Sunday, January 29, 2012

'Non Traditional Fieldwork' runs face first into proposed New York State regulations

My sensitivity for the challenges of being an Academic Fieldwork Coordinator runs quite deep; I held that position at a college for three years and experienced the difficulty with finding student placements. There never seems to be enough fieldwork placements, there are challenges with finding places that will provide a quality experience for the student, and although there have been efforts to incentivize practitioners to take students that does not overcome the practical obstacles.

The repeating theme that the occupational therapy profession is not yet grasping is that there has to be some kind of understanding that services provided by students are not the same as services that are provided by licensed professionals. This has been a recurring theme for Medicare reimbursement of services provided by students. Fieldwork educators are very familiar with AOTA's efforts to establish clarity in these rules.

There is a parallel pushback against allowing student provided services to be reimbursed in the Medicaid system. In NY State there are restrictive rules about OT students providing Medicaid services to children. This has a large impact on practitioners willingness to accept students.

Large systems like Medicare and Medicaid are obviously motivated by creating high standards that promote public trust. If public dollars are going to pay for skilled services - then the services need to be skilled. This is understandable.

Now we are seeing new legislative perspective on this issue. While NY State tightens up regulation of OTA practice this has opened up the issue of student supervision as well. Current proposed regulations are getting much more restrictive for students - and now it is being proposed that OTA students can only be supervised by OTs and not OTAs. Furthermore, the degree of supervision that is being proposed in NY for a person who has a limited permit is more restrictive than what is generally being practiced for OT students - and there is no logic in the position that any student requires LESS supervision than someone with a limited permit. This means that if the current proposals for supervision of people who have limited permits is applied downward to students - there are going to be huge problems with models of 'non-traditional' fieldwork education. Also, removing OTAs from the equation and not allowing them to supervise OTA students will place a tremendous pressure on OTA fieldwork opportunities.

The pickle that NY State is in gets even worse - part of the proposed regs allows 'physicians' (which are not statutorily defined) to provide supervision of OTAs. This is a rather large concern because it might remove OTs from the loop and encourage optometrists or foot doctors (much less regular MDs) to hire OTAs in their offices, provide 'supervision,' and begin billing for OT services. Of course most people oppose this, but the State Board of OT comeback is 'you can't be AGAINST physician supervision and be FOR supervision by non-OTs for 'non traditional' fieldwork at the same time.

The concept of 'non traditional fieldwork' is interesting but we have not had enough discussion that relates to whether or not it 'constitutes OT' or is 'just something an OT can do with their education.' These are important legal distinctions. This also raises the issue of whether or not these 'non traditional' sites provide appropriate preparedness for taking the certification examination and practicing OT. Apparently, if we don't tackle this issue ourselves we will see regulatory boards step in like in NY.

My very strong suggestion to AOTA and ACOTE is to PUT ON THE BRAKES when talking about 'non traditional fieldwork.' The notion that "one-to-one supervision, a hallmark of traditional placement models, is replaced by alternative supervision practices such as collaborative learning or distance supervision" (Hanson, 2011) is starting to look like an idea that might have some pretty big legal problems associated with it in some contexts.

The current crisis in NY should be examined and studied CLOSELY by all other states. Opening up a practice act is a can of worms, and now we are seeing some major unintended consequences. There were issues to address in NY but this is an amazing study in why it is important to open up ONE ISSUE AT A TIME - or at least to have enough eyes on the ball when multiple issues are opened that unintended consequences are held to a minimum.

(links in text)

Hanson, D. (2011, Nov.14) Expanding practice borders: The value of nontraditional fieldwork models, OT Practice, pp.6-8.

Thursday, January 26, 2012

Are three hour autism training courses helpful?

I received an email today from an agency that provides three hour training courses on autism required by the NY State Office of Teaching Initiatives (OTI) for all candidates seeking a Special Education Classroom Teaching certificate. The three hour course is popular because it is frequently used by CSEs as a training mechanism for educational staff who are working with children who have an autism spectrum diagnosis.

I think the intent here is good - many professionals and paraprofessionals who work in special education may not have a lot of information about specific conditions and presumably anything that provides some information might be helpful.

