Health Advocacy

Purpose of performance evaluations/reviews

- Assess performance relative to the standards and expectations - Identify areas for improvement - Identify and develop areas of strength - Provide a forum to develop plans for professional growth and development

Supervision of OT

- Based on education and training after initial certification; are autonomous practitioners able to deliver services independently - Responsible/Accountable for ALL aspects of safety and effectiveness of the OT service delivery process - Encouraged to seek supervision and mentoring to develop best practice approaches and promote professional growth

Supervision of OTA

- Based on their education and training; must receive supervision from an OTR/L - Delivers OT services under the supervision of and in partnership with an OTR/L

Setting Productivity Standards

- Carefully set the benchmarks and be sure the administration understands them - Consider your particular setting and case mix when identifying units of measurements for productivity 1. # of visits (patients) 2. # of billable minutes 3. # of billable procedures - Monitor productivity to identify trends, utilization, and to justify current and future staffing

Communication Strategies to reduce resistance and fear of change

- Clearly share reasons for change early on - Highlight the benefits and impacts of change - Ensure leaders actively communicate throughout the change process - Use various methods to communicate the message of change - Provide opportunities for dialogue - Repeat the messages of change periodically

when/how are HCPCS codes used?

- Codes used for outpatient services and supplies - Used by OT to report fabrication/fitting of orthoses Example: Wrist extension control cock-up, non-molded, prefabricated, off the shelf

Disciplinary Action

- Hot Stove Principle - Progressive Discipline

Outcome Measures

- Improved client outcomes - Productivity - Efficiency of systems - Increased satisfaction - Cultural change

Barriers to Change: Fear of

- Loss of power - Loss of skills - Loss of skills + competence - Loss of income - The unknown

Barriers To Change: Traditional & Set Ways

- Loyalty to status quo - Failure to accept need for change - Insecurity - Preference for Familiar - Breakup of work groups - Different personal ambitions

Considerations for complexity levels in OT CPT evaluation codes

- Occupational Profile and amount of medical record review - Number of performance deficits that result in limitations or participation restriction - Type of Clinical decision making

Key characteristics of Constructive Feedback

- Open - want a discussion where the person can reflect on the feedback - Descriptive and specific - provide examples so there can be improvement - Objective - focus on behavior not the person - Well-timed - Balanced

Implementing Change

- Organizational Change - Planned change - Unplanned change

Activity Measures

- Performance measures - Compliance measures - Speed of Adoption - Involve stakeholders - Communicate - Adjust, but "stay the course"

External forces of change

- Social, political, cultural shifts - Technological changes - Workforce diversity

Regulations for Supervising OTAs

- States vary in OTA supervisory requirements - OT/OTAs must be knowledgeable about and comply with these requirements

Practical uses of performance reviews

- To determine competency - To meet Accrediting Standards - Merit Raises/Promotions - To support Termination (adhering to laws that protect against unlawful termination) - Recommendations

Internal Forces of change

- Top-down from the leadership - Declining effectiveness - Deficiencies in existing systems and employee expectations

Hot stove Principle (4 principles)

- Warning: warmth from nearing the stove warns the employee of wrongdoing, provides supervisor with the time to reiterate expectations - Consistent: Just as the heat from a stove is consistent, supervision must be consistent with the staff members - Objective: anyone that puts their hand on a hot stove is going to get burned; fair and equal discipline - Immediate: immediate feedback and discipline ASAP, do not wait to discipline someone for something that happened months ago

Change occurs when...

1. An organization decides to adopt new practices 2. If there is a cultural change in the organization

Justification of Staff

1. Consider the Regulatory Requirements - Client-to-staff ratio for individuals and groups - Supervisory requirements - OTR: OTA 2. Consider Type - OTR vs. OTA - Additional qualifications of experience - Support staff 3. Consider the Number/Schedule - Full Time Equivalent (FTE) 4. Productivity Considerations

Purpose & Use of Job Descriptions (6)

1. Establishes necessary competencies (performance stands) and skill sets 2. Should contain essential functions of the job (ADA compliance) 3. Includes the purpose or summary of the job, duties, supervisory relationships, position qualifications, and specifications 4. Be written for the position NOT the person 5. Have a salary range, but no specifics 6. Used for employee recruitment, selection and evaluation

untimed CPT codes

1. Evaluations and re-evaluations 2. Supervised modalities (e.g. paraffin bath) 3. Group therapeutic procedure codes

Goal of Supervision

1. Fosters growth and development 2. Promotes effective utilization of resources 3. encourages creativity and innovation 4. Provides education and support to achieve a goal 5. Ensuring safe and effective delivery of OT services

