Thursday, February 16, 2012

In NYS a single OT can still supervise a million OTAs, for a while at least.

According to the NYS OT Board, supervision guidance for OTAs in NYS has been placed on hold, at least until the next Board Meeting.

Of course the State Board wouldn't state why there are is no new supervision guidance - just that the previous regulations on supervision remain in effect. This is probably welcome news to many school districts who use models where a single OTR supervises many COTAs across a wide geographic area.

It is my best guess that school districts would have found themselves in the very unfortunate position of being out of compliance with the new regs, which would have impacted their ability to receive Medicaid reimbursement, which would have likely cost hundreds of thousands of dollars if not more in lost revenue.

So you see they HAD to pass these emergency regulations and bypass public comment, but I will do the State Board a favor and help them rewrite their justification (I also fixed their date errors from the letter to the Regents):

Emergency action is necessary for the preservation of the public health and general welfare to immediately conform the Commissioner's regulations to chapter 460 of the Laws of 2011, and thereby ensure that such regulations are in effect on February 14, 2012, the effective date of such law, to implement the new practice and supervision provisions consistent with statutory requirements, EXCEPT FOR WHERE IT MESSES UP OUR ABILITY TO GET MEDICAID REIMBURSEMENT, IN WHICH CASE NOTHING IS A GREATER EMERGENCY THAN OUR ABILITY TO RECEIVE THOSE FUNDS. (italics mine)

Chalk this one up to yet another entry into the category of "Ooops, we didn't stop to think about that."

Expect some changes or clarification to the supervision requirements once the school year ends and once districts have a reasonable opportunity to change their staffing patterns - or once someone instead effectively lobbies the State that the previously recommended 5:1 ratio is not a good idea if it impacts the government's ability to collect Medicaid payments from the Feds. It will be interesting to see if the previously recommended supervision ratio stands now that someone obviously noticed that there are rather large fiscal implications and it will cost more money to implement the new 5:1 model.

Meanwhile, many parents around the state will bemoan the fact this Spring that their children are rarely if ever really seen by an OTR.

The sanitized reporting of the NYSOTA website states: "Regulations regarding supervision of occupational therapy assistants and occupational therapists with limited permits have been placed on hold when last minute concerns were raised regarding the impact the regulations may have on school-based practice. The state board anticipates resolving those concerns and promulgating additional supervision regulations in March or April."

Really, what is wrong with just reporting on the issues so people can understand how this legislative sausage is actually made?

People will be better served having full information about how and why these decisions are made. For the record, I will eat my UDO forms if this didn't have anything to do with Medicaid reimbursement. :D

Updates will be posted as needed.

Tuesday, February 14, 2012

Update on OT Practice Act and new regulations re: COTAs and supervision

Feb.6 letter from Doug Lentivech to the Professional Practice Committee of the NYS Board of Regents re: emergency regulations relating to OT Assistants, OT Students, and Limited Permittees.

Here is the revised language of the regulation that allegedly will not be available to the public until after it is published in the New York State Administrative Register.

This information was sent all over NY State today and was released by an Albany law firm who I assume must represent someone in the know.

I can't state definitively that these are the final versions, but the state or national associations aren't releasing anything and this came from a reputable source so I am going on the assumption that these will be the final regulations.

I encourage OT practitioners to contact the NYS Board for OT if they have questions about these (proposed??/accepted??) regulations. They presumably will be retroactive to today so OTs around the state will want to be aware of new requirements with as much advance notice as possible.

Of particular note is that the State Board for OT values public protection so little that they are removing a provision that stops people with limited permits from practicing when they have failed their certification examination.

The maximum number of COTAs that an OTR can now supervise is 5 FTE. If they are employed less than full time the total number of COTAs can not exceed 10. That means that some employers will need to hire more OTRs because there are many places around the state who are employing COTAs in excess of the current OTR to COTA ratio.

There are new requirements for supervision in general as well as documenting the supervision of COTAs, OT students, and limited permittees that will have a major impact on OTR time.

Finally, there was some deft tap dancing around the statutory language that required COTA students to be supervised by OTRs. The regulations as written seem to allow for COTA students to be supervised by a COTA fieldwork educator but the requirement for OTR supervision of the whole process remains. That places a new wrinkle in requirements for COTA student placements which previously did not always include direct OTR oversight.

Public participation regarding these regulations has been hijacked because they are being proposed as emergency regulations.

Friday, February 10, 2012

When professional decision making is compromised by policy: A study of preschool outcome measures in NY State

Quality indicators are monitored when public monies are used, such as for Public Law 108-446, the Individuals with Disabilities Education Act (IDEA) 2004. The act mandates that states develop and submit a six year State Performance Plan (SPP) to the government. For each of the quality indicators that states report on there has to be improvement activities and targets. The idea of all this is to drive improved quality within the system

Quality indicator 7 for preschool services requires that a percent of preschool children with IEPs demonstrate improved positive social-emotional skills (including social relationships); acquisition and use of knowledge and skills (including early language/ communication and early literacy); and use of appropriate behaviors to meet their needs. Performance on this indicator is assessed using standardized tests after children have participated in their preschool program.

