Friday, July 27, 2012

Who has responsibility for your occupational therapist???

Corporate practice and the health care professions in New York State might not be on the top of everyone's interest list but there are some things that professionals and the public need to be aware of. 

In New York State and in many other states for that matter there are restrictions on who can hire professionals to provide services.  These kinds of laws prohibit any random person from starting a corporation and hiring OTs or PTs or any professional and billing for those services.  The reason why those laws exist are because people think that there is potential for abuse/fraud/unethical choices when professionals are not 'owned' and 'supervised' by people within their own professions.

Now of course just because an OT hires and OT or a PT hires a PT that does not guarantee that unethical things won't happen.  Still, there is generic concern so these laws were enacted to prevent abuse.  So, in order for PTs and OTs to both be hired by a corporation there needs to be representation of ownership in the corporate structure.  That means that there has to be an OT 'owner' and PT 'owner.'  Even when one of those 'owners' only has a small or even fractional controlling interest in the company, having their name within the corporate ownership structure means that SOMEONE is responsible for the fact that the corporation is hiring and employing people from that profession. 

Corporations in NY State have long struggled with compliance with these general business laws and have been subject to scrutiny over time by the Office of the Professions.  It was relatively common to see some professional start a corporation that they owned themselves (generally a P.C. designation) and then hire or contract other professionals illegally.  Not for profits also ran afoul of the law because they are not technically owned by a person/professional but rather are managed by and answer to a Board of Directors - and sometimes NONE of those Directors represented the professions that were hired by the agency.  So, there were some problems with the law and how it interacted with the way that many corporations were structured for providing services.

The Office of the Professions, using the State's coercive powers, slapped some wrists and caused some corporations to restructure.  Other corporations just held their breath, dove deep, phoned their State representatives, and prayed for the day that the law might change.  Well that day has come.

The NY State Education Department is now granting waivers (for a hefty fee, of course) for those agencies who are providing multidisciplinary professional services in a currently 'illegal' structure.  The specific waivers I am referring to are not broad and apply specifically to Early Intervention Agencies and Special Education Schools. 

Should anyone care?

Well, supporters of these waivers will tell you that the exigent problem of non-compliant not-for-profit agencies mandated this action.  This is one of those 'IT IS FOR THE CHILDREN' arguments.  If these agencies were not provided with waivers then thousands of children across the state would not have OT or PT or speech therapy services.  I can understand the need to address this to some degree, and I don't really oppose the concept of an otherwise regulated not-for-profit educational entity given some slack, but something much more insidious got slipped into these regulations.

You see, the law now allows ANY early intervention "agency" that is DOH approved to get one of those waivers.  That means that the person who previously had to change their corporate structure does not need to do that.  So the speech therapist can now hire OTs and PTs all the while operating under a previously illegal corporate structure like a for-profit PC. 

I think there is a BIG difference between a waiver being potentially provided for a not-for-profit educational agency and a for-profit solo practitioner.  The not-for-profit is still answering to a full BoD and is probably under a lot of SED scrutiny in general.  The for-profit solo practitioner answers to themselves and an IPRO audit every three years.

These waivers that are now available to the small for-profit solo practitioners or businesspeople to hire professionals outside of their own fields does not protect the public, and in fact flies in the face of longstanding general business corporation law in New York State.

This is a trend in NY State - we are giving up 'control' of our practice to outside forces.  The recently enacted occupational therapy laws allow supervision of COTAs by non-occupational therapy professionals.  Now this new waiver allows occupational therapists to be hired and supervised by non-occupational therapy professionals.  I am using occupational therapy as an example; this problem cuts across many professions.

Corporate ownership of professionals was illegal in New York State for many years.  Until now.

Consumers should begin to ask: Who owns this agency, and who is making sure that the services I am receiving are consistent with standards of the health care professions?  It is a fair question that I hope more consumers will learn to ask.

Wednesday, July 25, 2012

Bidirectional bias as ABA and SI proponents fight in the public square

More for the file 'whose kung fu intervention for autism is strongest.'

Lang, (2012) published a systematic review of sensory integration therapy for autism spectrum disorders that at the same time has academically dishonest and potentially useful information.

The review errs in its rather lopsided inclusion of articles that measure the effects of isolated intervention strategies that would probably best be identified as addressing components of sensory processing as opposed to measuring a sensory integration methodology.  This is nothing new; there have been some good articles in the American Journal of Occupational Therapy recently that have contributed to debunking the use of seat cushions to promote attending behaviors and debunking the use of weighted vests to promote attending behaviors.  These findings are yet to filter into practice because a lot of people really like the idea of quick and easy answers to complex problems.  Finally we are getting to a point with our research where we are showing that solutions don't come that easy.