Performance Review Process (6)

1. Frequency 2. Scheduling 3. Contributors 4. Behavior Directed 5. Feedback 6. Sign Off

Supervision: General Principles/Responsibilities of OT Manager

1. Get the work of the organization done 2. Manage in a constantly changing environment 3. Be action and results oriented 4. Generate Energy & motivation 5. Elicit trust in staff 6. Communicate skillfully 7. Understand and implement mission, policy/procedures 8. Ensure compliance with regulatory requirements 9. Represent the profession

Role of the Leader in Transactional Leadership

1. Leader directs efforts of others through tasks, actions, and structure 2. Leader provides clear direction & expectation of tasks and work objectives 3. Leader uses reward/punishment

Guidelines for Supervision, Roles, & Responsibilities during the delivery of OT Services: OT Personnel are expected to

1. Meet applicable State and Federal Regulations 2. Adhere to Relevant Workplace Policies 3. Adhere to the OT Code of Ethics 4. Participate in ongoing professional development activities to maintain continuing competency

Models of Communication

1. Participatory Model 2. Programming Change 3. Integrated Conceptual Model

CPT codes are used to...

1. Report medical, surgical, and diagnostic procedures and services to various entities (physician, insurance company, accreditation organization) 2. Billing 3. Quality measure reporting 4. Research

6 Basic Needs of Workers Related to Resistance & Fear of Change

1. Security 2. Inclusion/Connection 3. Power 4. Control 5. Competence 6. Justice/Fairness

Timed CPT codes

1. Therapeutic procedures, per 15 minutes

Progressive Discipline (4 steps)

1. Verbal Warning 2. Written Warning 3. Suspension 4. Termination

Informal Feedback Model: SKS Method

1. What should Person STOP doing? 2. What should Person KEEP doing? 3. What should Person START doing?

OT CPT Evaluation Codes

3 Evaluation codes based on level of complexity Low Complexity: 97165 Moderate Complexity: 97166 High Complexity: 97167

3rd party payers and group treatment

3rd party payers may limit the amount of time in group treatment and/or the group therapist to patient ratio ex: Medicare A only allows up to 25% of patient time/week spent in therapy; Maximum of 4 clients per group per OT/OTA (acute-care settings, inpatient rehab facility)

Low complexity clinical scenario

76 y/o female referred after R distal radius fx due to treadmill mishap Lives alone in community, volunteers at the hospital's pediatric unit 3x/week; wants to perform ADLs, especially dressing No prior medical conditions

High complexity clinical scenario

76 y/o female referred after R distal radius fx in the middle of the night due to wandering she is a long-term care resident, previously mobile with a walker, toilette herself, but admits to being forgetful; isolating self in bedroom, wants to be able to toilet safely, use walker, take art group Early-stage dementia; history of TIAs, CHF; prior rehab for stroke with limited L arm function

Moderate complexity clinical scenario

76 y/o female referred after R distal radius fx that occurred at BBQ when she tripped over her friend's dog She lives with partner in a retirement community; participates in social activities; wants to perform ADLs such as toileting, dressing, and fall prevention Has history of diabetes, related macular degeneration. Received prior OT services for low vision

Supervision

A cooperative process in which 2 or more people participate in a joint effort to establish, maintain, and/or elevate a level of competence and performance - Based on a mutual understanding between the supervisor and supervise about each other's competence, experience, education, and credentials

Organizational Change

A modification or transformation of an organization's structure, processes, or services

Evaluating Change

Activity Measures: How is change progressing? Outcome Measures: Were the desired results of change achieved?

