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       ECI  DOCUMENT 0609

Continuing Education (CE)
Licensure vs. Certification
Referrals
Supervision
Practice Questions

Continuing Education (CE)

Q: Can extra continuing education contact hour be carried over to the next renewal cycle?
A: No. The Board requires you to obtain 30 hours of continuing education for each 24-month renewal cycle. Everyone gets the same amount of time to earn the same number of continuing education. However, if you earn more than 30 hours in a renewal cycle, the Board does not consider the CE "wasted." Any time a licensee get training or education; it benefits the patients as well as the therapist.

Q: Does an inactive licensee have to do continuing education?
A: Yes. The Board wants the inactive licensee ready to come back to work at any time. The CE keeps the licensee on-track with the profession. The inactive licensee is also part of the continuing education audit.

Q: Are the courses in Occupational Therapy Theory or Occupational Science, Frames of Reference and Foundation knowledge counted as Type 2?
A: Yes. The Board recognized that OT practice and skills on built on this competency for decision making.

Q: Can I use weight training as a Type 2?
A: Yes if you are using that technique with your patients.

Q: Can I watch videos?
A: Yes. However they must still fit into Type 1 and Type 2 criteria. Also the course must require a post-test, and provide a certificate of completion for your files. All CE must be relevant to occupational therapy and fit into all criteria as written in rule Chapter 367. Continuing Education.

Q: My mail contained information about workshops which are approved for Florida or PT or Ohio; does that mean the Board approves them?
A: No. There presently is not an approval method in place by the Board. Rather you should use your professional judgment to ask yourself these questions:

1. Does the course teach me skills specific to occupational therapy practice with patients or clients? That's Type 2. If you cannot tell from the brochure, call the course provider and ask this question.
   
2. If the course is applicable to professionals such as quality improvement, Documentation, e.g., CPT coding, TWCC, PPS, Medicare, Medicaid; General information such as "What is Autism," these fall into Type 1 or general information. Please read Chapter 367 concerning Continuing Education for more information.
   

Q: What do I need to have for an audit?
A: Send in certificates of attendance, certificates of completion, college transcripts, sign-in sheet for in-service, or employer computerized facility training.

Q: Can I sign the renewal form affidavit before I finish the 30 hours?
A: No. The course you are signed up for to finish your hours could be cancelled; there could be an illness or weather problems which prevent you from attending. When you have finished all your CE mail your renewal. You can always mail it overnight.

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Q: Please explain about OT services and ECI.
A: In Texas, when special instruction is medically necessary, it is now called developmental service (DS). CMS agreed to reimburse for DS as long as the child receiving the service had a medical necessity for developmental services and personnel on the interdisciplinary team included professionals from a medically related field. Medically related professionals include licensed physicians, registered nurses, licensed physical therapists, licensed occupational therapists, licensed speech/language pathologists, licensed professional counselors, and licensed master social workers-advanced clinical practitioners.

DS is a separate and distinct service. If appropriate, the licensed professional on the team may provide his or her own related professional service at the needed frequency and intensity, or refer to another appropriate medical provider whenever indicated through the IFSP process. A physical therapist may provide consultation and supports to a DS provider or deliver physical therapy directly, or both, depending on what the interdisciplinary team deems appropriate for a child. Depending on need, a child may receive both DS and PT and/or OT. DS does not replace physical or occupational therapy. For AOTAs explanation please click here for PDF document.

Q: What is the difference between my role as an OTR in an Early Childhood Intervention (ECI) setting and my role providing Developmental Services (DS)?
A: In an ECI program, an OT might do one of the following.

1. provide occupational therapy services to client families based on an OT assessment
2. serve as a case manager (called a Service Coordinator in early intervention program) to program client families (may or many not be the same families served in OT role)
3. Serve as a program supervisor, manager or administrator
4. provide training to other professionals
5. one of seven designated professionals )OT, MD, RN, PT, SLP, LPC, LCSW) who can provide Developmental Services (DS) monitoring or DS services for children participating in Early Childhood Intervention (ECI).  The designated professional monitoring DS needs to attend or review any Individualized Family Service Plan (IFSP) for the child receiving DS and assess the child's needs at a minimum of once a year.

Children receive DS services as a result of the IFSP.  Once the child's outcomes are developed by the team, which includes the parent(s), the team decides who would be the most appropriate person to assist the family with the outcome/strategies.  Besides the Early Intervention Specialist (EIS) anyone of the seven professionals could provide DS services and, as an example, in some ECI programs an occupational therapist may provide 30 minutes of occupational therapy and 30 minutes of DS services.  The DS services may be a more generalized fine motor session that would not necessitate an occupational therapist to provide.  The EIS has an overview of general early development and training in working with families in the natural environment.