Anyway, the review tells us what we already know with all these other quick and easy interventions - that they are probably largely ineffective.  That's a good thing and potentially useful.  However, to call these interventions 'sensory integration therapy' is essentially dishonest, especially in consideration of all the conversation about fidelity (Parham, et al 2011) and what constitutes SI.  One could forgive Lang and  colleagues for their mis-characterization but they acknowledge fidelity as a problem

...the immense differences in SIT procedures across studies and the lack of a treatment fidelity measure in the majority of studies prevents direct comparison of the studies with positive and negative findings.

They also make some other admissions, such as "It is possible that the application of some other coding system may have yielded different conclusions" but I don't expect that the insurance company reading this study and looking for a reason to avoid paying for some services will highlight that quote.  This is where their dishonesty is at its peak because as researchers are sometimes wont to do, their overall conclusions overstate the data that they have actually collected.

Now enter AOTA with their expected response in opposition to the Lang review.  Jane Case-Smith and Roseanne Schaaf wrote a response that includes the typical AOTA components of defensiveness and more defensiveness.  The AOTA response questions whether or not biased methods were used in the review.  The answer to that of course is yes, in exactly the same way that the AOTA response is biased in the opposite direction.  The legitimate concern (as noted above) is whether or not consumers (aka insurance companies, etc.) will bother to pick through the bias in a search for truth - but they have their own bias and desires so that is not a hard issue to know what they will do with the information.

The AOTA response fails in exactly the same way their responses to these issues in the past have failed.  I am still waiting to see an honest response regarding the following issues:

1. A large marketplace exists that is fleecing families by selling products that are often being used in a single-solution context.  You can dance all around weighted vests and other similar interventions by saying "these prescriptions are embedded in a multi-faceted treatment plan and not offered in isolation."  That is really not true based on practice that I see from the street level perspective.  If all these studies indicate that these weighted vest or brushing or other interventions are not effective then why continue to parse the issue?  The AOTA response does at least state that "single modality strategies that are provided in isolation do not appear to result in positive effects."  Maybe we should celebrate the small admissions?

2. The sensory integration intervention protocol, at least as described by OT researchers presently, is not realistic in most occupational therapy practice.  In order to have adequate fidelity, researchers have promoted a protocol that can only be validated by a handful of self-appointed experts and the structural elements that are required are not found in the vast majority of family homes, preschools, schools, and other places where pediatric occupational therapy is most typically provided.  Additionally, intensity and frequency of such intervention is not realistic given the reimbursement structure or service delivery model available in many settings.  As I have mentioned previously in this blog, what in the world is the point of an intervention that can't be applied in the real world of MOST practice settings?

3. AOTA routinely defends a single intervention protocol and fails to adequately acknowledge that there are many occupational therapists who use a number of different approaches.  This is a disservice because when the professional association fails to acknowledge the limitations of a single approach, and when it fails to acknowledge that it is only ONE approach among MANY that are legitimately used, that defense promotes the notion that sensory integration interventions are synonymous with occupational therapy interventions.  That misrepresents the practice of many therapists.

And here we come full circle where the special interests are 'duking it out' over whose intervention is best.  Well here I will serve both sides of this nonsense some comeuppance:  street level practitioners are not interested in the politics of this; they want to use interventions that are effective and they want people who are in the halls of academe to put aside their respective bias in the interest of what is actually good for the people who ask us to provide services.  The Lang review and the AOTA response are both reflective of ingrained bias.  It is getting boring when I have to pick up professional journals and it feels like I am reading an editorial page of a newspaper.  Shame on both.


Case Smith, J. & Schaaf, R.(n.d.) Response to Systematic Review of Sensory Integration Therapy for Autism Spectrum Disorders.  Retrieved from

Lang, R., O'Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., . . . Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004–1018.

Parham, L.D., Smith Roley, S., May-Benson, T.A., (2011) Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration Intervention, American Journal of Occupational Therapy, 65, 133-142.

Monday, July 23, 2012

Take care

There was an interesting conversation on the AOTA forums recently about whether or not a COTA should be 'bathing' patients in a nursing home.

Some of the conversation centered around the 'skill set' of the COTA and whether or not the COTA was being used in a nursing assistant type of role.  Then there was discussion about whether or not this was appropriate, and some people thought it might be appropriate as long as it wasn't being billed out as direct occupational therapy (unless there was some therapeutic self care training aspect to the task).

Most of these points were valid - but as is typical in online forum posts there is a real lack of detailed information so it is almost always near impossible to know if any answer provided is really the best answer for what is being 'asked.'

Something else jumped out at me though while I was reading the conversation.  Someone said,

I say not bathe the patients because that is not what they went to school to do with their time, if they are trying to get the patient to participate in the bathing then I say go for it but if it has nothing to do with the patients therapy goals then I say they shouldn't be doing it.

