Prof Dev Midterm Study Guide

Core Critical Thinking Skills

• Interpretation

• analysis

• evaluation

• inference

• self-regulation

Interpretation

to comprehend and express the significance of a wide variety of experiences, situations, data, events etc

analysis

to identify the inferential relationships statements, questions, experiences, information, opinions…

evaluation

to assess the credibility of the statements which describe the person’s perception, experience, situation, judgement, belief of opinion

inference

identify and secure elements needed to draw reasonable conclusions

explanation

present in a cogent and coherent way the results of one’s thinking and how they arrived at the judgement (answers to Qs should show thought)

self-regulation

apply the powers of critical thinking to oneself and improve on previous opinions

disposition towards critical thinking…characteristics

• clarity in stating questions

• orderliness in working with complexity

• diligence seeking relevant info

• reasonableness in selecting and applying criteria

• care focusing attention on concerns

• persistence through difficulties

• precision to the degree permitted

cognitive heuristics

thinking maneuvers that influence system 1 and system 2 thinking

system 1 thinking

• quick, holistic, associational judgements

• automatic, well-trained, reactive (soft skills)

• good for big picture thinking but lacking detail

system 2 thinking

• renders considered, deliberative judgements (reflective, reasoned, systematic)

  • Makes thoughtful, careful decisions based on reflection and reasoning.

• requires more time to reflect to find a solution

• great on details, poor on seeng the big picture

• can bolster or override system 1

Types of professional reasoning

• scientific: condition, theory, “typical pathway

• diagnostic: blend of science and subjective client-based info

• procedural: therapy regimes based on science, habit or culture of the practice setting (includes transfer of knowledge from work with other cases)

• narrative: used to understand the client’s situation based on their story and personal experience with the condition (allow client to tell you about themselves)

• pragmatic: realities of services delivery (scheduling, payment, skills) - limitations are often related to insurance

• ethical: “right” action with competing principles, risks, benefits - check the legality of actions according to state/federal law)

• interactive: used to form collaborative interpersonal relationships (approach to family dynamics to build the best relationship)

• conditional: blending of all forms

Novice

• no experience in practice and depends on theory

• heavy on procedural reasoning, no context clues due to lack of experience

• narrative reasoning to establish social relationships

• stress is on pragmatic reasoning

• sees overt (obvious) ethical issues

progressing novice

• must know assessments and how to administer

• professional reasoning allows for knowing what evals and interventions should be done and why

• better observational skills

• can tell how a session is going and what to adjust for better outcomes

advanced beginner (<1 year)

• recognizes repeated, meaningful situational components

• start of using experimental knowledge to guide choices

• may still struggle to prioritize (inclusion and exclusion)

• increase in skill of pragmatic and narrative reasoning

competent (1-3 years)

• mastery within a population with increase in organization and efficiency

• long term goals awareness grows

• may still be stuck in system 1 thinking

• good for FWE-articulates theories well

proficient (3-5 years)

• sees big picture in a situation

• holistic understanding and improved decision-making

• creative combination of different diagnostic and procedural reasoning approaches

• learns from experience to inform expectations and adapt plans

expert (5-10 years)

• no reliance on principles, rules, or guidelines to determine actions (serve as references if experience is insufficient)

• procedural and pragmatic reasoning occurs in greater detail

• intuitive in clinical situations

• performance is flexible and proficient

STATE (Patterson article)

• S: Share your facts (not controversial/arguable)

• T: tell your story (explain what your conclusion is given the facts)

• A: ask for others’ paths (invite others to share their facts and path)

• T: talk tentatively (present your conclusion as a story rather than as a fact)

• E: encourage testing (create a safe space for disagreement)

types of supervision

• administrative supervision

• clinical or professional practice supervision

• functional supervision

administrative supervision

• focus on performance and ensuring prof development meets employing or standards

• ex) attendance, schedules, benefit usage, appropriate completion of job tasks

• other professionals can do this for OTs

clinical/professional practice supervision

• focus on provision of support, training, eval of supervisee’s prof performance

• ex) improving interviewing skills, use of OT techniques, and professional reasoning

• can only be provided by a member of the supervisee’s field

functional supervision

• provision and oversight for a specific skill the supervisee must develop

• ex) proficiency in wheelchair assessment and positioning

OT

• MSOT/OTD entry level

• responsible for eval and service decisions (big picture)

• all parts of service

• advocates, supervises, leads

• at minimum, weekly review and inspection of all aspects of OT services by the OTA

• makes treatment plan with OTA input

OTA

• technical degree AA/AS and assist with eval

• experts in intervention (not making decisions/interpretations)

• no completion of documentation: can advocate, supervise and lead

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OT:OTA ratio

• 3:1 is the highest acceptable ratio

• supervision must be decided by OTA knowledge, skill, and OTA

Methods of OTA supervision

• direct, face to face: observing, modeling, client demos, discussion, teaching and instruction

• indirect: phone convos, written correspondence, electronic exchanges

Reimbursement - Who Pays?

