Objectives Occupation -Based Practice … for Occupation -Based Practice Debbie Amini, EdD , OTR/L,...

Documentation for Occupation-Based Practice

Debbie Amini, EdD, OTR/L, CHT, FAOTA

Chicago, IL

April 8, 2016

Objectives

• Describe the importance of documentation that

captures OT interventions and outcomes

• Describe the components of best practice

documentation

• Identify the components of occupation based goal

statements

• Apply the tenets of occupation based goal writing to

your practice setting

Why?

• 2 Reasons….

• Reimbursement Trends

• Articulating best practice OT

Occupation based documentation supports the

requirements of 3rd party payers

• Medicare Guidelines

• Medicare Benefit Policy Manual, Chapter 15, Sections 220-230

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

• Impact Act of 2014

• Purpose: Improve the data collected from clients at long term care hospitals, in-patient rehab facilities, skilled nursing facilities and home health agencies. The goal is to have more consistent and accurate data of patient status and resource use and to understand quality of care. Data must reflect functional outcomes.

Support best practice occupational therapy

• Supports the profession as we work toward occupation based outcomes with the client as the active participant.

• Reinforces the efficacy and importance of OT services.

• Supports and articulates OTs scope of practice to outside agencies and consumers.

• Positively influences trends in reimbursement for services.

• Ensures accurate reporting of what we address and how it is addressed through our lens.

• Ensure alignment of clinical problems, goals and interventions to improve ease of treatment planning, execution and reporting.

Getting Started

• Documentation for occupation based practice

starts with a practice lens that is occupation

based

• Occupational Therapy Practice Framework, 3rd edition

• Overarching Statement:

“Achieving health, well-being and participation in life through engagement in occupation”

Evaluation that includes

• Occupational Profile

• Use outcome measures such as COPM

• Analysis of occupation

• Information obtained in profile informs choice of high quality measures to identify and form a baseline of deficits in skills, patterns, factors or the environment/context that limit participation in the identified area

Areas of Occupation

per Occupational Therapy Practice Framework 3rd edition 2014

• ADL’s: Self Care activities

• IADL’s: Care for others

and Home

• Rest and Sleep:

Preparation for and

rejuvenating rest

• Social Participation: Ability

to interact with others

• Work: Vocational and

Avocational pursuits

• Play: Spontaneous

enjoyable activity

• Leisure: Planned time

away from work and ADL’s

• Education: Planning for

and attending learning

events

Client Factors

Are supports or barriers to participation, but are not problems or goals

• Values, Beliefs and Spirituality

• Body Functions

– Mental functions

– Sensory functions

– Neuromusculoskeletal and movement-related functions

– Cardiovascular, hematological, immunological, and respiratory system functions

– Voice and speech functions, digestive, metabolic and endocrine system, genitourinary and reproductive functions

– Skin and related structure functions

• Body Structures

– Structures of the nervous system

– Structures of the skin

– Structures of the musculoskeletal system

– Etc…

Performance Skills


• Motor skills

– Posture

– Mobility

– Coordination

• Process skills

– Energy

– Knowledge

• Social interaction skills

– Physicality

– Information exchange

Performance Patterns


• Habits

– Acquired tendencies that can support or interfere with performance

• Routines

– Patterns of behavior

• Rituals

– Symbolic actions

• Roles

– Set of behaviors

Context and Environment

Important to consider and include in problems and goals as needed

Contexts Environments

• Cultural: Customs, beliefs and activity patterns

• Personal: Aspects of the client themselves (age, gender, socioeconomic status, etc)

• Temporal: The experience of time as shaped by engagement in occupation. Also, stage of life, time of year, etc.

• Virtual: Communication occurs without physical contact via airways or internet.

• Physical: Natural and built

non-human surroundings

and the objects within them

• Social: Presence of and

relationships with persons,

groups and populations with

whom clients have contact

Targeting Outcomes

• Occupational performance

• Improvement

• Enhancement• Prevention

• Health and Wellness

• Quality of life

• Participation

• Role competence

• Well being

• Occupational justice

Types of Required Documentation

1. Initial Evaluation*

2. Plan of Care *

3. Treatment Note*

4. Progress Report

5. Discharge Summary

Requirements of Initial Evaluation

The evaluation must include:

• Objective statements indicating a decline in occupational performance

• Objective measures

• Statement that SKILLED service is reasonable and necessary

• Indication that qualified personnel are providing services

Decline in Occupational Performance

• Document the diagnosis/diagnoses and specific problems to be evaluated.