 It is perhaps technically true that they did not go to school so they could bathe patients.  However, it is entirely possible that one of the reasons that they got into school is because they expressed an interest in doing this kind of task.  Caring, in a broad sense, is an attribute that is often considered favorably when someone is applying for admission to a health care profession training program.  Somewhere along the line it seems that the desire to provide care got redefined along strict guidelines of goals and whether or not the patient was 'participating' in the task.  I think that is unfortunate.

That leads us to a rather large philosophical question: Is the care that is provided as occupational therapy different than the kind of care provided by other health care professions?  That is a loaded question and non-English speakers may get lost in my word-play, but of course the issue here is that in that sentence you can see that the word 'care' has accidentally taken on some meanings that perhaps need some attention.

I think the words are important.  I don't want to be care-less with my verbiage.  See, I am still engaging in word-play.

Once I told someone that 'I could care less' about whatever topic it was that we were talking about.  I will never forget the stare-down I got and reprimand that followed because that person knew that actually I cared very deeply.  Since that time I try not to 'not care,' or more accurately, 'claim to not care.'

As therapists we are paid for our care, or perhaps we are paid for the expression of our care.  Perhaps we aren't supposed to care about the pay; we are supposed to be motivated by our own intrinsic expression of compassion.  To care is to emote alongside the Other.

If I pause and think about moments of caring expression in my OT career I think immediately of Cameron and the way that his feet felt cold under my hands as I massaged them.  It was not my job to go around massaging people's feet in the hospital, but at that moment in my care for him it seemed to be the only action that made sense.  Now years after the fact, I have no idea if that session was billed.  Was I unethical?

This could all be quite different than the situation of the COTA in the nursing home.  Maybe some nursing home owner is trying to use COTAs as nursing aides when there is a staffing crunch and they are regularly asked to complete ADLs.  Maybe they are billing it out and hoping it will be paid for since a licensed professional provided the 'care.'  Or maybe it is simply a desire for compassion, and maybe even the nursing home owner pitched in and helped that day when too many staff called in sick - because the needs of the residents on that day superseded the professional role boundaries of the staff.

I guess we have a lot of opportunities every day to think about our care.  Or if we care.  Or how we care.

I suggest that if someone utters the words 'Take care' to you, accept their parting statement as a gift and opportunity to think about whether you are taking care or not.

Tuesday, July 17, 2012

More road paving for paraprofessional EI services in New York State

What motivates a memo from your government?

Today I was sent a memo from OPWDD that addresses the issue of interagency coordination between the Office for People with Developmental Disabilities (OPWDD) and the Early Intervention Program in NY State.  Why are they motivated to better coordinate services between governmental agencies?  Simple answer, if you read the news.

Costs for special education services are soaring in New York, as documented in this NY Times article.  Quasi-privatization comes at some cost, which really can't be denied.  If you want to get depressed go and read some audits from the State Comptroller's office.  If you are less motivated to read these audits then just watch the news and you will see several articles like this every year.  In sum, there are bad eggs out there who are gaming the special education system at taxpayer expense.

The problem with the Times article AND the problem with the resulting memo from OPWDD is that it assumes that privatization is the problem.  The actual problem is that the people we send to Albany (and the people they appoint to sit in the various Departments) don't do a good job in their auditing and regulatory functioning.  Why is it that you can go and search the Comptroller's audits and find example after example after example of companies who have hidden unauthorized costs in their Consolidated Fiscal Reports that the State in turn uses to establish reimbursement?  How many times does the same problem need to happen before there is some actual effectiveness to an audit process???

Of course the very large majority of quasi-private providers to the early intervention and preschool systems are following the letter of the law and struggling to function within the system.  Edicts and demands and requirements are passed down to law abiding providers that stifle service provision and yet do nothing to actually solve the problem of where most fraud and abuse is actually coming from.

So the Government's answer is to eliminate private providers and turn service back to the State - and we all know how efficiently the State runs things.  This is the ultimate hilarity - if the State can't find a way to functionally regulate a quasi-private system then how in the world will they be able to manage the system once they 'own' the whole thing?

Anyway, back to the OPWDD memo... a couple months ago I talked about how the State is reigning in the quasi-private system.  The current memo takes it another step forward and states:

While there are many beneficial services available through the EI program, OPWDD offers other supports through OPWDD’s Home and Community Based Services (HCBS) waiver, which may assist young children who also enrolled in Early Intervention with developmental disabilities and their families, including the following:

Respite: Short-term relief for a child’s primary caregivers provided in the home or other approved site.
Community Habilitation: A flexible, individualized service designed to improve individual skills and increase community integration.
Family Education and Training: Education and training to enhance the knowledge, skills and decision making capacity for caregivers of a child with a developmental disability.
Environmental Modifications: Adaptations to the home that are necessary to increase or maintain a child’s ability to live at home with independence.
Plan of Care Support Services: Providers of PCSS assist an OPWDD eligible child to enroll and maintain eligibility in the HCBS Waiver by reviewing the ISP every six months and performing the annual level of care evaluation.