• grants

• foundations

• insurances

  • private

  • managed care

  • medicare

• subsidized government - Medi-caid (Medi-Cal)

• private pay

Part A vs Part B

• Part A: hospital insurance

  • covers inpatient stays

  • no monthly premium

  • SNF coverage requires 3 night qualifying acute hospital stay, with 7 days/week nursing and 5 days/ therapy

  • pays through PPS, where amount is set before services are deliered

• Part B: medical insurance

  • covers doctors’ services and outpatient care

  • funded by monthly premiums from those who enroll, plus a yearly deductible

Part A pays by setting

• acute hospitals : DRG

• SNF": RUGs based on the MDS

• Home health: case mix from OASIS, paid every 60 days

Part B

• part b pays through the medicare physician fee schedule using CPT codes

• timed codes follow the 8 minute rule

Part C (Medicare Advantage)

private option

Part D

drug plan

IRF rules

• 60% of patients must have 1 of 13 diagnoses, tolerate 3 hours of therapy, receive therapy from 2 disciplines, one of which is OT or PT

Medicare coverage requirements

• qualified OT or OTA under supervision provides treatment

• physicians order is required

• treatment is reasonable duration/amount

• furnished under a plan of care

• results in practical functional improvement

Medicaid

• joint federal/state, means tested and varies by state

• OT is an optional benefit, states may limit visits

CHIP (1997)

covers children in families that don’t qualify for Medicaid

IDEA

funds school-based services with most financing from local taxes, and guarantees a Free and Appropriate Public Education (FAPE)

who counts as a third part payer

• Private insurance (employer-sponsored, private non-group)

• Managed care (HMO, PPO, POS)

• Medicare (Parts A, B, C, D)

• Medicaid and CHIP

• Workers’ compensation

• Self-insured employers, who fund their own plans and decide which services to cover (for example, whether to include OT)

Prospective Payment System (PPS)

medicare pays a predetermined amount based on patient classification, not on what the provider bills after the fact

Diagnostic-Related Group (DRG)

• PPS method for inpatient acute care hospitals under Part A

• hospital gets one fixed payment per stay based on the diagnosis and all charges fall under the same amount

• result: shorter hospital stays and more patients discharged to SNFs, home health, rehab

Patient-Driven Payment Model (PDPM)

• PPS method for Part A skilled nursing facilities

• replaced RUGs

• pays based on patient characteristics (GG)

• quality and performance

Resource Utilization Groups (RUGs)

• replaed by PDPM

• payment classification system for Medicare Part A skilled nursing facilities

• paid mainly by therapy minutes

Patient-Driven Groupings Model (PDGM)

• PPS method for home health

• classification is based on patient characteristics, using OASIS items (grooming, dressing, bathing, etc)

Fee for service (FFS)

• providers are paid for each service they deliver after the fact

• the more services billed, the more the provider is paid

• payment is retrospective, based on what was billed

• Medicare Part B

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who must demonstrate and document service ompetence under the AOTA supervision guidelines

• Both OTs and OTAs

• show competence in clinical and professional reasoning and in specific assessments, techniques, and interventions

• aides must show competence before performing tasks

what should an OTA not accept when delegated responsibilities?

tasks beyond their legal and professional scope, or beyond their demonstrated skill and competence

what factors does the OT consider when delegating to an OTA

• the complexity of the client’s condition

• OTA knowledge, skill, competence

• complexity of the intervention

• needs of the practice setting

• scope of practice

• payer requirements

what must an aide do before performing delegated tasks

• demonstrate competence

• must be trained on the task and equipment

• know precautions and warning signs

• must not perform billable functions

how can aide competence and supervision be documented

with an orientation list, performance review, skills checklist, or in-service participation

what can supervision documentation include as evidence of competence

• frequency of contact

• methods of supervision

• content areas

• evidence of areas of practice and levels of competence for the setting

what question in pragmatic reasoning relates to competency before taking a case

“what are my practice competencies”

Benner’s levels of proficiency

• novie, advanced beginner (under 1 year)

• competent (1-3 years)

• Proficient (3-5 years)

• expert (5-10 years)

Role delineation

• defining the skills, tasks, and educational qualifications for a job

• step forward toward establishing competency, because you define what the role requires before showing someone meets it

who can provide medicare-covered OT treatment?

• qualified OT or an OTA under supervision

• requires physicians order, plan of care, reasonable duration and amount, and practical functional improvement

what should billable-service documentation show

• unique skills of an OT

• complexity of the service

• therapeutic rationale

• document what you did to effect change, not just what you did during the session

sequence for establishingand keeping service competency

1. define role and scope

2. self-check your competencies and place yourself on Benner’s scale

3. close gaps through supervision, mentoring, continuing education and certification

4. demonstrate competence

5. document it

6. maintain it through continuing competence and professional development

7. tie it to payment: qualified provider, and documentation of skilled care