Monday, January 28, 2013

Good job Wisconsin OTs!


This letter from Teri Black WOTA President is worth re-publishing.  Diligence for these kinds of threats is imperative.  I doubt this is the last time we will see something like this - and it serves as a demonstration of the potential weaknesses.  Too many states lack the resources to meet this kind of issue head on and practitioners need to be more engaged.

Good job on this one, Wisconsin!

ACTION ALERT RESOLUTION!  It Worked!!
From Teri Black WOTA President

Thank you to those who wrote to your local school board members.  The resolution by the Wisconsin Association of School Boards to create a new level of personnel in the therapies to deal with the shortage of Speech, OT and PT in schools was voted down at their annual convention.   
The three Presidents of OT, PT and SLP Associations met with the school board association lobbyist and let him know our issues with the resolution. He agreed to ask the WASB to take OT and PT out because we had the assistant level and they were not aware of that when the resolution was written. We decided to do the action alert because they were still going to vote on the resolution and we were hoping to educate School board members about our professions. The shortages of therapies is more pronounced in Speech.
I received advice from AOTA and NBCOT and really want people to know that dealing with issues like this is where the value of your professional associations shows.  Would you have known that this was happening if we hadn’t sent out the action alert?  I know many took action on this and that makes a great partnership, just like AOTA and many practitioners writing to legislators kept the Medicare Therapy cap from being put into place once again.  You are seeing this because you are a member please ask your colleagues who are not members to join WOTA to allow us to continue our work.

The WASB Policy & Resolutions Committee met Tuesday evening and agreed to amend the proposed resolution 14-13 as follows:
Resolution 13-14: Shortage of Speech and Language Pathologists and Other Special Education Service Providers
Create 4.61(a) as follows:
To address shortages of DPI-licensed providers of certain special education services (such as speech and language pathology services, occupational therapy, physical therapy, etc.), the WASB supports recommends creation of a DPI license pathway for persons who hold a bachelor’s degree in communicative disorders or an equivalent content area and have received satisfactorily completed specified additional coursework and training that would lead to a mid-level licensure that would enable the holder of such a mid-level license to provide such specialized specific enumerated services under the supervision of a master’s degree-holding speech and language pathology licensee in the area of such specialized service.

The finished product read as follows:

Create 4.61(a) as follows:
To address shortages of DPI-licensed providers of speech and language pathology services, the WASB recommends creation of a DPI license pathway for persons who hold a bachelor’s degree in communicative disorders or an equivalent content area and have satisfactorily completed specified coursework and additional training that would enable the holder of such a mid-level license to provide specific enumerated services under the supervision of a master’s degree-holding speech and language pathology licensee.

In recommending the above changes the committee tried to incorporate as many of the concerns expressed as to ambiguity or vagueness in the prior language, while still trying to give effect to intention of the boards who brought the shortage issue to WASB's attention that there be a debate by the membership regarding their concerns about the shortage.

When the amended resolution (in the form shown above) was brought before the WASB Delegate Assembly it was turned down following about 20-25 minutes of debate and several unsuccessful attempts to amend it.

Since that time, WASB has heard from a number of school board members (e.g., from Tomah, Lodi, etc.) who are interested in sitting down to discuss their particular SLP shortage situations if WSHA is interested.

Friday, January 18, 2013

Destruction and deconstruction of occupational therapy documentation


In the novel 1984, Winston Smith had the responsibility to take old documentation that no longer was determined to reflect current reality and then dispose of that documentation down a 'memory hole.' 

I don't know how often most occupational therapists think about the things they write.  I think about it a lot.  In part I spend a lot of time thinking about it because I have this pragmatic issue with where I have to store all of my patient files.  When I worked for other institutions I never worried about the long term storage of my documentation.  I would write things, and eventually they would end up in files somewhere, and maybe those files were microfilmed and stored - I really have no idea.

Now I have the responsibility for keeping my own files and since there is a pragmatic space concern to it all I also have the understanding that I can't keep those files forever.  That gives me the power of purging, which I actually explored a little bit here.  The issue flared up again today because I took an unusually occurring spare hour and  found a whole pile of charts that were eligible for destruction.

The process is painful to me, and that is interesting, so I have been thinking about it.  I am so fond of some of those kids - now represented by nothing more than initial evaluations and a series of notes culminating in a discharge summary.  But it is not just the notes.  It is the memory of the joy of play, the hard work and accomplishment that pushed the children's development forward, the thanks from the parents - from spoken words of kindness in a card to little treats at Christmas.  I still have some of their pictures, all organized in a collage.  What does the memory of this work mean?  Does the memory disappear once the charts go down the memory hole?  If the memories are still somewhere, are those efforts and those lives all still a part of me?  Are they even correct - and if they are not - what does that mean?  Would Langston Hughes be upset if I said, "These are my pages, for OT?"