Q: Do I need a referral for school practice?
A: The TBOTE Rules do not require a referral for OT for non-medical conditions. Based on the definition in the Rules, this would include ADHD. Other examples of non-medical conditions would be cerebral palsy, learning disabilities, autism, and spina bifida. This is not an exhaustive list, and in all cases the presumption is that the child with the disability is otherwise healthy. In each of these cases, the disability is static, not acute or progressive. Many folks take medication to help manage symptoms (antihistamines, decongestants, seizure meds, stimulants for ADHS etc.). It is important to know if the child is taking a medication so precautions can be adhered to, but just the fact that someone takes medication does not require the OT to get a referral.

Examples of medical conditions that would require a referral would be for a student with cancer, rheumatoid arthritis, muscular dystrophy (might not be needed during times of stability, but would be needed during times where the student is clearly degenerating and functional or medical status is changing), or when a CP child has a rhizotomy or gets a baclifen pump. The flu or another virus is not cause for a medical referral, but significant change in medical status or functional condition would be. At some facilities they get a medical referral on an annual basis, the but Rules do not specify a frequency.

Q: We recently had an ARD (Admission, Review & Dismissal) on a child where the parent disagreed with both the OT time and goals. The student’s former IEP (Individualized Education Program) is expired but the parent wishes for us to continue services. We have revised the IEP, which still does not satisfy the parent though she still wants us to continue with services. How do we proceed?
A: Sometimes parents disagree with the IEP developed by the ARD Committee (IEP team). They may disagree about instructional issues, placement or related services issues. Sometimes occupational therapy is the issue, either because parents desire the service for their child when the rest of the team does not see the need, or there is disagreement about the amount of time required (parents desiring more time than the team feels necessary). There are several ways the parent may proceed, including the following:

1. The parent can agree to disagree, signifying their disagreement by checking "disagree" by their signature on the ARD paperwork, but indicating they do not desire to pursue a remedy (mediation or hearing). In this case, the new IEP takes effect and everyone moves forward with the new plan.
2. The district can "table" the meeting -- i.e., hold a 10-day recess, during which time both the district and the parents can gather any further information that may help the IEP team move forward to consensus. At the end of 10 days, the IEP team reconvenes to complete the discussion and come to a final decision. At this juncture, if the parents still disagree, they can decide whether to move forward to mediation, a due process hearing, or do nothing. If they do nothing, the new IEP goes into effect. If they file for mediation or a hearing, there is a "stay put" requirement. That means that the old IEP (with all services provided as specified in that IEP) stays in place until the dispute is resolved through the mediation or hearing process.

In order for occupational therapy or any other related services to be provided, Texas Rules require a written Plan of Care based on a current occupational therapy evaluation. In the case of school practice under IDEA, the Plan of Care is the IEP, specifically the relevant goals and objectives being supported by occupational therapy (collaborative goals and objectives are fine, as long as it is clear in the written document what OT is supporting). So, in answer to your question, there must be an IEP in place in order for OT to be provided. When confusion arises in cases of disagreement, school-based OTs and OTAs should look to the district special education administration for guidance regarding which IEP to follow. If there is no IEP, an ARD meeting must be held to decide which goals and objectives OT will address before any services are provided.

http://www.tea.state.tx.us/special.ed/

Finding a way to support speech goals may be difficult (what is OT “relating” to?). The OT should work with the ARD committee to determine if there is an education need for occupational therapy, and if so, to develop goals that support the student’s special education program.

Q: Can an Occupational Therapist write the Restorative Nursing Program for a patient?

Q: I have had a director of Special Education ask me about OTs refusing to do sensory integration therapy in the schools.  There are more and more demands for SI therapy in the schools, many times by parents, and the director wanted to know what position she should take with her OT. What do you suggest? 
Q: To me, if the OT does not feel she has the competence to safely serve children using a sensory integration model, then she should not be using the techniques.  How would you advise?

A: Sensory Integration/Sensory Processing is one of the theoretical frames of reference in occupational therapy.  ALL occupational therapists working in schools should have a working knowledge of Ayres' original work in this area and also of the current work by Winnie Dunn, Lucy Jane Miller and others that is contributing to the evolution of thought regarding this framework (as with any profession, keeping up with the literature is critical to practice competency).

Through observation of the student in context, and, through use of assessment tools such as the Sensory Profile School Companion and Sensory Processing Measure for Home and School, any occupational therapist should be able to detect atypical sensory processing as part of the OT evaluation, and be able to document whether or not it is contributing to learning and participation difficulties. If a student is identified as having atypical sensory processing that is interfering with his learning and participation, any occupational therapist should be able to provide strategies to the IEP team that can be incorporated into his daily routines at school (including features of a sensory diet, using auditory or visual cues and/or social stories to prepare the student for transitions, consulting with the teachers to ensure sensory motor opportunities are included in his recess time and PE program, etc.). 