Parents who come to my office often verbalize frustration that the aides or classroom staff in schools are not adequately prepared to understand their children's needs. I assume that this dissatisfaction is what drives families to private practitioners in some cases.

I have an interest in certification so I got to wondering what this certificate actually provided or promoted. If it was effective, why do so many parents still talk about how the schools are not properly educated about autism? These seem to be legitimate questions.

I tried to find out more about the autism certificate course and quickly ran into dead ends. I scanned the OTI website and couldn't find any information about outcome assessments of this educational requirement. I looked for information about how the curriculum was developed and that wasn't available either. I called a local colleague who teaches the course and that person was not aware of any outcome or effectiveness studies that have been done. I tried to call OTI but ended up in a circular pattern of button pushing. According to the phone recordings, most OTI staff are dedicated to reviewing applications and not dedicated to answering the phones.

So I am left wondering: is that autism training certificate program effective in any way? If there are studies done on the effectiveness of the requirement where are they? I can rather easily find reams of data on three hour defensive driving courses (interestingly, they are absolutely ineffective) but I can't find any data on effectiveness of three hour autism courses.

I was twittering with another colleague today about the Touch television program that assigns prophetic powers to a child who may have autism. My concern is that the many hours that this show will be aired will fill people's heads with all kinds of ideas regarding the abilities of people who have autism. I know - it is just fiction - but not all minds are discerning. Will the three hour course overcome the powerful and entertaining but incorrect messages contained in a slickly produced television drama?

Or will this television show have a deeper influence on the development and perpetuity of an unhelpful cultural archetype that reinforces the 'autism as special power' myth. In recent years we have had 'Rain Man' and the 'Curious Incident' book and 'The Boy who Could Fly' and many others.

Does the myth matter? I am not sure. It would be nice to know if these three hour training courses met any real need though, or if we need to do something better.

Wednesday, January 18, 2012

Understanding upcoming changes to early intervention and preschool services, Part 1

Early intervention and preschool services to children who have disabilities will be scrutinized heavily in the upcoming year and many reforms are being discussed. This summary is a general outline of some of the salient drivers that are impacting reform efforts in New York State.

I strongly recommend starting your reading with the Reforming Mandates, Reducing Costs report that was written by the New York State Association of Counties. This report was submitted to the Medicaid Redesign Team last year to provide input about the unsustainable increasing costs of these programs.

Mandated Medicaid costs are crippling County budgets, and have been for many years. Most recently the State entered into a settlement agreement with the Federal Government often referred to as the State Plan Amendment. This settlement is the contract between New York State and Federal government whereby the State agrees to administer the Medicaid program in accordance with Federal law and policy. This agreement imposed backdated requirements that made it virtually impossible for Counties to receive payments for services that should have been reimbursable as they were compliant with rules in place at the time. This placed a very large strain on this particular component of Medicaid reimbursements to Counties.

Recently enacted property tax caps complicate the situation. You don't need to be an accountant or the County Comptroller to understand that rising costs, lack of reimbursements, and constricted income all spell a recipe for disaster. In short, Counties are being crippled by these programs.

County budgeting staff are at their wits end, and that is why you see proposals from Counties like removing them from the fiscal, contractual and programmatic responsibilities of the program, limiting eligibility to individuals that have greater delays in development, requiring some family financial participation based on income, increasing the County role in developing and writing Individual Education Plans, centralizing organization to the County as opposed to the district level, requiring parent participation for non-working parents, and eliminating contracting/fee for service arrangements because of the inherent conflict of interest with the current system. All of these and more recommendations were made to the Medicaid Redesign Team.

Some of these recommendations are more reasonable than others, but the point in reading this report is that it will help people understand the desperation of Counties.

Providers and parents may not understand these dynamics as well as they need too - I frequently hear calls to contact the NYS Department of Health, or to lobby the school districts, or to make noise in general to their legislators about how these services can not be touched. All of these call to action are potentially misguided. The ability to understand the problem starts at the level of the Counties and their Medicaid budgets and an analysis of the unsustainable growth of these programs and the inability to meet these costs within the current and expected fiscal environments.

You will not help this situation by yelling at your CPSE Chairperson. You have to start with your County legislators and understanding the broad dilemma that they are in.

