Tuesday, November 29, 2016

Guest entry: Taking a stand for patient safety with the Hospital Readmissions Reduction Program

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information in the form of a narrative blog post is provided courtesy of a graduate student who is interested in promoting increased awareness of impacts of the Hospital Readmissions Reduction Program.  Because the author only has fieldwork experience and the facility or patient could be possibly identified, with the student's permission I have conducted my standard 'ABC Therapeutics mash-up' of details and narrative so that the intent of the experience could be expressed while maintaining confidentiality. 

In school occupational therapists learn all about diagnostic conditions.  They also learn about ways that people might have difficulties with their occupations.  Occupational therapists also learn how to assess and treat those people so that their conditions will not limit them in the future.

Occupational therapists also learn that some conditions are acute, that some are chronic, and that some are progressive.  None of that really matters though because the best thing about occupational therapy is that knowledge about disability can be matched to the patient’s need, no matter where they are in this process.

That is how it is supposed to work.

These skills that I learned in occupational therapy school did not prepare me well to respond to the needs of one of my patients on my Level II fieldwork.  I completed my fieldwork at a large hospital and I saw people with common diagnoses including heart and lung diseases, joint replacements, and similar acute conditions.  Unfortunately, I learned that a person's care is not always determined by what I think is most appropriate as a professional.

The pace of work at the hospital was fast and the evaluations were simple, but functional.  One aspect of my experience that I did not expect was my work in the hospital’s emergency department.  When a patient entered the ED, the doctor would write an order for an occupational therapy evaluation. The occupational therapist would ask the patient about their home setup and prior level of function as well as have the patient complete simple ADL tasks and transfers. Throughout the evaluation, the occupational therapist would assess the patient’s cognition and safety awareness as well.  Was the patient able to safely complete essential ADL tasks? If not, the occupational therapist is responsible to document that the patient is functionally unable or unsafe to return home and must document appropriate discharge recommendations.

I learned that in October 2012, Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act, which established the Hospital Readmissions Reduction Program. This program was established with the purpose to reduce hospital readmissions – which is defined as an admission to the same or another subsection hospital within thirty days of an initial hospitalization.

The purpose of the program is to improve quality of care and to  reduce Medicare spending. Under this program, Medicare payments to many hospitals across the United States are deducted three percent to hospitals with ‘excess’ readmissions.  The program specifically looks at the kinds of diagnostic categories that I saw on my Level II Fieldwork, namely heart failure, myocardial infarction, pneumonia, COPD, THA/TKA, and CABG.

During my Level II Fieldwork, I evaluated many people; however, there is one person who literally and figuratively 'stands' out.

Mary came to the emergency department with complaints of severe pain in her hip after a recent hospitalization for a total hip arthroplasty. Mary is an active and healthy 66-year-old woman who had a big personality and even bigger life responsibilities.  She is a caregiver for her disabled spouse, watches her grandchildren during the week, volunteers at the local library, and enjoys socializing with her friends. She had a small physique, but her personality was oversized! She was very friendly!

"I have to be independent," Mary told me during the evaluation.  "My husband had a stroke and he needs me - and what would my babies do if I didn't watch them?"   I loved how she called them her babies, even though she was the grandmother!

During the evaluation, she had difficulty with simple dressing tasks using adaptive equipment.  She was also unable to transfer to or from the toilet. In fact, when asked to demonstrate, she unsteadily stood facing the toilet with her hands on the wall as if she was getting arrested and her legs apart straddling the toilet as if she was aiming at a target.

My immediate thought was, "How is this safe?  And if she is this unsteady, how is she able to do all of these other tasks safely?"

In fact it was not safe. I became very anxious thinking of all the things that could go wrong in this situation. Does the walker fit over her toilet at home? If not, does she rely on the wall for support? Where is the toilet paper located? How does she reach the toilet paper if it’s behind her? How does she keep her pants from falling to her ankles? If her pants fall, how does she reach them without breaking her hip precautions or losing her balance?  How is she caring for her husband or her grandchildren when she could not even safely care for herself?