I have to purge Jackie's chart.  I have to destruct it but I am getting hung up on deconstructing it.  Deconstruction of meaning is so complicated and so full of possibility for being incorrect.  Don't we mean for our evaluations and notes to all be correct?  What I think, though, is that in the "chart" the constructed representation of what 'happened' it is usually entirely incorrect.  In the deconstruction that follows years later when you think about it and prepare to throw it all down the memory hole this becomes evident - because this unknown and new representation of Jackie is not just the Jackie-of-the-notes.  I know this now because I was at a restaurant the other day and I saw her whole family at another table - at first it was only the mother that I recognized but then I squinted and tilted my head and noticed that the mother was with Jackie-not-of-the-notes!  This new representation of Jackie wears a college hoodie and is a beautiful young woman - and I would have found out more but I had no intention of intruding on their privacy.  I hope she goes to that college.  I really hope that she goes to that college.

Each day ticks away a new possibility to purge, and each purge is a brute application of the reality that Derrida says there is nothing outside the text.  It is a concept that in all honesty makes me question the validity of note writing so deeply that I am simply thankful that the memory hole exists. Text (or rather con-text) changes so radically that it makes those charts so presently incorrect.

I guess that makes every day a good day, mostly because this allows Jackie-not-of-the-notes and all of my other kids to be unfettered from that text.  More unfettered.  I hope.

Monday, January 14, 2013

New regulations promote risk of FERPA violations

I mentioned a while ago that I was going to write about FERPA violations that I see on a regular basis.  There are new regulations in New York that promote electronic record keeping by educational programs, so now seems like a good time to document some of my experiences in the last couple years related to FERPA violations.

As background I will report that I am a strong proponent of technology and I believe that technology applications provide us with excellent opportunities to improve efficiencies in service delivery.  I am not a Luddite.  Or anything even remotely similar.  However, parents should take note that educational records are not as secure as they should be.  Here is a new ruling that should make parents  be even more concerned with privacy of their educational records:

SECTIONS 200.2 and 200.4

Teacher Access to Students’ Individualized Education Programs (IEPs)

Consistent with Chapter 279 of the Laws of 2012:
Section 200.2(b)(11)(i) provides that, in lieu of providing a paper or electronic copy of the IEP, school district policy may provide that the student’s teachers, related service providers and other service providers have access to a copy of a student’s IEP electronically; and that if the policy provides that the IEP is to be accessed electronically, the policy must ensure that the individuals responsible for the implementation of the IEP are notified and trained on how to access the IEP electronically.
200.2(b)(11)(i) each regular education teacher, special education teacher, related service provider and/or other service provider, as defined in clause (a) of this subparagraph, who is responsible for the implementation of a student’s individualized education program (IEP) is provided a paper or electronic copy of such student’s IEP, including amendments to the IEP, made pursuant to section 200.4(g) of this Part, prior to the implementation of such program or shall be able to access such student’s IEP electronically.  If the policy provides that students’ IEPs are to be accessed electronically, then such policy shall also ensure that the individuals responsible for the implementation of a student's IEP shall be notified and trained on how to access such IEPs electronically

 In simple terms, there will probably be even fewer paper copies of IEPs floating around - and greater reliance on using the electronic record.  For the vast majority of cases in NY, that means that the www.iepdirect.com website will be relied upon even more for communication and documentation of educational records.

For purposes of educating the public, I will outline common ways that school districts and their agents commonly violate FERPA law.  These are not exaggerated in any way and I do not list them to stir any local pot.  This is just fact and is my direct experience.

1. Some school districts do not have controlled procedures for 'assigning' children to providers within the IEP Direct system.  That means that when I log onto the IEP Direct system that I have FULL access to EVERY child who receives special education services in the entire district.  It is standard practice to restrict viewing only to those children that a provider has responsibility for.  In one district I not only have access to every preschool child (I am a preschool provider) but I also have access to every school age child!  I have brought this issue to the district's attention for as many years as they have had the IEP Direct system in place, and they don't fix it.

What does full access mean?  Well, I can view a child's IEP, every evaluation that was completed on a child - including the social history that sometimes includes information that is particularly sensitive.  That information is helpful if I am your child's service provider - but it is not information that should be freely available to anyone who happens to have access to the system.

