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OCTH 754 final

QuestionAnswer
tool used to articulate that OT care is grounded in concept of meaningful occupations, looks at domain and context OTPF
having to do with politics, country's system for governing members; ex. high-functioning disabilities not fitting definition, insurance policies political
interaction between people, family, and social supports impacting family and community relationships; ex. language barriers, support system social
factors that determine financial situation, status of trading goods and services; ex. insurance, vehicle access economic
uncontrollable identifying info that influences diversity, background and similarities in specific areas, cultures; ex. culture's belief of healthcare demographic
characteristics describing area, latitude and longitude, culture; ex. access within town geographic
all people should have the opportunity to participate in everyday occupations regardless of who they are occupational justice
policies and other things that restrict participation in everyday occupations of individuals and populations occupational injustice
inclusion through occupational participation occupational rights
social exclusion from participating in occupations occupational alienation
exclusion from participation based on context occupational deprivation
restricting population from participating in occupations when others have more opportunity occupational imbalance
"we envision that OT is a powerful, widely-recognized, science-driven, evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs" centennial vision
what two things are consistent focuses of centennial vision mental health and universal design
strategies: build capacity for profession's potential and mission; demonstrate value of OT; build inclusive membership community; linking education, research, and practice centennial vision
"as an inclusive profession, OT maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living" vision 2025
strategic principle guiding AOTA: diversity, equity, and inclusion woven throughout AOTA; promotes these values in OT transform
strategic principle guiding AOTA: policies, payors, and public-level efforts advocate
strategic principle guiding AOTA: resource for knowledge, professional development, and leadership build
occupational/job, education, and income achievements; can be for individuals or families; ex. access, quality of life, health quality socioeconomic status
conditions in which people are born, grow up, live, work, and age; ex. economic stability, education access and quality, healthcare access and quality, built environment, social and community context social determinants of health
group of individuals that share a common situation, social differences/implications between groups; ex. lower, working, middle, upper class
when individual groups in society do not have equal access to opportunities and rewards, demographics; ex. gender, sexual orientation, ethnicity, age, disability, and wealth; this is unfair, unjust, avoidable, and unnecessary social inequality
gap in access to healthcare, treatment provided, and health outcomes that are unfair and/or related to social inequalities or actions of health professionals; ex. refusing care for a specific demographic group health disparity
dimension of access to services: amount/type of services based on population need; ex. lack of a children's hospital in an area, transportation, lack of access in rural areas availability
dimension of access to services: location/supply related to population location and transportation; ex. transportation, lack of access in rural areas accessibility
dimension of access to services: organization/appropriateness of services, population's ability to use services; ex. work hours, 24/7 ERs accommodation
dimension of access to services: attitude between provider and population; ex. language, culture, religion, culture, SES acceptatbility
dimension of access to services: price related to ability to pay; ex. insurance does not ensure access, authorization, out of network, preferred providers, specialized care affordability
reformed US healthcare by expanding access to affordable and quality services, expanded coverage to include millions of Americans Patient Protection and Affordable Care Act
expanded coverage of prev health services, expanded Medicaid & CHIP, linked payment to outcomes for Medicare, mental health & substance abuse services, rehab & preventative care, eliminating lifetime benefits, prohibiting denial or pre-existing conditions Patient Protection and Affordable Care Act
created insurance marketplace and exchange where people could buy/shop for insurance rather than employer-provided Patient Protection and Affordable Care Act
the Patient Protection and Affordable Care Act provides free ____ ____ such as wellness checks, screenings, and vaccines preventative care
ended lifetime and yearly dollar limits Patient Protection and Affordable Care Act
this population is more likely to delay or forego care due to costs, less likely to receive preventative care and services for major health conditions and chronic diseases, often face unaffordable medical bills when they do seek care uninsured
under what did states expand Medicaid coverage to low-income adults Patient Protection and Affordable Care Act