Because of this, I recommended that she receive skilled services at the hospital and then transfer to another facility (SNF) for additional skilled services to maximize functional return and safety.  I based my recommendation on other patients that I saw who were in in the rehab program.  I thought that perhaps Mary just wasn't ready to be home, especially if she was supposed to be the primary caregiver for other people.

However, the hospital disapproved of my recommendation and this caused a lot of tension between the rehabilitation director and my supervisor.  That is not generally a situation that you feel comfortable creating when you are a Level II student!

The rehabilitation director, my supervisor, and myself all met to discuss the issue. It was apparent that the rehabilitation director was using this meeting as a ‘teaching opportunity’ since I was a student, as she stated, “this is the part of healthcare you don’t learn in college.”

This made me feel discouraged and defeated.

Despite my attempts to defend my recommendations, the hospital discharged Mary with a script for more pain medications and outpatient therapy services.

I believe that the hospital's decision to avoid readmission was influenced by the threat of reduced Medicare payments. During the meeting with the rehabilitation director regarding this issue, I was told, “it is cheaper for the patient to receive outpatient services.” I left the conversation feeling frustrated.

Whose needs were met in this situation - the patient or the hospital?

Instead of focusing on the patient and her needs, which we are taught to do in school, the hospital is focused on financial incentives or penalties. This not only affects the patient as it puts her at a higher risk for falls at home or other serious injuries, but this also affects the occupational therapist who is held accountable for discharge recommendations.

Overall, I understand the importance of reducing excessive and preventable healthcare spending, which is the primary goal of the Hospital Readmissions Reduction Program.  However, I believe that hospitals should not solely focus on the financial penalties imposed by the Centers for Medicare and Medicaid Services (CMS) nor that occupational therapists decisions should be influenced by this policy.

Instead, both hospitals and occupational therapists should focus on providing appropriate, quality care to patients in need of skilled services.  Patients like Mary rely on our ability to make decisions and recommendations that are in their best interest, and not that are influenced by the bottom line of some hospital's balance sheet.

Monday, November 28, 2016

Guest entry: Advocating for FERPA rights

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information is provided courtesy of Sarah Watson, a graduate student who is interested in promoting increased awareness of privacy concerns and FERPA in context of computerized record keeping and documentation.

Extra note: I was really happy to see one of my students tackle this topic - I have seen many privacy breaches because of improper permission settings in common software used by many school districts, most notably the IEP Direct product.  School support personnel need to be regularly inserviced on how to use permission settings so that providers do not have blanket access to a district's entire special education database.  This is a common problem.

Additionally, procedures need to be tightened so that notices about IEP meeting schedules that have protected information are not sent out in global emails to multiple agencies who are all providing services to school districts.

"I am an occupational therapy graduate student at Keuka college. I have created an infographic for my Global Advocacy class on Family Educational Rights and Privacy Act (FERPA).

The infographic has been a result of a semester long project on the policy process. I encourage everyone to read it and watch the video. I am very passionate on the topic of FERPA and the educational community that it impacts as a future occupational therapist.  Protecting student privacy is so important and can happen only when the right steps are taken. 

Please SHARE and feel free to comment and ask questions.

This assignment is for my final project and my goal is to have several people look it over! Thank you!"

Click here to open up the chart in your browser!

Wednesday, November 23, 2016

Guest entry: Advocating for a loan repayment bill that could impact occupational therapy

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information is provided courtesy of Nagella AL-Balushi, a graduate student who is interested in promoting a bill that improves health professional workforce distribution via a loan repayment program when practitioners work in underserved areas.

"Greetings fellow OT students and future colleagues,

I am a graduate OT student seeking opinions, feedback and thoughts about a legislative bill that would potentially have a great impact on the field of OT if passed​!

This act would have three main professional consequences including establishing a new​​​ ​federal loan repayment system​​​, ​increasing the overall distribution of our ​health care services, and ultimately making the role of OT more commonly understood across the nation.

The Access to Frontline Health Care Act is designed to provide a federal loan repayment system for health care professionals (including Occupational Therapy) in exchange for two years of service at a federally regulated agency, such as hospitals, clinics, nursing homes, and schools located in underserved areas.