The SPP requires that exit assessments only need to be conducted for preschool children with disabilities when they stop receiving preschool special education services due to program completion or declassification during the school year in which the school district is required to report exit data on this indicator. Annually, NYS requires a representative sample of one sixth of the school districts in the State to report progress data on this indicator. When a district is not required to report exit assessment data it is common that the district DOES NOT APPROVE requests for exit assessments. Also, terminating availability of declassification services by allowing EVERY child to simply age out of the program also negates the procedural trigger for exit assessment.

The sum total result is that children complete their preschool services and unless the school happens to be mandated for data sampling in that given year there is a really good chance that there will be no exit assessments. When there are no exit assessments that means that the CSE has no hard data to consider - and eligibility for that system is constricted. Also, parents are left in the dark not knowing the actual status of their child's progress as measured by full assessment.

Basic standards of practice would dictate that a therapist would want to have some kind of reasonable assessment data to make determinations about progress made, recommendations for future eligibility, and for feedback to families. Basic standards of practice are compromised by these policies.

School districts blatantly disregard basic standards of practice in favor of ONLY following the bare reporting requirements of the State Performance Plan. In the mail today I received a notice that read as follows:

The above mentioned memo advised you to request full evaluations for students you are considering for declassification. However, because we are not reporting on State Indicator 7 this year, you do not need to request a full evaluation for students you are declassifying.

What happens on the street is that very few children are referred directly to CSE - unless it is VERY obvious that they would have eligibility due to notable diagnosis (cerebral palsy, autism, etc.). In truth, very few children have such severe diagnoses and most kids who receive special education services have 'softer' developmental delays like learning disabilities, attention deficit disorder, or other problems that are often relatively less severe. This causes most children to 'age out' of special education, never receive a full exit assessment (unless the state happens to be looking for data that year!), and they are not again picked up on the elementary school side until they are failing in first or second grade.

I can't comment on the heart of the people who write memos indicating that there shouldn't be exit assessments since the state isn't looking. However, I can state that it is odd to dictate your practice based only on the likelihood of whether or not someone is watching your conduct at any given time.

One would hope for a more universal standard of 'appropriate practice.' In my opinion, any preschool child who has been receiving services should receive periodic reassessments to measure progress, particularly if they are at the terminal point of their preschool participation.

How can we recommend declassification services, and even if they were approved - how can anyone know what still needs to be worked on unless we have good assessment going on?

How did we get to this point? There are groups lobbying for even less oversight of the 'declassification' process for preschoolers. Professionals working in school systems need to understand that pressures for 'reform' are driven primarily by municipalities and counties who don't have the funds to support programs any longer and also by special interest groups representing school business officials who struggle with the challenge of meeting standards with a shrinking resource pool. When you hear the words 'mandate relief' you have to understand that this has absolutely NOTHING to do with what is professionally/educationally appropriate but it has EVERYTHING to do with what districts can afford.

I never thought that outcome assessment could be considered a radical request - apparently it is if the State isn't looking for data that year. But here we are.

Friday, February 03, 2012

Practitioners around NY State begin learning about EI reform proposals

Earlier this week I noticed a large uptick in Google searches regarding early intervention that were landing on this blog so I started wondering what was going on. Turns out that there was a NYS Association of Counties meeting this week and the Department of Health gave a powerpoint presentation about the Governor's proposal. Copies of the powerpoint started to make their way around the State - and that got people doing some Internet searches for more information. Here is a link to the presentation for those who have not been able to see it yet.

The powerpoint doesn't offer information that is materially different than what is already listed in the proposed budget but it is in a more readable format.

The largest issues proposed include:
1. Providers will be approved through the Department of Health and won't have contracts with local municipalities.
2. There must be an arms length relationship between service coordinators, evaluators, and service providers.
3. Providers will be required to establish and maintain contracts or agreements with a sufficient number of insurers, including Medicaid and CHP.
4. Providers will have to use the State's Fiscal Agent to bill third party payors.
5. All of this will be achieved by a mandate on insurance companies requiring them to coordinate through the State Fiscal Agent to pay for EI services.

Details that are still a little unclear include how the rate will be negotiated. Currently, there is no alignment between EI rates paid by municipalities, rates paid by insurance companies, and the Medicaid rates. It is unclear whether or not the rates will change based on the information released so far. The current plan calls for providers to continue providing services whether or not they have been reimbursed - so there will need to be some clarity so providers understand the rule systems they are being asked to operate under for reimbursement.

It is likely that this will drive some providers out of the system and that will likely create delays in service provision. That means that private therapies, at least for families that have those resources, will likely replace the EI system as the de facto methodology for children receiving services. It is another form of indirect cost sharing, and is probably intentional.

Stay tuned for ongoing analysis.