2. During a recent Department of Health Early Intervention audit we experienced a FERPA violation on the part of IPRO, the auditing agency (rather ironic, as their purpose is to make sure that PROVIDERS don't engage in such errors).  In preparation for their audit IPRO sent my agency a list of children who we had never seen through the early intervention program.  We recognized some names because we knew the children through the CPSE special education system.  However, we were not aware (prior to the release of information) that they were previously in the Early Intervention Program - apparently some of the children were seen by another agency - or they were just working off of a preschool database and not an early intervention database.  Who knows - but when we brought this to their attention IPRO informed us that they made a 'database error' and sent a revised list of children.  We were also informed of 'staffing changes' and that a different person would be completing our audit - I am not sure if this was related to the FERPA violation.

3. A billing manager for a rather large school district routinely sends out distribution list requests to service providers.  In response, it is common for a provider to respond with specific student data and send out their information to every agency on the distribution list - and then the district would re-re-disclose the same confidential information by forwarding it all to everyone on the list as an exemplar of how to handle the concern that the original district had!  I don't think that many parents would like it if they knew that their child's data was disclosed as part of an exemplar.

4. An agency who provides coordination services works with multiple providers would routinely violate FERPA with emails listing meeting dates for children - and the lists would include multiple children who were all being seen by different agencies.  That means that although I had interest in one child on that list - I certainly was not supposed to be privy to the data of the other 30 children!

5. The last example I want to talk about also relates to our last IPRO audit.  We were found to have a deficiency on our release of information form because we did not have a space on the form that listed WHY information was being transmitted.  I told the reviewer that I did not want to include this information because in my opinion it was not my business to know why a parent would want information transmitted.  Interestingly, the auditor looked at it a totally different way - they indicated that this information needs to be on the form because parents have a right to know MY purposes when I am asking THEM for permission to send their data to other places.  This was a real juxtaposition - the auditor's automatic assumption was that I was the origination for releasing information and I had a responsibility to tell families why I was sending their information out.   In fact, I would NEVER ask a family to send information somewhere - I would only send it where THEY told me to send it!  And it is none of my business to know why they want me to send it somewhere!!!  This is a real illustration of a fundamental problem with the way this process is viewed.  For the record, I complained to the State about this requirement but I have not heard back from them about this  yet.

Parents should know that when they receive services in early intervention and school systems that there is great risk to the privacy of those records.  New regulations that promote use of electronic communication technology are likely to increase the risk of FERPA violation.

Is this a big deal?  YES!  It does not matter if the data released 'only' indicates that a child is receiving occupational therapy.  Your child's educational records are supposed to be private and you should have the expectation that information is not released.

In my opinion these types of FERPA violations don't occur out of malice but they do occur out of carelessness, out of a disregard for the sensitive nature of the information, and out of a warped sense of who should be initiating the release of information.  The frequency and magnitude of these violations is significant.  Parents should demand more accountability from their districts and providers when it comes to privacy of educational records.

Tuesday, January 08, 2013

Public systems continue march toward paraprofessional service delivery models

The subtitle to this should be:
A Wisconsin case study of how the system REALLY feels about the value of therapist training, licensing, and certification.

I am going to pick on Wisconsin today, but this is a problem that people need to be aware of because it stretches beyond the borders of that state.

What does a municipality do when there are rules to follow and they can't meet the mandates of the rules?

Make up their own new rules, of course!

Wisconsin bureaucrats demonstrate their true Machiavellian nature when they allow otherwise unqualified teachers in the classroom in the presence of personnel shortages.  They are not alone; there are several other states that have such 'emergency' routes to teacher certification - although now they have been largely replaced by programs called 'alternative' teacher certification.  When we use words like 'alternative' instead of 'emergency' then the spotlight is taken off of the bureaucrats who failed to plan and implement a system that meets needs over time.  Yes, it really is 1984.

Here is a graph of the number of people seeking alternative teacher certification routes since the 1980s.  

Source: National Center for Alternative Certification, http://www.teach-now.org/intro.cfm
Now I know there are tons of studies out there that talk about how effective these alternatively qualified teachers are but there is also face validity to the concern that our educational system has some problems.  We are told constantly that there is a crisis in American education.

Correlation does not imply causation, but it seems reasonable that we consider and continue to research the role of these alternative certifications that allow otherwise unqualified people to deliver public education.

Why does this matter?  Well Wisconsin is about to throw certification of people who deliver educational services under the bus.  Again.