The Access to Frontline Health Care Act was drafted in 2015 by Congressman David Loebsack of Iowa and ​thanks to his time and effort in creating this Act, the Access to Frontline Health Care Act would be able to save various working professionals in healthcare from the despair of endless student loan payments.

 The ​reasoning behind establishing the loan repayment system is to incentivize recent grads to work in remote areas to ​create a more balanced distribution of health care workers across the country. ​ Not only will you​, the professional,​ receive aid in paying back your student loans, but more importantly you will have the ability to help those who truly need it and don't have regular access to your services! ​

On the biggest scale, by providing services in areas where OT or other health professions are not commonly found, we are diversifying our profession and spreading awareness of what Occupational Therapy is to people who would not normally have reliable access to our services.

The infographic attached ​is provided to give you a visual explanation of the Access to Frontline Health Care Act, and the overall impact it would have the U.S. health care system. As mentioned before, I would love​ ​to hear your opinions about the Act and its potential effect on the OT profession. ​

Regardless if it is positive or negative, all feedback is beneficial!!

Thank you for your time and good luck in your future endeavors!

CLICK HERE to see the infographic in your browser.

Link to Bill: https://www.congress.gov/bill/114th-congress/house-bill/1707

Sunday, November 20, 2016

Guest entry: Advocating for canine training programs that benefit veterans

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information is provided courtesy of Nina Fusco, a graduate student who is interested in increasing awareness to HR 3016, particularly those sections that support canine training programs that would benefit veterans who have PTSD and other conditions.

"The Veterans Employment, Education, and Healthcare Improvement Act is a federal bill currently in committee in the Senate. Upon meeting with a legislative aid from Senator Gillibrand's office, it was recommended to me that attaining statewide and nationwide support would be the best course of action. Support from both New York and the nation will help push to amend and reintroduce Veterans Employment, Education, and Healthcare Improvement Act. 
I have provided a link to a presentation I created on this bill, that I have posted on YouTube. 

I hope you will consider taking a few minutes out of your day to watch and listen, and getting back to me with some feedback.  Thank you."

Guest entry: Advocating for co-payment reform in New York State

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information is provided courtesy of Tori Persons, a graduate student who is interested in legislation that would help alleviate the burden of out of pocket costs for people receiving occupational therapy services.  

"Existing laws in New York have stated that health plans must cover occupational therapy services.

However, the insurance companies have found loopholes and bypassed these laws. They did this by shifting the majority of the costs for OT services onto the patients by increasing the cost of copayments.
This increase in copayment cost has caused financial burdens on patients, changed access to occupational therapy services, and overall has defeated the purpose of insurance coverage for occupational therapy.
There is currently a bill in New York Assembly to expand health insurance coverage for occupational therapy services. The bill is in the very early stages and has not been put to a vote in either the state Assembly and Senate. 
Occupational therapy practitioners across New York State have the opportunity to advocate for our patients by encouraging legislators to vote for the passage of Bill A9384. 

Friday, November 18, 2016

Guest entry: Advocating for people who have traumatic brain injuries

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics.  

This information is provided courtesy of Ashlee Lytle, a graduate student who is interested in advocating for people who have traumatic brain injuries.  Under a current plan, transitioning this population to a managed care system will impact the quality of their care.

"As I am soon entering the profession of occupational therapy this May, I have become increasingly interested in the individuals that I will soon be providing services for. 

After researching information regarding traumatic brain injury, which is my area of interest, I came across the transition plan proposed by the Medicaid Redesign Team to remove the Traumatic Brain Injury (TBI) & Nursing Home Transition and Diversion (NHTD) waivers that currently exist and transition these services into Medicaid Managed Care. 

Placing individuals who have experienced a traumatic brain injury into the managed care system will jeopardize their frequency as well as quality of services available to them in the community. 

There is currently a bill in the Assembly awaiting approval to prevent this transition known as Bill A09397.

