Professional Standards and Responsibilities

will demonstrate a concern for the safety and the well-being of the recipients of their services;

OT professionals shall intentionally refrain from actions that cause harm

OT practitioners shall respect the right of the individual to self-determination

OT personnel shall provide services in a fair and equitable manner

OT personnel shall comply with institutional rules, local, state and federal, and international laws and AOTA documents applicable to the profession of OT

OT personnel shall provide comprehensive, accurate, and objective information when representing the profession.

OT personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity

when a therapist knows the correct action to take but an existing barrier prevents the therapist from taking this action

when there are two or more potentially morally correct ways to solve a problem, but the solutions are exclusive from one another

• failure to do what other reasonable practitioners would have done under similar conditions
• doing what other practitioners would not have done
• end result was harmful to the patient

primary role is to implement treatment; can contribute to the evaluation, but cannot initiation treatment or individually evaluate patients prior to the OT's evaluation; can contribute to the development and implementation of the intervention plan and the monitoring and documenting of the individual's response to the intervention under the direction of the OT

prep for the clinic area, cleaning, organizing, clerical work, assisting with transfers after demonstrating competence

daily, direct contact at the site of work

direct contact at least every two weeks at the site of work

at least monthly direct contact with supervision available as needed by other methods

provided only on a needed basis, and may be less than montly

NBCOT may ask questions that require an individual to refer someone to another team member

one or more members of a one discipline evaluate, plan and implement treatment of the individual; other disciplines are not involved; at risk due to narrowness of perspective

number of professionals from different disciplines conduct assessments and interventions independent of one another; members' primary allegiance is to his/her discipline; limited communication can lead to lack of understanding perspectives

all disciplines relevant to the case at hand agree to collaborate for decision making; evaluation and intervention is still conducted individually within the defined practice areas, but there is a greater understanding if each practitioners' perspective; use group skills effectively

characteristics of interdisciplinary teams are maintained and expanded on; members support and enhance the activities and programs of other disciplines to provide quality, cost-effective service; members committed to ongoing communication; evaluations and interventions are planned cooperatively; role blurring is acceptable; interdisciplinary and transdisciplinary teams are the most common and considered the most effective in today's health care system.

most important and primary member of the treatment team; consumers' occupations, values, interests and goals must be determined ad used in all treatment planning

• seeks to expand access to health insurance for all individuals and to improve the quality of the health care provided
• Key components of the ACA inlude
• Accountable Care Organizations (ACO) provide financial incentives for health care providers who develop an integrated network to collaborate when treating patients across care settings and care episodes--aim is to lower health care costs while meeting quality performance standards
• Patient Centered Medical Homes (PCMH) are places of care designed to meet patients' complete needs for mental and physical health via preventative, acute care, and disability/chronic illness management services

division of the US department of health and human services is the federal agency that develops rules and regulations pertaining to federal laws governing the Medicare and Medicaid programs

a person receiving services

payment system in which the provider is paid prospectively (i.e. on a monthly basis) a set fee for each member of a specific population regardless if no covered health care is delivered or if extensive care is provided; often per member per month PMPM; healthier the enrollees are, the more the provider retains

monetary amount to be paid by a patient, usually expressed as a percentage

standardized recommended intervention protocol for a specific diagnosis

the  amount a patient must pay to a provider before the insurance benefits will pay (annual dollar amount)

refusal of a payer to reimburse a provider for services

a code that describes a patients' medical reason or condition that requires health service

descriptive categories established by CMS that determine the level of payment at a per case rate

the payment system under which the provider is paid the same type of rate per unity of service (typically 80% payer and 20% patient)

established by the ACA to allow consumers to compare the cost of insurance plans in their area

most common control of managed care, Maintains control over services requiring enrollees to see only doctors within the HMO network and to obtain referrals before seeking specialty or ancillary care

method of maintaining control over costs and utilization of services (include HMOs and PPOs)

negotiated per day fee for service (typically in inpatient and SNF settings)

similar to HMOs but often offers more choice of providers, percentage of payment often decreases with the choice

individual is responsible for payment

codes that describe specific services performed by health professionals

nationwide payment schedule that determines the Medicare payment for each inpatient stay of a Medicare beneficiary based on DRGs

the entity responsible for delivery and quality of services

agencies and companies who are the primary reimbursers for health care in the US (e.g. blue cross, HMOs and PPOs)

The Medicaid form a primary care provider must complete to document the need for requested medically necessary covered services and their supporting rationale

• insurers must provide essential benefits to participate in their plans including mental health, substance abuse, behavioral health treatment, rehabilitative, habilitative, and chronic disease management services and devices and preventative and wellness services
• insurers can no longer refuse coverage to persons with pre-existing conditions
• insurers cannot raise insurance premiums based on a persons occupation, gender, pre-existing condition, health status or claim history
• insurers must allow young adults until their 26th birthday to be covered under their parents' plans, if these plans cover dependents
• insures cannot set caps on annual and lifetime coverage

cost controlling payment strategies such as case management, precertification or preauthorization, mandatory secondary opinions, and preferred provider networks