Personnel shortages of therapy practitioners is not a new issue in America's Dairyland.  This 1997 document from the Wisconsin Department of Public Instruction talks about the historic difficulties of therapy staffing and more recently in this Regional Services Network document pulled from the CESA 3 website there is ongoing discussion about speech language pathologist shortages and issues related to use of paraprofessionals to deliver services.  This is a quick search of public documents about this issue but superficially appears that it is not new in Wisconsin.

What concerns me today is that I was forwarded this document pulled off of the CESA 9 website that is a report on 2013 resolutions from the Wisconsin Association of School Boards.  Here is what the document states as a resolution:

Resolution 13-14: Shortage of Speech Language Pathologists and Other Special Education Service Providers  Create 4.61(a) as follows:
To address shortages of licensed providers of certain special education services (such as speech and language pathology, occupational therapy, physical therapy, etc.), the WASB supports creation of a license pathway for persons who hold a bachelor’s degree and have received specified additional training that would lead to a mid-level licensure that would enable the holder of such a mid-level license to provide such specialized services under the supervision of a licensee in the area of such specialized service.

Rationale:
The committee advanced this resolution to allow the membership to decide whether to endorse the creation of a license pathway for persons who hold a bachelor’s degree and have received specified additional training in the provision of certain special education services (such as speech and language pathology, occupational therapy, physical therapy, etc.) as a means to address current shortages of licensed providers of such special education services. Persons licensed to  provide such specialized services under this new licensure pathway would practice under the supervision of a licensee in the area of such specialized service. 

This resolution is an extraordinarily short sighted recommendation to solve a staffing problem that has existed for a very long time that has apparently not been able to  be solved in the Badger State.

When you can't fix a problem, just make up a new set of rules.

Therapists in Wisconsin should be very concerned about this kind of recommendation because it represents a total lack of understanding and appreciation for the value of the professional's respective certifications.  How is the public supposed to feel protected by licensing and regulatory control when there are forces in the State that are willing to toss the value of that licensing away just so they can meet their staffing mandates???

Well, if we look at the teacher certification as a leading example then we really should not be surprised at all.  The ends justify the means, and when they can't solve a problem they just make up new rules. 

I documented some possible movement toward use of paraprofessionals for early intervention systems in NY State last year.   States all around the country are moving toward these models.  We see it in education with manipulation of routes toward teacher certification.  We see it in all kinds of human service delivery systems.  The systems are not adequately funded, they are not well organized for efficiently delivering services, and ultimately the professionals in those systems are replaced by generically trained human service personnel.

And we all scratch our heads and wonder why our public care and public education systems are inferior?

Monday, January 07, 2013

Social justice follow up: Brass tacks for the occupational therapy profession

This post is a follow up to the 2011 Social Justice Debates in Occupational Therapy and also in general response to the ongoing conversation on this topic that can be found on the OT Connections public forums.

Here are some Monday brass tacks that I hope will generate some thought and conversation.  These are not the same brass tacks that address the concern about what to do with the social or occupational justice heathens who have made public proclamations on forums and on websites; these are brass tacks that hopefully start a conversation on how the social justice provisions have actually been operationalized in the occupational therapy profession.  There is a lot to talk about from different perspectives, to be sure.

In context of this old and lengthy conversation, and as reported by the original author of the motion, one of the significant concerns with this motion was that it was de facto law in several states due to its inclusion in several practice acts by reference.

A couple years have gone by, so isn't it a good opportunity to see how this has 'mattered??'  As has been discussed, there are academic concerns regarding definitions and morality of 'social justice' and then there is the street-level concern about how this all impacts practice.  Over the past week I have made a soft attempt at determining how it has impacted practice.

Taking a look at AOTA public notification of enforcement re: ethical violations, there are no current listings of violations of Principle 4 (social justice principles) since the 2010 document has been in effect.  However, it is noted that many recent determinations were still using the 2005 standards so it still may be too early to determine how Principle 4 is being considered.

That led me to start a of state-by-state analysis for those disciplinary cases that cite social justice provisions in the AOTA code of ethics. 

I struck out.

So what does that mean?  Well, first of all my search-fu may just be weak, and in order to conduct a proper analysis I would have to FOIL all the documents from states to see how/if the standards were applied, but that is just a hot mess of a struggle that would probably require funding in order to complete.

I contacted AOTA to see if they (as a non-public entity but still operating with an apparent quasi-regulatory function) would release documentation of their ethics case decisions and was told that the only information released would be whatever is posted in the publications (and presumably on the website as well).  That means that they don't release information.