I strongly encourage those who are interested in advocating for these individuals to take a look at the info-graphic, located below, that was created to give you knowledge and resources to refer to in order to educate yourselves and understand the importance surrounding this issue. 

Thank you for taking the time to read this. 

Just try and remember that you can only make a difference if you try.

To see the info-graphic in your browser in a larger format, click on this link!"

Guest entry: Advocating for occupational therapy wellness programs

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan  to increase awareness of their topics.  

This information is provided courtesy of Emily Scholl, a graduate student who is interested in promoting occupational therapy's involvement in wellness programs.  She found an interesting bill that promotes wellness in NY State and is advocating for occupational therapy to be added to the existing bill.

"Occupational Therapy should be added to the list of qualified wellness programs in NYS Assembly bill A4238.

The 2015-16, in-process, NYS Assembly bill A4238 authorizes NYS health insurers & HMOs to provide policyholders with reductions in healthcare premiums and potentially waiving related costs or co-payments, in exchange for active, voluntary participation in approved wellness programs. 
This policy would operate on a non-health contingency basis, which means that obtaining these financial rewards would NOT be based upon personal health details. Participation would be enough.

People want to live healthy, successful, meaningful lives. OT should be added to the list of wellness programs in this bill.
Why?  Lifestyle education and enacting personal change is hard. It requires moral support, goal-setting, guidance, enjoyable activities, collaboration, and a greater degree of involvement than just knowing what one “should” be doing. The features of wellness programs that are outlined in this bill would be greatly supported by the occupational therapy professional skillset. 
If we can get car insurance discounts for participating in related programs, why not get health insurance discounts for participating in occupational therapy wellness programs?  This would allow the citizens of NY to save on rising healthcare costs AND improve health!  
Check out the poster attached below or click on this link for a larger version in your browser.  Thank you!"

Guest entry: Advocating for a workload approach in school systems

A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share.  The students researched a topic of their interest, met with their legislators, and developed a broad action plan  to increase awareness of their topics.  

This information is provided courtesy of Jenna Soldaczewski, a graduate student who is interested in promoting a workload approach in school systems.  She found out how a parallel profession in NY (speech therapy) promoted change by advocating for alterations to the Part 200 NYS regulations that govern special education:

Many occupational therapists in school settings have caseloads so large that it negatively impacts the way that they can help children.  Some therapists have proposed using a 'workload' approach for better managing productivity in the school systems.

After studying the caseload versus workload approach debate I created a quick presentation to encourage and inform OTs about what they can do to advocate for a 'workload' approach.

This presentation provides facts and information on the topic and also encourages OTs to speak with policy makers.  This information is specific to New York State but could be generally applied in other locations.  Please feel free to share the presentation with other professionals or on social media sites to spread the word regarding this topic.

My goal is to encourage as many people as possible to use this information to engage with policy makers.

Click here to see the presentation via your browser, or scroll below.  Thank you!

Tuesday, November 15, 2016

Support for ESSA - not as simple as you think

This week has been identified as the #OTWeekOfAction by the American Occupational Therapy Association.  They are encouraging member actions on a number of policy initiatives; however, as noted in the previous blog post, it is important for occupational therapists to independently assess the nature of these proposals before blindly writing letters of support to Congress.

Individuals may learn that they agree with the positions of the professional association or they may learn that they disagree. 

Today's topic is the Every Student Succeeds Act (ESSA) which is an important law for pediatric practitioners to be aware of.  The act was signed into law in December 2015 and its purpose is to replace the No Child Left Behind Act.  ESSA has new requirements for accountability and transparency in school operations and includes mandates for low performing schools.  It continues the NCLB testing regime and mandates 95% participation in testing for grades 3-8.  However, only 1% of all students can be given alternative tests (around 10% of all special ed students).  Large new block grants are proposed for a range of new policy initiatives and mandates.

The problem is that much of this is unfunded by the federal government and represents new mandates for local school districts that are already burdened under local property tax caps.  Additionally, there is no 'portability' in funding that would allow the money to 'follow' students into charter or private schools if the parents wish to move their children out of low performing dysfunctional educational programs.