This dovetails quite neatly with the previous memo that talks about what codes can be used by paraprofessionals, because the majority of 'Family Education and Training' and 'Community Habilitation' services are provided by unlicensed people with generic 2 or 4 year human service degrees.  It makes sense that as the State bumps against cost problems that it would look to existing programs within the structural hierarchy of the State to take control over some functions that were previously relegated to the quasi-private system.

All of this will be reinforced next year when NY State takes over the contractual relationship with providers - this was previously managed locally through Counties.  As the State will be in a better position to control the workforce it will also be in a better position to control the service provision system and to shuffle aspects into theoretically less expensive paraprofessional systems (that they also hope will be Medicaid reimbursable!).

What does it mean for families?  Well if your child 'qualifies' for the OPWDD system then you will have some aspects of care shuffled off in that direction and away from the existing Early Intervention/Department of Health system.  Since the OPWDD 'Community Habilitation' system is not populated with licensed professionals (PT, OT, or speech therapists) it is unclear how those needs will be met.  Families can probably expect to hear a lot more talk about what constitutes 'medical necessity' and what therapies meet Medicaid-reimbursable guidelines.  This will drive program costs down significantly.  This will also drive service quality down significantly.  Families will then be driven out of these State-operated systems and those who have means and resources will seek out services privately.  Those who don't have means will be stuck with what the State is able to provide.  If you think that this sounds eerily familiar to what will happen with the broader Affordable Care Act then you are correct.

Stay tuned as this all continues to unfold.

Friday, July 06, 2012

Things that happen at 2am

It was very early in the morning - so early that it was actually still nighttime.  Of course this is not an appropriate time for any rational person with a daytime schedule to be awake, but I couldn't sleep so it seemed that the most sensible thing to do would be to go food shopping.  Don't ask.

Anyway, as I strolled up and down the aisles I was lost in thought regarding how decisions were made for product placement on shelves and whether or not the items I would be interested in would be at my eye level.  In my dreamy 2am somnambulatory state I felt an unexpected tap on my shoulder that caused me to whirl around suddenly to see who was interested in getting my attention.

"Good evening, sir!" said the unfamiliar face of a 30 something year old young man.  The voice was not familiar either.  Then I squinted and tilted my head just enough to catapult me back to 1992 when I knew Aaron.  Amazingly, the haircut was the same and was the predominant feature that sparked my recognition.  His closely cropped hair pointed out from his forehead in an unmistakable whorl pattern going in three different directions at the same time.  Aaron had to be the only person on the planet with that hair.

In 1992 I was still cutting my teeth and was a newbie occupational therapist; Aaron was one of the first children that I evaluated using the SIPT.  I quite honestly don't remember a lot about his needs other than he had some learning difficulties and a Mom who was interested in doing everything she could to help her child.  I remembered that he was quite a character even as a young child.  He would crack a joke about anything, would always be looking for funny things to laugh at, and in general thought that most of the world and its inhabitants were hilarious.  But more than anything I remember his hair, and as I stared at it all I could think to ask is "Aaron??!!  Oh my goodness - How do you even remember me!???"

"Actually I stalked you," he replied, half seriously.  "I moved up here around six months ago and I kind of meant to come visit and I saw your Facebook page!"

I have had a few people 'find' me via social media who I treated as children.  It is always an interesting mix of "OH YEAH!" recognition and then almost always fun memories of their therapy time.  It is really interesting to me to hear perspectives of people now that they are adults and the things that they remember most.  Some remember the swings.  Some remember a favorite puzzle.  Some remember funny things like a chair in the waiting room.

Aaron didn't want to talk about any of that.  He wanted to talk about now.  "Yeah, my life pretty much sucks right now.  I have this s***** job, my girlfriend just left me, I'm a drug addict, and I am still living in my mother's basement."

What do you say to an adult that unloads that information right after reintroducing themselves?

I think that we lack some long term perspectives on what happens to the children that we see in our occupational therapy practices.  I read a great book right around the time I was seeing Aaron titled "Learning disabilities and psychosocial functioning: A neuropsychological perspective" by Rourke and Fuerst.  It is a great book that still sits on my shelf in my office.  The book has a lot of information in it about the long term prospects for people who have learning and emotional and other difficulties.  At the time I had a sense that the book was probably important and I always tried to remember that their were long term implications for children who have developmental disabilities.  No one in the book had a name though - it was all statistics and probabilities and distributions and potential trajectories.

Twenty years later I was staring into the face of the statistics.  And I didn't know what to say.