Full-time equivalent (FTE)

An FTE of 1.0 means that the person is equivalent to a full-time worker (40 hrs/week) An FTE of 0.5 signals that the worker is only part-time "A statistic representing the number of full-time employees as calculated by the reported number of hours worked by all employees, including part-time and temporary, during a specific time period"

Administrative Supervision

Anyone can give administrative supervision (does NOT need to be an OT) Has to do with policies and procedures that are NOT clinical - Performance evaluations - Supervising staff

Performance Evaluation/Reviews

Appraisal of staff performance - Often performed after a probationary period and annually

Sign off

Both the supervisor and staff member should sign off on the review

Extrinsic Motivation

Comes from external sources - employee of the month, luncheons, celebrations - studies have shown that money is not the only motivating factor for professionals, recognition is just as important

Intrinsic motivation

Comes from within - employee wanting to feel good about the work they're doing - professionals are naturally intrinsically motivated - more intrinsic motivation necessary when you move higher up in position

Steps for change

Create a Climate for Change Step 1: Establish a Sense of Urgency Step 2: Create the Guiding Coalition Step 3: Develop A Change Vision Engage & Enable the Whole Organization Step 4: Communicate The Vision for Buy-In Step 5: Empower Broad Based Action Step 6: Generate Short-Term Wins Implement & Sustain Change Step 7: Never Let Up Step 8: Incorporate Change Into The Culture

CPT codes

Current Procedural Terminology - developed by the AMA and revised yearly - Some CPT codes are timed and others are not

Where does organizational change come from?

External Forces or Internal Forces

Scheduling

Have a dedicated time and private space to show respect to the staff member

HCPCS codes

Healthcare Common Procedure Coding System - Developed by the AMA and revised yearly

Un-Planned Change

Imposed on an organization Unplanned change is: - Unforeseen - Reactive

ICD-10 codes

International Statistical Classification of Diseases and Related Health Problems -The international standard diagnostic classification for all medical data concerning the incidence and prevalence of disease in large populations and for other health management purposes. - Developed by the Who

Management by Exception-Passive

Intervenes AFTER non-compliance or undesired behaviors occur - Reactive - "Root Cause Analysis" (what went wrong?)

Contributors

Involve the direct supervisor (will vary depending on work environment)

Inspirational Motivation (Transformational Leadership)

Leader communicates high expectations and inspires others to be committed to the shared vision of the organization - set a high goal for the group, ensure it can be achieved if "we all work together"

Idealized Influence (transformational leadership)

Leader conducts self in a manner that followers will take pride in being associated with and want to emulate Role modeling - - Attributes (quality) - Behaviors (action)

Individual Consideration (Transformational Leadership)

Leader identifies and develops subordinate's needs/strengths - Acts as a coach/mentor

Management by Exception-Active

Leader monitors and identifies any potential deviations early and corrects BEFORE undesired behaviors occur - Proactive - "Failure Mode Analysis" (what could go wrong?)

Intellectual Stimulation (Transformational Leadership)

Leader stimulates and challenges thinking in subordinates - Encourages innovative and creative problem solving

Role of the leader in transformational leadership

Leader works WITH subordinates to... 1. Identify needed change 2. Create a vision to guide the change through inspiration 3. Execute the change with the commitment of the members of the group 4. Raise the interests of individuals beyond self-interests to focus on the purpose and mission of the group

Integrated Conceptual Model

Leader's communication style impacts subordinate's commitment to change

Transactional Leadership

Leadership based on the exchange between the leader and the followers to achieve goals - focuses on the relationship between the leader and the subordinates (relationship = "transaction")

Transformational Leadership

Leadership that inspires and motivates followers to create positive changes and achieve goals

Billing for Co-treatment

Neither therapist can bill separately for the full session - the combined time therapists bill should be equal to the total duration of the treatment session - One therapist bills for the entire session and the other therapist does not bill OR therapists split the time and each bill for 1/2 of the treatment

OTs vs. OTAs: Supervision

OTs and OTAs are equally responsible for developing a collaborative plan for supervision OT is ultimately responsible for the implementation of appropriate supervision, but the OTA also has a responsibility to seek and obtain appropriate supervision

Moderate Complexity: 97166

Occupational Profile: Expanded review of therapy/medical records; additional review of physical cognition, psychosocial performance Patient Assessment: 3-5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Clinical Decision Making: Moderate analytical complexity, detailed assessments, minimal to moderate medication of assessments, may have comorbidities

High Complexity: 97167

Occupational Profile: Extensive review of physical, cognitive, psychosocial performance Patient Assessment: 5+ performance deficits Clinical Decision Making: High analytic complexity, comprehensive assessments, multiple treatment options, significant modifications of assessments, comorbidities affecting performance

