervention reimbursements have been temporarily shelved. Today Brad Hutton, Director of the NY State Early Intervention Program, sent out an email stating: The Department has removed from this regulatory package the changes to the payment of home and community-based and facility-based visits. The Department remains committed to continued examination of the EIP reimbursement methodology and intends to have more discussion about this and other proposals with its Reimbursement Advisory Panel in the coming months. I know that a lot of people are very happy about this, but it is important that we consider all of the events that led up to this recent decision. As I have discussed here frequently in the past there is no question that there is need to revamp billing for this program to help support collection of payments from insurance plans. The problem is that we just witnessed and experienced an extraordinarily irresponsible and haphazard attempt to fix the pro...

One of the biggest concerns that we hear about from parents relates to how their children are functioning socially in their schools. Most schools have 'anti-bullying' or 'bullying prevention' programs in place. Recently, there is a lot more talk about bullying in school environments but that hasn't seemed to stop the behaviors much in the perspective of many families whose children still struggle with the problem. It is important for parents to know that there are different kinds of bullying - and just because a program is established or policies are in place in a school that doesn't mean that bullying will cease to occur. Broad programmatic anti-bullying efforts like those listed on the OSEP website tend to speak to the whole school population and attempt to create a culture of respect that works on a very broad level. As a result, most kids understand that peer exclusion, relational aggression, and even direct bullying is not acceptable. However, ...

Well I believe in equal opportunity blogging so when NYS does something correct with the early intervention program I have to herald the effort. On August 17 Governor Cuomo signed a bill that facilitates payment of claims by health insurers to municipalities for early intervention services . In a previous blog post I talked about the 85% denial rate that exists because the state government doesn't know how to collect from private insurance companies. This new law causes the IFSP to meet any precertification, preauthorization and medical necessity requirements imposed on benefits under any insurance policy. There are additional new rules that prohibit insurers from denying claims based on the location where services are provided, the duration of the child's condition or that the child's condition is not likely to improve within a time specified in the policy, the absence of a referral by a primary care provider, or that the provider is a non-participating or non-n...

Life is complicated enough that I try to avoid having existential crises as often as possible, but it is Monday and humans are natural meaning-makers and I can't escape my tendencies. Anyway, I was perusing Facebook this weekend and saw a partially familiar face as a 'recommended' friend. I am not certain of the algorithm and logic that Facebook uses to make these recommendations - I imagine it is at least loosely based on 'degrees of separation' computations. The partially familiar face was Freddie, who I have not seen in many years. I worked with Freddie when he was on the cusp of his adolescence. I remember him as being an intelligent and extremely likeable fellow who had some pretty tough problems with his handwriting and social skills. He made a lot of developmental progress while I worked with him, and as with most kids there seemed to be a time when he just no longer needed the direct intervention. The last day of seeing a child for therapy is always a l...

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...