Under both IDEA 2004, and the No Child Left Behind Act of 2001, providers (teachers & related services personnel) must ensure their practices are evidence-based. The OT should stay abreast of the evidence for all interventions, including sensory-based interventions. At present (2008), there is research occurring to determine whether a "sensory processing disorder" exists separate from diagnoses of anxiety disorder, ADHD or Autism (see http://www.spdnetwork.org/research/index.html), and research comparing aspects of sensory processing to temperament (http://classes.kumc.edu/sah/resources/sensory_processing/summary_research/conceptual_articles.htm).  The IEP team (called the ARD Committee in Texas) has the ultimate responsibility for developing the IEP.  The OT presents his or her data from assessment to add to the data others have contributed to the Full and Individual Evaluation (FIE).  From all the data collected for the FIE, the IEP team decides 1) what the student's goals and objectives should be for the upcoming year, and 2) what supports and services are needed to help the student succeed.  IDEA 2004 stipulates that a related service must be provided if needed to assist the child to be involved and progress in general ed curriculum, to advance appropriately toward attaining the annual goals, and/or to participate in extracurricular and other nonacademic activities with other children with and without disabilities. However, the question that IEP teams must answer, as so beautifully expressed by Mary Muhlenhaupt, OTR, is not "Does Johnny need OT at school?," but rather, "Does an OT’s knowledge and expertise provide a needed component of Johnny’s program that will achieve identified outcomes?”  If the answer is yes, the OT needs to determine theoretical framework(s) for intervention planning (SI/SP, Motor Learning, Psychosocial, etc.) that offer the greatest opportunity for support in context. This information would not be stipulated in the IEP, as trials of several approaches may be necessary before determining the appropriate approach(es) for an individual student.  Data collection on student response to intervention and progress monitoring on IEP goals should be a routine part of all occupational therapy service in schools.

The Occupational Therapy Practice Framework: Domain and Process (2002), available at AOTA, should guide all OT practice, including school practice. 

Selected References

A Guide to the Individualized Education Program. (2000, July).  Jessup, MD:   (Available at [http://www.ed.gov/offices/OSERS] http://www.ed.gov/offices/OSERS).

Bundy, A. & Murray,E. (2002).  Sensory Integration: Theory and Practice (2nd Edition).  Philadelphia:  F.A. Davis.

Developing Educationally Relevant IEPs: A Technical Assistance Document for Speech-Language Pathologists. (2000, September).  Reston, VA: The Council for Exceptional Children.

Dunn, W., The Sensations of Everyday Life: Empirical, Theoretical, and Pragmatic Considerations (the 2001 Eleanor Clarke Slagle Lecture. The American Journal of Occupational Therapy.  55 (6).  608-620.

Dunn, W., Myles, B.S., & Orr, S. (2002).  Sensory Processing Issues Associated with Asperger Syndrome: A Preliminary Investigation. The American Journal of Occupational Therapy.  56 (1). 97–102.

Dunn, W. (1999). Sensory Profile.  San Antonio, TX: Psychological Corporation.

Foss, A., Swinth, Y., McGruder, J., & Tomlin, G., (2003, July). Sensory Modulation Dysfunction and the Wilbarger Protocol: An Evidence Review. OT Practice. CE 1-7.

Miller, L. J. (2003, February).  Empirical Evidence Related to Therapies for Sensory Processing Impairments.  NASP (National Association of School Psychologists) Communique, www.nasponline.org/publications/cq312si.html.

Miller, L. J. (2008, April 12). Physiological Measurement of Sensory Modulation Disorders. Presentation at AOTA Conference.  Long Beach, CA.

Muhlenhaupt, M. (1998, December). Does Johnny Need OT in School?  OT Practice. 26-28. 

Muhlenhaupt, M. (2000, December). OT Services Under IDEA 97. OT Practice. 10–13.

Mulligan, S. (2003, March). Examination of the evidence for occupational therapy using a sensory integration framework with children: Part one.

Sensory Integration Special Interest Section Quarterly, 26, 1-4. Mulligan, S. (2003, June). Examination of the evidence for occupational therapy using a sensory integration framework with children: Part two.

Sensory Integration Special Interest Section Quarterly, 26, 1-5. )

Swinth, Y., & Mailloux, Z. (January 28, 2002).  Addressing Sensory Processing in the Schools. OT Practice.  8 – 13.

Vargas, S. & Gregory Camilli (1999).  A Meta-Analysis of Research on Sensory Integration Treatment.  The American Journal of Occupational Therapy.  53 (2). 189 – 198.

Written by: Jean Polichino, MS, OTR, FAOTA; Director, Therapy Services Division, Harris County Department of Education.

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