Low Complexity: 97165

Occupational Profile: brief history relating to the presenting problem Patient Assessment: 1-3 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Clinical Decision Making: low complexity, limited amount of treatment options, no assessment modification, no comorbidity

Group Treatment

Patients are working as a group on some common skill develop or functional area and have the same or similar goals

Motivation

Process of providing a need or desire that causes a person to take some action - the act of inspiring others to move toward goal-directed action

Productivity Considerations

Productivity: Actual "Billable" time providing direct care consider non-billable time: Time spent in documentation, in-services, calling insurance companies 75-70% direct care + billable hours is the industry standard

Concurrent Therapy

Providing treatment to more than one individual client simultaneously during a specific time period but BILLED INDIVIDUALLY

Planned Change

Results from deliberative decisions to alter an organization Planned change is: - Intentional - Goal-Oriented - Proactive

Contingent Rewards (transactional leadership)

Rewards based on outcomes Reward individuals meeting goals and achieving expected outcomes by providing reinforcement for a job well done

Participatory Model

Shared understanding/input into the change process - Allows employees to process the change by dialoguing about it

Feedback

Should be constructive and instructive, and help the employee make a positive change

Frequency

Should be held annually and reflect the entire previous year - Employees should not be "surprised" by anything on their review - As a manager, you should be communicating with staff and not waiting until the yearly performance review to point out and correct mistakes

Behavior Directed

Should focus on specific behaviors rather than personality traits

Informal Feedback Model: Pendleton Model

Step 1: Staff states what was good about performance Step 2: Supervisor states areas of agreement and elaborates Step 3: Staff states what was poor or could be improved Step 4: Supervisor states what could be improved

Formal Feedback Model: Reflective Model

Step 1: supervisor asks staff to share their concern about their performance Step 2: staff shares and supervisor provides feedback on performance and offers support Step 3: supervisor asks staff to reflect on and identify what could be done differently to improve performance Step 4: after staff responds, supervisor elaborates and possibly corrects staff as needed Step 5: supervisor checks for staff for understanding

Transactional Leadership relationship

Subordinates get (or do not get) something for completing tasks/getting work done - "Give & Take"

Clinical Supervision

The process of direct observation of an employee's work, with emphasis on measurement of specific behaviors, and the subsequent development of plans to remediate deficiencies in performance - should be done by someone in your profession

Accepted methods for Concurrent therapy billing

Time Slice: 3 patients treated concurrently by 1 OT for 60 minutes, OT bills 20 minutes of direct therapy per patient to total 60 minutes Dovetailing: 1 patient treated over 40 minutes and can do the last 20 minutes independently, 2nd patients comes in at that 40 minute-mark, and is treated while patient 1 is working independently, OT cuts out overlapping 20 minutes

Evaluations are NOT

Timed procedures but there are typical durations provided

Programming Change

Top-down approach; Formal dissemination of information

Which leadership approach is being taken when a DME vendor with the highest % of sales is rewarded by his company with a bonus at the end of the year?

Transactional Leadership

An OT program wants to shift its focus from a traditional medical model to a client-centered model. Which leadership approach would you recommend they use to implement this change?

Transformational Leadership

Co-Treatment

Two therapists (of the same or different disciplines) treating one patient at the same time - Should be done when it is in the patient's best interest

When/how are ICD Codes used?

Used for medical/treatment diagnosis and some procedures alphanumeric codes that are used to uniformly describe every medical diagnosis, description of symptoms, and cause of death example 169.321: Dysphasia following cerebral infarction

CPT Billing Modifier

Used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided - Further describe a procedure code WITHOUT changing its definition

CPT code modifier example

ex: Modifier "CO" (OTA) when a service is performed by an OTA

Examples of CPT codes

ex: OT evaluation, low complexity ex: Paraffin bath ex: therapeutic procedure, one or more areas, each 15 minutes...

Management by Exception (transactional leadership)

focuses attention on differences between actual and desired performance

Re-evaluation code

only 1 code: 97168

Constructive Feedback

providing information about an event or behavior in order to facilitate change in behavior - focuses on modifying behavior in a positive manner

How is Group treatment billed?

using Group CPT Codes

Formal Feedback Model: PEARLS Approach

§ Partnership for joint problem solving § Empathetic understanding § Acknowledgement of barriers to progress § Respect for values and choices § Legitimization of feelings and intentions § Support for efforts as correction