• Document the client’s prior level of function. To set the stage for why current function is a decline.

• Document and describe how and why any complicating conditions (ex. ETOH abuse, Mental Illness) may affect treatment.

Decline in Occupational Performance

• Identify physical, cognitive, and psychological impairments that

interfere with independence or safety in occupational performance areas.

• Identify client needs and wants and how these are not currently being realized.

oCanadian Occupational Performance Measure



• Objective statements indicating a decline in occupational performance

• Objective measures

• Statement that SKILLED service is reasonable and necessary

• Indication that qualified personnel are providing services

Objective Measures

Objective measurements gathered from valid and reliable tools should describe the client’s functional performance in areas of occupation

• Used to Identify baseline function that will be used to determine change in future performance outcomes.

• Used to describe the specific problem being evaluated and identify the body part being treated.

• Used as links to explicitly connect client’s function to reproducible criteria

Valid and Reliable

• Must consider strength of tools used

• Valid tools measure what they say they will measure.

• Reliable tools provide reproducible results.

• Many tools in the world of OT are “home grown”. They have been used for years without benefit of supportive research.

• Be a good consumer of available resources and consider standardized assessments

Examples of Valid and Reliable assessment tools

• Executive Function Performance Test

• Bruininks-Oseretsky Test of Motor Proficiency, 2nd Ed.(BOT™-2)

• Texas Functional Living Scale (TFLS)

• Montreal Cognitive Assessment (MoCA)

• AMPS (Assessment of Motor and Processing Skills)

• COPM (Canadian Occupational Performance Measure)

• DASH (Disabilities of Arm, Shoulder and Hand)

• Client interview (typical OT approach to information gathering—interest checklist etc.)



– Objective statements indicating a decline in occupational performance

– Objective measures

– Statement that SKILLED service is reasonable and necessary

– Indication that qualified personnel are providing services

Skilled Service is Reasonable and Necessary

• Document that significant and realistic improvement is expected in a reasonable period of time OR that skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration (maintenance therapy).

• The amount, frequency, and duration of service must fit within accepted standards.


• Intervention must be specific and effective for the client’s condition (evidence based) – Sidebar: What is evidence based practice?

• The need for services that require the qualifications of an OT/OTA must be made explicit. The condition and treatment must be of the complexity and sophistication that warrant skilled service.

• The skills of an OT/OTA are necessary to meet the client’s need.

» Maintenance therapy – specific requirements Jimmo v. Sebelius


Are part of the initial evaluation and subsequent treatment

notes

• Example of a Skilled Therapy Statement:

“Skilled therapy is necessary to provide appropriately

designed cognitive activities to improve problem solving and

sequencing needed for independent meal preparation.”



– Objective statements indicating a decline in occupational performance

– Objective measures

– Statement that SKILLED service is reasonable and necessary

– Indication that qualified personnel are providing services

Qualified Personnel

Per AOTA, Various State and Other Payer Regulations• An OT or an OTA is providing the skilled service (check 3rd payer requirements)

• An OT initiates and directs the screening, evaluation, and re-evaluation process and analyzes and interprets the data.

• OTAs may provide objective data.

• OTAs act under the supervision of the treating therapist.

• The therapist must actively participate in the evaluation/re-evaluation



2. Plan of Care*

3. Treatment Note*

4. Progress Report


Plan of Care

• Problem List

• Long Term Goals

• Short Term Goals (not required for, but mentioned in

Medicare guidelines).

• Skilled services to be provided (including time frame and

intervention techniques)

Problems

• Must reflect area that client wishes to address

• Based on outcomes of assessments

• Must be relevant to diagnosis/reason for referral

• Should be areas that OT will address

• Do not list medical diagnosis as problem (list as

limitation or describe in text of report)

• Based on OCCUPATIONS not client factors, skills,

patterns or contexts

• Will set the stage to occupation based interventions

and outcome

Caution: Including Factors in Problem Statement

• Not necessary to add the reason for the functional problem in the problem statement. This information should be included in the outcome statements within the text of the evaluation.