provision of integrated, accessible healthcare services through sustained partnership with client in context of family and community, comprehensive care involving a team-based approach for addressing community needs primary care
since Patient Protection and Affordable Care Act there is an increased emphasis on what three things manage chronic diseases, improving population health, preventative services
quadruple aim-improving experience of care, improving population health, reducing cost of care, caring for physicians to help reduce burnout primary care
occupational engagement impacts management of chronic conditions and improves health and wellness, maximizing strengths and addressing barriers, developing habits and routines to promote a healthy lifestyle OT's role in primary care
codification of shared values of a society, serve to address ways issues/challenges are handled, divided into categories based on populations they serve and values they represent public policies
in the US, which type of leadership has the Constitution as their source of power and has the roles of financing, regulation, organization, and delivery government
in the US, which type of leadership has capitalistic markets as their source of power and has the roles of financing, organizing, and delivery free enterprise
type of government: individualism, healthcare is an earned reward through employment, and private charities treat the poor libertarian
type of government: society is the source of responsibility, healthcare is a prerequisite for work, and government programs treat the poor egalitarian
type of government: society is the source of responsibility, healthcare is based on the greatest good for the greatest number, treatment of poor is part of public health initiatives utilitarian
basic principle that deals with fairness and equitable entitlement in distribution of resources, goods, and services justice
concerned with deciding who gets resrouces when they are limited distributive justice
who is the biggest OT advocate AOTA
ethics and motivation, knowledge of systems and processes, assertive communication skills for advocacy
type of advocacy: helping a client who can not help themselves, empowering/providing resources to client, requires OTs and clients to have knowledge on reimbursement, most common type client advocacy
type of advocacy: advocate for OT referrals when appropriate, appropriate and ethical behavior of peers professional advocacy
type of advocacy: being informed on issues, lobbying, involvement in professional campaigns legislative and regulatory advocacy
what is the largest type of insurance coverage in US employer - based
protects individuals and organizations from financial loss; contract identifies covered services, patient costs, cost limits; contract between carrier and patient or carrier and provider insurance
criteria set by carrier of who can join risk pool eligibility
medical illnesses or injuries diagnosed by provider, often lists events that aren't too covered events
benefits available based on type of covered event covered services
rules that limit cost of services; ex. overall plan limit, out-of-pocket limit, deductible, co-payment, co-insurance beneficiary cost limits
amount available over a lifetime of a covered member overall plan limit
amount beneficiary is required to play during a plan year, limits on use of covered services; includes deductible, co-payment, and co-insurance out - of - pocket limit
amount paid before reimbursement begins deductible
percent of cost responsible for co - insurance
amount paid each time service is received co - payment
essential coverage limits providers must understand; reimbursement; ex. case rate, fee schedule, capitation provider cost limits
procedure, inclusive payment, ex. per diem/visit case rate
flat fee for a set period, ex. 1 month of care capitation
list of procedure payments, services covered under scope of practice, negotiated between provider and carrier fee schedule
type of reimbursement plan: work-related coverage or commercial, privately purchased coverage private medical insurance
type of reimbursement plan: Medicare or Medicaid public medical insurance
type of reimbursement plan: personal out-of-pocket payment, no coverage, pay for services rendered self - pay
varying inpatient coverage, not all include outpatient coverage, high or low deductible plans, flexible spending accounts available, usually reimbursed fee for service, limits on services and $ amounts private medial insurance
often requires pre-authorization before services, most require physician referral, coverage based on diagnosis and number of visits, restrictions may be yearly or per incident, restrictions out of network private insurance OT coverage
coverage for those 65+, under 65 with certain disabilities, and people of any age with end-stage renal disease; must be under a physician's care; services must be reasonable and necessary; paid for by government, payroll taxes, and premiums Medicare
part of Medicare: covers inpatient PPS acute hospital, critical access hospital, SNFs, home health, inpatient rehab facility, inpatient psychiatric hospital part A
potential consequence of using a diagnostic-related group for payment may encourage a focus on shortening stays
defined by needing a supportive device, special transport, and/or requires assistance from others to leave home; has inability to leave home without extensive effort; exception for medical appointments homebound