This lack of funding portability is significant because it limits parental choice of methodologies to help their children in low performing districts.  Ironically, this is the precise aim of ESSA - to help those same students.

ESSA introduces us all to a new term: specialized instructional support personnel.  This terms replaces the previous term 'pupil services personnel.  The purpose of this renaming is to ensure that relevant stakeholders are included in school-wide decision making.  I become concerned whenever a new law comes ready-made with an entire 'organization of organizations' to prop it up.  On a practical level, the professional associations are hoping that this will allow their respective interest groups to infiltrate new areas of intervention, such as expanded roles for speech language therapy professionals in literacy initiatives, or expanded roles for occupational therapists in bullying prevention programs. The intention behind these objectives is probably good, but the reality is that there is little evidence to support the effectiveness of all these new initiatives and given the limitations in funding it is unlikely that states can afford the proposals.

The testing mandates are an important issue for many people interested in federal education law.  The new ESSA eliminates 'Adequate Yearly Progress' (AYP) mandates but keeps the testing regime intact.  States are more free to establish their own metrics for progress, but the fact that excessive testing is still required will remain burdensome for many schools. 

Professional associations, like AOTA, ask members to support these kinds of initiatives but responsible civic participation means that we can't just support programs that serve as special interest slush funds.  If there was evidence that all of these new programs were effective then it would be easier to support.  If there was portability of funding so parents could place their children in charter or private schools it would be easier to support.  If our economy was different and if there was more discretionary funding it would be easier to support.

The end result is that good intentions of new federal mandates end up being unfunded and partially funded.  This has a negative impact on practice.  I understand that the intention is to have more money flow into schools so that there are new programs and expanded opportunities for students.  Few people disagree with these noble goals.

However, what happens instead is that the mandates are handed down from the federal government and there is NOT ENOUGH MONEY allocated to fund the programs.  That leaves the states responsible for funding, and they are already cash-strapped.

Cash-strapped states then wander through a dizzying array of federal mandates - some legal, some in regulation, and some only in guidance - and have to decide what precious and sparse funds will be allocated in what directions.  Decisions are made - and in the world of unfunded IDEA mandates the districts have great latitude in how they interpret 'qualification' for service.

So what starts off as a noble idea ends up as an unfunded mandate that siphons money away from existing IDEA programs.  School administrators start to fiddle with their numbers of special education students and implement local policy around eligibility determination to meet budgets.  Even worse, special education students are trimmed from their designations to meet testing targets, or to satisfy RTI percentages.

Perhaps it is not correct form to state openly that these are the end results of new unfunded mandates but it is my lived experience.

Professional associations, including AOTA, would provide a better service to their members if they stopped encouraging people to write Congress for full funding on something that will never happen and instead focus on providing education on unfunded mandates and how they actually impact local schools.  They should also focus on providing members with skills to advocate for students who get removed from special education rolls and how to establish defensible and reasonable eligibility requirements for services that will protect children and families.  Finally, they should educate members on methods to counsel families on home activity programs, options for private therapy, and how to meet needs outside of the educational system given the constricted funding.

So don't be a policy lemming.  Don't advocate for something that won't happen, can't happen, or if it does happen will not be helpful for the people you are intending to help.

Background resources:

 Fact Sheet: Congress acts to fix No Child Left Behind

National Alliance of Specialized Instructional Support Personnel

The Every Student Succeeds Act: An ESSA Overview

The Every Student Succeeds Act: More programs and federal intervention in pre-K and K-12 education

New Details on ESSA Funding for Healthy, Safe, Well-Rounded Students

US Department of Education Every Student Succeeds Act

Tuesday, November 08, 2016

The importance of rational policy analysis for occupational therapists

The OT Capital Briefing in the November 7, 2016 OT Practice analyzes two Supreme Court cases that are summarized together as follows:

If the Supreme Court finds in favor of the families in both cases, the expertise occupational therapy practitioners provide will be more important than ever to ensure students with disabilities receive a meaningful education, and that schools fully comply with the ADA and Section 504.