• Unnecessarily limiting. Confuses the focus of intervention.

EX. Client is unable to don LE clothing due to limited shoulder ROM.

This statement creates the impression that no other issues exist. What if shoulder movement becomes normalized and client continues to be unable to don pants? Will require re-working problems and goals.

Examples of Factor vs. Occupation-based problems

Factor-based

• Client has low self-esteem.

• Child obtained 50th

percentile on the BOT2.

• Client cannot flex left

shoulder beyond 90

degrees.

• Client has poor endurance.

• Client cannot close hand to

grasp.

Occupation-based

• Client unable to engage in

social pursuits.

• Child is unable to participate

in arts and crafts class with

peers.

• Client is unable to engage in

leisure activity of yard care.

• Client unable to prepare meal

for family.

• Client cannot feed self

Plan of Care

• Problem List

• Long Term Goals

• Short Term Goals (not required for, but

mentioned in Medicare guidelines)

• Skilled services to be provided (including

time frame and intervention techniques)

What are goals?

• Statements that describe the state of being that is being

worked toward in treatment. Reaching that state of

being should indicate that the initially identified

functional problem has been appropriately resolved.

Where do occupation-based goals come from?

• A client centered evaluation

• A client centered and evidence based plan of care

• Appropriate documentation of relationship between

assessment tool outcomes and occupational deficits

• Occupation based problem statements

2 Types of Goal Statements

•Long term goals• Can be known as treatment goals

• Are the goals recognized primarily by most 3rd party carriers

• When complete, should indicate that the occupational problem has been resolved or reduced

• Must be measurable, occupation-based, timed and client focused

• Specifically address problems

Long Term Goals

• Client unable to engage in social pursuits.

• Client will consistently engage in desired social interactions with family members by 10-15-15.

• Client is unable to dress self independently

• Client will independently dress self using adaptive equipment by 10-12 -15.

Short Term Goals

• Are sub components of LTG’s

• When completed, should indicate that LTG has been reached.

• Should be occupation based, measurable, timed, client focused and relate specifically to the LTG.

• Should be a minimum of 2 for each LTG

Short Term Goals

Client unable to engage in social pursuits.

Client will consistently engage in desired social interactions with family by 10-15-16.

• Client will contact mother one time to secure details about upcoming family event by 9-15-16.

• Client will arrange and take transportation to 2 hour family event by 9-23-16.

• Client will have 4 positive conversations (10 minutes each) with a minimum of three family members during family event by 10-7-16.

Short Term Goals

• Child is unable to participate in arts and crafts class with

peers.

• Child will fully participate in second grade arts and crafts class with peer group at close of school year

• Child will create a three inch clay pot using assigned pinch method by April 1, 2016.

• Child will demonstrate the ability to create a holiday card using three shapes accurately cut out of construction paper using scissors by April 15, 2016.

• Child will demonstrate the ability to create a construction paper zoo scene including the gluing of previously cut out animal shapes by May 1, 2016.

Optional 3rd level Behavioral Objective

• May help therapists who really really need to make the

connection to body functions and structures explicit.

• Use as daily or weekly sub units of short-term goals.

• Not looked at by third party payers, but can serve as

guides for therapists who need to see relationship

between factors and occupations.

Examples of Behavioral Objectives

• Client is unable to dress self independently• Client will independently dress self using AE by 10/12/16

• Client will don pants using a dressing stick by 10/5/16

• Client will demonstrate full grasp of right hand to securely hold dressing stick.

• Client will independently doff pants by 10/1/16

• Client will increase should flexion to 135 degrees to allow reaching to feet for pant removal.

Telescoping of Problems, LTG’s and STG’s

Test of occupation-based goals and problems

If goal relates to more than one or two areas of occupation it

is likely NOT occupation based.

Goal will be a component of an occupation. It is a client factor

or skill that is needed for completion of many occupations.