part of Medicare: pay 20% after deductible is met; fee-for-service payment; covers hospital outpatient departments/clinics, SNFs, OT services in SNFs, home health, outpatient rehab, private practice part B
requires evaluation, certified plan of care, treatment encounter notes, medical necessity, progress reports documentation
part of Medicare: managed by external insurance payers, may require pre-authorization, functions more like private coverage, should follow Medicare rules and regulations, bundled and fee-for-service payment part C
federally- and state-funded programs; eligibility: low-income elderly, kids, pregnant women, those with disabilities, parents with low income; reimbursement rates are low Medicaid
what percent of people enrolled in Medicaid are children 43%
type of pediatric funding: program that provides reasonable health coverage for kids (not families) in low-income families but earn too much for Medicaid, administered by states CHIP
type of pediatric funding: coverage for screening and diagnostic services up to 21 years; covers medical visits, vision, hearing, and dental early and periodic screening, diagnosis, and treatment
type of pediatric funding: Medicaid must pay for education-related services that are medically necessary; IDEA schools / early intervention
provides a standard language when describing function and disability; framework rooted in person, their performance, and their performance context; health is defined as a good match between person's health status and context surrounding activities International Classification of Function
focuses on changes in body structure and function, person's level of capacity, person's level of performance; used by WHO along with ICD-10 International Classification of Function
problems in body system, physiological or psychological impairment
execution of task or action activity
involvement in a life situation participation
difficulties with executing activities activity limitation
problems experienced in a life situation participation restriction
physical, social, and attitudinal environment in which people live and conduct their lives; can be barriers or facilitators to person's function environmental factors
allows for a standardization for reporting across disciplines and countries; important for advocating for OT outside of US, understanding and applying EBP across countries, understanding rates of disability and limitations across the world, dev. practice International Classification of Function
promotes OT internationally; promotes right to access of occupations and works against global conditions that threaten the right to occupation including poverty, disease, and social determination, displacement, natural and man-made disasters, and conflict World Federation of OT
important work and resources on human rights and OT, environmental stability and OT, diversity and inclusion in OT, COVID and pandemic responses affecting OT World Federation of OT
global healthcare payment model: social health insurance model; employers and employees contribute to sickness funds, private insurance covers everyone, government controls cost; France, Germany, Netherlands Bismark model
global healthcare payment model: national health service; government is sole payer through central health service standard benefits for all, no out of pocket costs; Australia, Ireland, Italy Beveridge model
global healthcare payment model: publicly run plan that everyone contributes to, private sector providers, no claim denials, medical necessity is defined nationally, government processes all claims; Canada and Taiwan National Health Insurance model
global healthcare payment model: market-driven healthcare; wealthy can purchase commercial insurance, if no insurance or can't afford patients pay for procedures out of pocket, no cost controls in place; Chile, China, Nigeria Out of Pocket model
how many tribes are there is SD 9
what percent of SD's population is AI/AN 8.3
how many federally-recognized tribes in US 574
person belonging to tribal nations of continental US and tribal nations of Alaska American Indian / Alaska Native
all native people of US and its territories as well as people from Canadian First Nations and Indigenous communities in Mexico and Central and South America who are US residents Native American
eligibility: set by each government, require lineal descendance from citizen, blood quantum requirement tribal citizenship
each tribal nation determines their own criteria sovereign nation
states with highest population of AI/AN Alaska, Oklahoma, and New Mexico
where is IHS headquarters Rockville, Maryland
mission: raise physical, mental, social, and spiritual health of AN/AIs to the highest level; vision: healthy communities and quality healthcare systems through strong partnerships and culturally-responsive practices Indian Health Service
goals: ensure that comprehensive, culturally-appropriate personal and public health services are available and accessible; promote excellence and quality through innovation; strengthen program management and operations Indian Health Service
head of this area is located in Aberdeen, SD; tribal involvement is a major objective of the program and several tribes have assumed management of their healthcare systems via contractual arrangements with IHS Great Plains Area IHS
Department of Interior, DHHS, Administration for Children and Families, Department of Education, Department of Justice, Housing and Urban Development federal agencies that provide funding for IHS