Based on these preliminary efforts these are my conclusions on whether or not any of this 'matters' from the brass tacks perspective of ethics enforcement:

1. It still might be too early to tell, but so far there is no evidence that social justice ethics provisions are being cited in occupational therapy disciplinary cases.  Or the evidence may be hard to find.  Who knows.  The fact that I am typing 'who knows' is itself a concern.

2. AOTA decisions that MIGHT include reference to these provisions are secret, except to the degree that you can go back and look at 'Findings of Fact' that have been published by a State regulatory body.  Not exactly easy to do.  Secret is a problem in that these provisions have become de facto state law for many people.

3. There may be some legal basis for a complaint against a State for adopting ethics statements that practitioners are held up to when in fact there is no evidence that the State itself (via its Board) or any people being held to those standards had any input into the development of or commentary on those ethics statements.  In English, someone who is not an AOTA member is being held to the standards of an AOTA member when they could have explicitly opted out of the AOTA standard because they disagreed with the AOTA ethics statements.  Or they could have been kicked out.  That is quite a conundrum!

4. There are several points of internal consistency that need to be explored relating to social justice aspirational provisions in the ethics statements (Principle 4) and provisions relating to fidelity toward colleagues (Principle 7).  The OT Connections forum threads alone, over time, have really magnified the potential threat to Principle 7 that has occurred by codifying Principle 4.

5. The larger question emerges on the 'fairness' (I can't believe I am using that word) of non-transparency of  quasi-regulatory non-public bodies.   Here it is important to make discernment between codes of conduct which are rather specific and legally based (heh, mostly) and the more broad and sweeping principles in a code of ethics.  This is yet another debate.


6. There is a technical and practical issue of whether or not a person concerned about these issues has 'standing' unless they have been subject to a disciplinary action.  So looking at this from a pragmatic point of ethics decision analysis might be somewhat moot, at least until a regulatory or quasi-regulatory body has applied their boot to your posterior.

Debate on ethics provisions seems far from closed - there are so many issues to explore.

Christopher J. Alterio, Dr.OT, OTR

(also published on my blog for purposes of controlling perpetuity)

Thursday, January 03, 2013

The meaning of a barrel

I would like to introduce you to my barrel.

It is 20 years old.  

One of its principal identifying characteristics is its blue color.  Although I haven't done the math to determine whether or not it is of optimal dimension (a la Keppler) I have always considered that it is the precisely correct size  for many purposes.  Toddlers can stand it it quite well and not be overwhelmed by its height, and although that is no confirmation by differential calculus it is a pragmatic measure that I have always appreciated. 

So what is the meaning of a barrel?  To Keppler it was an obsession based on not wanting to be ripped off by a wine merchant and it ended up feeding his thought process that led to our understanding of planetary motion.  That intrigues and amuses me more than I can probably express.

For me the meaning of my barrel is both personally and socially derived, just as described by Hasselkus (2002, p.3).  I purchased the barrel when I was working at another facility as a very young therapist.  Some months after I left that facility I received a phone call from the Director who offered to sell me a lot of the equipment because the clinic was closing.  For a modest donation I was able to purchase the barrel along with a lot of my other equipment that is still in my clinic.

 My earliest recollection of using the barrel in therapy was with Brittany, a toddler who had hemiplegic cerebral palsy.  She would stand inside the form and support herself by holding onto the lip of the barrel while practicing stoop and recover missions to rescue small plastic animals that were 'dropped' nearby her feet.  This was endless amusement for her and something that she never really tired of.  That barrel is responsible for helping her develop the requisite strength in her lower extremities that she needed for mobility.  That barrel is responsible for helping her develop skill in using her hemiplegic arm.  That barrel is responsible for helping her understand how to maneuver her body through space.

I was thinking about this because yesterday I was playing with another child in that same barrel - another toddler - but this one had Erb's palsy.  The goals remained the same though - improving lower extremity strength, improving control of an extremity, improving confidence and understanding of how to plan movements through space.  I guess I do a lot of the same things that I did 20 years ago.  At least the stuff that works.

So in between these years many other children have also used that barrel.   Zachary rolled on it.  Aaron threw Beanie Babies into it.  Heather straddled it.  Nicholas crawled through it.  On and on.

What strikes me most though is that Brittany is technically old enough to be a mom, and maybe she is bending at her knees and maintaining her balance and using her hemiplegic upper extremity to pick up her own child.  If that is true, then that means that the barrel has really accomplished something.

That is not a bad thought to help push you through a day.


References:

Hasselkus, B.R. (2002). The meaning of everyday occupation.  Thorofare: Slack, Inc.