“Client will actively flex shoulder to 160 degrees 3 out

of 4 attempts by 10/1/16.”

Writing Goals in Measurable Occupation-based format

• Several sources offer acronyms for what to include in goals.

• Regardless of acronym, good goals contain the following basic parts:

– Indication of WHO is completing the goal

– Indication of WHAT is being completed

– Indication of HOW is it to be completed

– Indication of WHEN is it to be completed

– Indication of WHERE the behavior is to be completed (if needed)

COAST Method

C: Client will perform

O: What Occupation

A: With what level or assistance or

independence

S: Under what specific condition

T: Time frame

Client

– Goals should be written with the client as the center of the outcome.

– Caregiver goals which are sometimes written, can still be client centered.• Try: Client will demonstrate receptivity to having splint

donned by spouse after instruction.• Versus. Spouse will be instructed to apply splint to client’s

hand.– Write from the client’s perspective, not the therapists’.

The client will demonstrate independent teeth brushing using adapted toothbrush 100% of attempts by December 1, 2016.

Occupation

– Indicate the performance that must be completed before the goal is considered met.

– Based on ‘Occupations’ as described in the Framework.


Assistance

• How much assistance will be required when goal is complete

(min assist, moderate assist, verbal cueing).

• Can be phrased in terms of ability of client (independently,

without assistance).

• May be implied.

• Add specialized equipment or context if it supports

performance.

The client will demonstrate teeth brushing using

100% of attempts by December 1, 2016.

• Specify when, where, and with whom the performance should occur or under what circumstances.

• Criteria by which goal completion will be measured.

• May be written as a percentage of all attempts.

• May be written as a number of successes out of number of trials (3 out of 4 attempts)

• May be written as “consistently” or “all attempts”

• May not be written. Consistent ability may be implicit in goal statement. “Client will feed self independently using overhead suspension sling to support dominant arm within 2 weeks.”


Time frame

• Identify the date by which the goal should be met.

• Long term goals should not exceed expected time of

treatment.

• Short term goals cannot exceed time frame for long

term goals and should be attainable within weeks, not

months.

The client will independently brush teeth using adapted toothbrush

100% of attempts by December 1, 2016.

Diagramming Goal Statements

• The client will prepare a light meal 100% of attempts in the OT kitchen with standby guarding of OT practitioner by 11-25-16.

• The child will demonstrate the ability to complete in-class English assignments during time provided by classroom teacher using laptop computer to write answers to prompts 90% of attempts by May 1, 2015.

Client-Occupation-Assistance-Specific condition-Time frame

Plan of Care

• Problem List

• Long Term Goals

• Short Term Goals (not required for, but

mentioned in Medicare guidelines)

• Skilled services to be provided (including time

frame and intervention techniques)

Interventions

• Treatment interventions that are occupation or activity

based can easily be created when STG’s reflect the

problems and the LTG’s.

• Interventions can be designed to work on the

occupation itself or on factors, skills or patterns that

specifically address occupational performance.

• Choose interventions based on evidence, frame of

reference, and the type (according to the Framework)

that fit the situation best.

Occupation based practice and goals does not mean…

• That factors, skills and patterns are not

independently addressed.

• That interventions such as preparatory methods

and tasks cannot be used.

IN FACT

• Factors can be addressed outside of an activity

• Non related activities and occupations can be

used to address underlying factors and skills.



2. Plan of Care*

3. Treatment Note*

4. Progress Report


Treatment Note

Documentation is required to create a record of all skilled treatment/intervention and time spent in providing the services to justify services billed.

Include

Date of treatment

Name of specific treatment/intervention

As required by the payer, use correct CPT coding language (NEW CPT coming soon)

Name/credentials of who delivered the service

Medicare Part B—Time spent in treatment/intervention represented by timed codes and total treatment time in minutes.

63

Treatment Note

• Daily documentation may include:

• Patient self-report

• Adverse reaction to treatment

• Communication with other providers

• Significant, unexpected changes in

clinical status

• Equipment provided

Payers or state practice acts may require different

documentation in treatment notes.