• largest single payer for OT services
• administered by CMS
• persons eligible for Medicare services include
• persons over 65 years
• individuals of all ages with end stage renal disease/permanent kidney failure that may require dialysis treatment or a kidney transplant
• persons with long term disability who have recieved government funded disability benefits for 24 months
• retired railroad workers

• pays for inpatient hospital, SNF, home health, rehabilitation facilities and hospice care
• Part A is automatically provided to all who are covered by the social security system who qualify for medicare
• services provided in acute care hospitals receive a prospective, predetermined rate
• Part A covered services have specific time limits and require deductible and coinsurance payments by the beneficiary

• pays for hospital outpatient physician and other professional services including OT
• Part B is supplemental and must be purchased by the beneficiary (usually a monthly premium)
• Part B services have no specific time limit and require 20% co-payment
• Inpatient Part A requires 5 days a week services and Part B covers 3 days a week outpatient services

• Resource utilization groups
• reimbursement is provided for services provided in skilled nursing centers

• covered if the individual is home bound and needed intermittsent skilled nusring care, PT or ST before OT began
• confined to the home

• DME are covered if used in beneficiary's home and if necessary and reasonable to treat an illness or injury to improve functioning
• Physicians prescriptions needed and must include diagnosis, prognosis, and reason DME need
• criteria for DME include:
• 1. repeated use can be withstood
• 2. primarily and customarily used for a medical purpose
• 3. generally not useful to a person in the absence of injury or illness
• self help items such as bathtub grab bars, and raised toilet seats are not reimbursable because other people can use them and they are not considered medically necessary

• state/federal insurance program for persons who have an income that is below an established threshhold and/or have a disability
• states administer the program but recieve at least half of their funding from the federal government (ACA is leading to increased federal contributions to expand Medicaid programs)
• mandated services must be provided if federally funding is recieved

• REQUIRED
• inpatient and hospital stays
• outpatient
• home health
• early periodic screening
• services identified to treat a condition
• SnFs receiving medicaid must provide skilled rehabilitation services to residents requiring them

• OPTIONAL
• OT, PT, SLT
• DME
• Services provided by independent licensed professionals
• targeted case management
• prescription medication
• dental care, eyeglasses
• crisis response service
• transportation
• psychiatric care
• related services provided by school systems to children with disabilities (overlaps with IDEA)

• designed to compensate employees who have job-related illness or injuries
• funded jointly by individual employers or groups of employers and state governments
• can include cash and medical benefits
• rehabilitation and disability management to return the person to gainful employment is a primary focus

• identification and background information
• evalation and reevaluation documentation
• intervention plan and goals
• SMART (specific, measurable, attainable, relevant, time-limited)
• RUMBA (Realistic/relevant, understandable, measurable, behavioral, attainable/achievable)
• Activities or treatment procedures
• intervention implementation documentation
• Discharge planning documents

• chronic
• status quo
• maintaining
• little change
• plateau
• making slow progress
• stable

• same as
• uncooperative/non compliant
• dislikes therapus
• confused/disoriented
• inability to follow directions
• patient refused to participate
• custodial care
• treatment repeated
• unmotiviated
• extreme depression
• fair to poor potential
• chronic/long term condition
• general weakness

• Health Insurance and Portability Accountability Act
• sets standards and safeguards to assure the individuals right to continuit in health care coverage and to ensure privacy and securit of health care records
• must be informed of the setting's privacy policies
• must obtain the person's permission or give the person the opportunity to object discussing a person's status with a family member/significant other
• information disclosed must be limited to the minimum needed information
• physical identifiable patient info can only list last names, no diagnoses
• storing documents out of sight
• password protected computer files
• individual has the right to access records

established medicare and SSI (supplemental security income) to receive monthly income allowing them to live in community

• prohibits discrimination on the basis of disability
• required federal agencies to develop action plans for hiring, placement and advancement for persons with disabilities

• prohibits discrimination on bases of disability, religion, sex, color, race national origin, family status
• Requires owners of homes to make reasonable exceptions to their standard tenant policies to allow individuals with disabilities equal housing opportunities (allowing a seeing eye or service dog in a "no pets" apartment)
• tenants can make reasonable modifications to common areas and to their private living space
• newly build residencies (4 or more families) must be build to meet accesibility guidelines

• prohibits discrimination against qualified individuals with disabilities in employment, transportation, accomodations, telecommunications, and public services
• individuals who are actively abusing substances or compulsively gambling or persons with other behavviors are not protected by ADA
• Allows questions about individual's abiltiy to perform job tasks but not to ask if they have a disability
• Qualified individual is one who can perform the essential functions of the job with or without reasonable accomodations
• reasonable accomodations must be provided by businesses with 15+ employees

• acquistion or modification of equipment or devices
• modification or adjustment to examiniations, training materials, or publications
• provision of ancillary aids or services
• modified or part-time work schedules, job restructuring or reassignment
• auxilary aides