This is a confusing summary because neither case has anything to do with OT specifically and in fact if the Supreme Court finds in favor of the families there may be unintended consequences that are damaging.

In the first case, Endrew F. v. Douglas County School District, the issue of concern has to do with what constitutes FAPE, or a free appropriate public education.  In this case the parents removed their child from school because they believed that his progress was insufficient as it relates to his autism condition.  The enrolled him in a private school instead and are seeking compensation to pay for that since they allege that the school did not provide FAPE.

The school rebutted that it was their responsibility to provide a 'non-trivial' educational benefit and various courts have indicated that the benefit has to be more than 'trivial' and at least 'substantial.'  This is the nut of this case - what exactly constitutes 'appropriate?'  It is a challenging standard and a fair analysis probably falls somewhere in the middle.

A biased analysis would hold that students who have disabilities should be allowed maximal benefit from education, but that is probably unreasonable given that even regular education students don't receive that level of maximal benefit.  There is no compelling reason why children who have disabilities should  be afforded a higher standard of excellence as compared to what is offered to every other student.  Additionally, if school districts had to pay for this maximal standard of excellence it would financially strain systems, and that would cause districts to cut back in other areas where possible.  This could be very problematic - both for families who need services as well as for the service providers.

No one has been able to define appropriate in FAPE yet with any standard, so 'reasonableness' needs to  be applied. That means something less than maximal and certainly something more than 'trivial.'  Sending a child to a self contained private school is likely more than some middle ground level of care that can be considered 'appropriate' in most circumstances.

Occupational therapists should hope that the Court finds a way to define this middle ground without allowing families to demand services that will strain and damage the educational system.


In the second case, Fry v Napoleon Community Schools, the Court has to decide whether or not families have to exhaust due process procedures before filing an ADA lawsuit.  In this case the family sued a school district for allegedly inflicting emotional distress by not allowing a kindergarten aged child to bring a service animal into the school and because of the evaluation process that the school employed in determining if the service animal would be a viable option in the school.  The district gave the service animal a trial but then determined that they would instead offer a human aide. 

Due process would have required the family to go through a series of designated steps to attempt to resolve the differences at the local level.  The family did not utilize due process proceedings, removed their child from school, enrolled the child in another school, and initiated the lawsuit.

The school provided a reasonable accommodation to the child in the form of a human aide.  More importantly, the family failed to follow due process rules.  Those rules are important and protect families from all sorts of bad decision making and malfeasance.  If the Court rules in favor of the parents they are sending a message that due process proceedings are not always relevant and that families can simply bring suit for damages without first trying to resolve differences.  Due process is a two way street; if those proceedings are weakened then schools also could claim that some decisions can fall outside of that due process.  That would be horrible for families.

Occupational therapists should hope that the Court reaffirms the critical nature of due process proceedings and the importance of exhausting those mechanisms before advancing to higher court levels.  That will be the best outcome for families.


In both of these cases it is important to carefully analyze the details of what is actually being litigated.  So often the truth of what is being discussed gets lost in poor reporting about the topics.  For example, many news outlets focus on the 'evil school district vs. the child in the wheelchair with Wonder the GoldenDoodle' meme instead of focusing on the decidedly less appealing 'what is the importance of due process' angle.

As OTs become more savvy with policy analysis they will avoid the bias-trap of media reporting and try to approach a more 'rational comprehensive' method of considering the actual facts.  They will also become more savvy by dropping the naive notion that just because an issue might have the superficial appearance of something that should be supported, it is important to dive deeply into the actual policy to make sure we are promoting what is best for the people who seek our services.

Recommended reading:

Birkland, Thomas A. (2016). An introduction to the policy process, 4th ed. New York: Routledge.

Saffer, A. (2016 Nov 7). Supreme Court weighs two cases on students with disabilities.  OT Practice, AOTA.

SCOTUS Blog http://www.scotusblog.com/case-files/cases/fry-v-napoleon-community-schools/

SCOTUS blog http://www.scotusblog.com/case-files/cases/endrew-f-v-douglas-county-school-district/