64

Sample Treatment Note

September 8, 2015

Client participated in treatment session consisting of 45 minutes of therapeutic activities using one-handed dressing techniques for donning and doffing pants and socks and using a button aid to fasten the buttons of his shirt. Client engaged in 15 minutes of purposeful therapeutic reaching activity prior to dressing to enhance active shoulder motion in preparation for dressing. Skilled intervention of OT practitioner continues to be required for design and administration of appropriate therapeutic activities to continue skill development.

O.B. Therapist, OTR/L

66

Date

Specific

interventions to

justify billing code

Signature and

professional title

Time spent in intervention

Include Skilled Therapy Statements

Examples:

• Client was able to demonstrate safe use of stove after skilled service instruction in compensatory techniques for reaching from wheelchair.

• Client was able to successfully don and doff shirt with minimal assist after completion of skilled service program of graded upper-extremity strengthening activities and occupations.

• Client demonstrated less pain and fatigue during the meal preparation activity after skilled service instruction of joint protection techniques and presentation of adapted equipment such as a jar opener and non-skid mat.

65

SOAP Note format

September 8, 2015

S: “I am having a pretty good day”

O:Client participated in treatment session consisting of 45 minutes of occupation focused activity using one-handed dressing techniques while donning and doffing pants and

socks, and using a button aid to fasten the buttons of his shirt. Client engaged in 15 minutes of therapeutic reaching activity prior to dressing to enhance active shoulder

motion in preparation for dressing. Skills required for dressing have improved, client now requires only moderate physical assistance to complete dressing tasks. Skilled

intervention of OT practitioner continues to be required for design and administration of appropriate therapeutic activities to continue skill development.

A:Improvements in ADL performance and shoulder mobility continue. Client continues to benefit from OT services including ADL retraining and functional activities to address

UE weakness and limited AROM.

P: Continue with current plan of care 2x/week for 60 minute sessions.

Person-centered Electronic Record For

Outcomes Reporting and MeasurementEMR developed in partnership between

Cedaron and the American Occupational

Therapy Association

Summary

• Occupation based practice and documentation are not just a nice idea, they are necessary

• Use of tools that provide insight into the needs, wants and desires of the client will actually make goal writing, intervention planning and documentation much easier

• Base problems on client reported participation deficits that are classified as OCCUPATIONS in the Framework

• Use the test of occupation-based problems

• Create LTG’s that specifically address the problem (when LTG is

reached, problem is resolved)

• Create STG’s that are components of LTG’s. Upgrade STG’s as

needed until LTG’s are reached

References

American Occupational Therapy Association. (2014). Occupational therapy practice

framework: Domain and process, (3rd ed.). American Journal of Occupational Therapy,

68(Suppl. 1), S1-S48.

American Occupational Therapy Association. (2013). Guidelines for documentation of

occupational therapy. American Journal of Occupational Therapy, 67(6 Suppl.)S 32-S 39.

Brennan, C. (2007). Documentation: The key to successful justification of occupational

therapy services. AOTA AudioInsight Seminars. Bethesda, MD: AOTA.

Brennan, C., & Robinson, M. (2006). Documentation: Getting it right to avoid Medicare

denials. OT Practice, 11(14), 10–15.

References

Cedaron: AOTA Perform http://www.cedaron.com

Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated

Centers for Medicare & Medicaid Services. (2015). Medicare benefit policy manual (Internet-only manual, Pub. 100-02, Ch. 15). Available http://www.cms.hhs.gov/manuals/IOM/list.asp

Chapter 15 Covered Medical and Other Health Services

https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/

Downloads/bp102c15.pdf

Eschenfelder, V. G. (2005). Shaping the goal setting process in OT: The role of meaningful occupation. Physical & Occupational Therapy in Geriatrics, 23(4), 67-81.

Quinn, L., & Gordon, J. (2010). Documentation for Rehabilitation: A Guide to Clinical Decision Making, (2nd ed.). Saunders.

The End

• Thank you…..

Questions or comments?

Debbie Amini

[email protected]

Objectives Occupation -Based Practice … for Occupation -Based Practice Debbie Amini, EdD , OTR/L,...

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Transcript of Objectives Occupation -Based Practice … for Occupation -Based Practice Debbie Amini, EdD , OTR/L,...