Readers here are being informed that Governor Cuomo HEARS the Counties and UNDERSTANDS the dilemma. He released his Executive Budget yesterday that calls for some dramatic reform to how these systems are administrated. This WILL have a large impact on service eligibility and service provision - it WILL NOT just be a switch to billing a new entity.

Future posts here will cover the inability to NY State to effectively administrate EI billing, inability to recoup revenues, and inability to effective coordinate via the well-intentioned but very broken NYEIS system, the Counties' calls to the Governor to act on these problems, the rock and hard place of Counties with respect to the property tax cap, and what the Governor's proposals will mean for actual service provision.

This will also include a deep exploration of our own social and cultural values. The large question to answer is 'What is society's responsibilities for these programs.' It will be an interesting ride for the next couple of years as all this plays out.

Stay tuned for ongoing analysis.

Tuesday, January 03, 2012

Tear down the wall: Broken models of mental health service delivery

I have a longstanding interest in Systems and their impact on our ability to care for people. In 2005 (I can't believe I have been blogging that long) I wrote a blog entry about foster care policy and its impact on occupational therapy.

I try not to get outraged on a daily basis because it makes it a little challenging to maintain focus. If you think about foster care too much though it is hard not to get a little upset.

These Systems are populated by well intentioned and kind people who have to do yeoman's work to make the System run. The problem is not with the well intentioned and kind people who work within these Systems - the problem is with the System creators who have set up a structure that in my opinion fails to meet the needs of the people being served.

That's not so good.

Mental health care Systems are notoriously poorly designed; we have systemic problems like homelessness and poor care coordination and uneven access to care. The Systems are so poor that the American Academy of Pediatrics recommended a model of school-based mental health service delivery. I like the concept, but I am noticing more and more that school systems are ill-equipped to handle mental health needs of children.

The primary point of difficulty that schools have with this kind of service delivery is in the MODEL that is used for defining problems. As an example, an Intake History that I read recently started off describing all of the problem behaviors of a child including lying, cheating, stealing, profanity, attention difficulties, poor ADL compliance, and aggression. Somewhere in the middle of the second page of the Intake was a section with diagnostic information, and it was left blank because the information was not available at the time the Intake was completed. Digging through the educational file, I eventually learned the following:

1. Diagnosis of Dysthymic Disorder, early onset
2. Parental abandonment
3. Possible sexual abuse
4. Multiple foster home placements

This child's story is sordid and would bring most people to tears.

I am stuck because I am trying to understand how we have created a System where the well intentioned people have no MODEL for understanding the nature of the problem. They are just educators, or perhaps people with a B.S. in psychology or a generic human services degree - and they start off with defining the problem as lying, cheating, stealing, etc. etc.

How does that happen?

The System is populated with clinical social workers and an occasional consulting psychiatrist and even an occasional occupational therapist - but the NON-CLINICAL MODEL that is perpetuated causes people to start identifying the problem as the presenting behavior, or by how the child is functioning in the context of the school. Somewhere along the line we have forgotten that this is a child whose parents have abandoned her who has been to multiple foster home placements and repeatedly raped.

If these facts are true, how horrible is it that we have created a System that places the PROBLEM on the middle of the second page (where it was unceremoniously left blank) and only ambitious people who dig through old records are able to find a psychiatric report that lists the REAL PROBLEM??!

To make matters worse we then relegate the care of these abused children to people who do not have enough input and guidance from mental health clinicians. I really don't know where all the mental health clinicians are. I can speak for my field of occupational therapy - only 2% of OT practitioners even work in mental health settings. Occupational therapy has abandoned mental health and moved on to other pastures. Only now is our professional association starting to make some much needed moves to re-insert the profession back into the mental health care Systems.

I suspect that this issue of abandonment of mental health is not unique to OT. Every professional who still has involvement in these Systems has a unique opportunity to educate the Systems on the value of using a more clinical model for the purpose of FRAMING PROBLEMS.

Eventually these Systems need to be absolutely torn down and replaced. They are broken and we need to stop pouring money and misplaced effort on propping up failure.

Unless we are intent on continuing to fail.