this population dies at higher rates than others from tuberculosis, diabetes, suicide (highest rate in youth among all groups in US), alcoholism, vehicle crashes, injuries native Americans
history of genocide and boarding school experiences have led to what along with poor health outcomes historical trauma
traumatic events before age 18; strong predictor of risk for numerous chronic and behavioral health outcomes; include poverty, racism, and substance abuse; can lead to depression, anxiety, and poor health outcomes ACEs
describes what OTs do and why, tells or story to government entities or other payers and researchers, avoids denials coding
descriptions of various procedures provided, supplies and DME are not included, 5-digit number codes describing medical services provided that show up on patient billing, required for reimbursement, service-based or time-based current procedural terminology codes
type of CPT code: billed as 1 unit regardless of time it takes to complete; accounts for varying complexity of clients, not being charged or reimbursed more or less for time; ex. evaluation codes, PAMs service - based codes
type of CPT code: per 15 minutes of therapeutic modality, Medicare 8-minute rule vs. AMA rule of 8s or Midpoint Rule, site of employment typically determines which method to follow time - based codes
type of time-based coding: allows therapists to bill for a unit that lasts at least 8 minutes but not exactly 15 minutes, timed services only, created by CMS Medicare 8 minute rule
type of CPT code: evaluation of significant changes in client's functional or medical status; revised plan of care to create new goals or update; update to initial OT profile reflects changes in conditions and goals re - evaluation codes
0 units = 1-7 minutes, 1 unit = 8-22 minutes, 2 units = 23-37 minutes, 3 units = 35-52 minutes, 4 units = 53-67 minutes Medicare 8 minute rule
midpoint of substantial portion rule, 1 unit requires at least 8 minutes to bill for a service, may be used by private insurance payers, each service is reviewed and assigned units separately AMA rule of 8s
if a client does 40 minutes total of therapy (33 of one code and 7 of the other) how would Medicare 8 minute rule bill that 2 units of one code and 1 unit of the other
if a client does 40 minutes total of therapy (33 of one code and 7 of the other) how would AMA rule of 8s bill that 2 units for the 33 minute one and 0 units for the 7 minute one
new codes allow for training when client can not actively engage in training activities or when caregiver is not ready to learn a new skill on the client, Med B reimburses for this, for informal and unpaid caregivers, must be documented as necessary caregiver codes
standardized Medicare payment for lymphedema compression items; OTs need a certification to implement; coverage-Med B; items-standard and custom fit, bandaging, accessories, and aids lymphedema treatment act
role is not always clear; continues to be a push for direct access to therapists; not only reduces costs but also improves overall health, quality of life, and daily participation of individuals and their caregivers OT's role in primary care
healthcare if shifting to value-based vs. what volume - based
these are changing our perspective on healthcare and future of how OTs will be utilized; looks at readmission rate; shift to prevent care; OT's role is educating, focus on overall health, OT is preventative, safety accountable care organizations
involvement in well child exams, working with social worker for kids/behaviors, ER collaboration, ergonomics, mental health, working with people with disabilities, schools OT in primary care
set charges on certain items, however at times you are working with a population that has limited resources private billing
level of care: services delivered following a referral from a provider; ex. specialist physicians and therapies acute secondary care
acute inpatient care: advanced medical services needed; OT interventions-ADLs, ROM, bracing, positioning intensive care units
acute inpatient care: often entry into hospitalizations; next higher level from ICU; once medically stable able to transition to this form of care; OT interventions-ADLs, transfers, safety, IADLs, strengthening acute care
once tolerance has been built this is an option; must tolerate at least 3 hours of therapy per day; OT interventions-ADLS, more advanced neuro techniques, IADLs, strengthening, community reintegration, plan for home inpatient rehab
after staying in acute care for at least 3 nights; less intense; needs continuous therapy before leaving; focus is on home setting situation; needs to be evidence of improvement to remain at this level of care skilled care / swing bed
requires collaboration; focus on what next placement will be; reimbursement/billing-day rate charge, services come out of this acute care
level of care: highly-specialized care; patients are in a more critical condition; ex. cancer units, burn units, neurosurgery, transplant units, cardiac surgery tertiary care
ex. of tertiary care: management of ADLs through adaptations; management techniques to support health and ability to participate in meaningful activities; ex. cognitive strategies, low-energy tasks focused on restoring participation cancer / transplant units
ex. of tertiary care: wound care, splinting/bracing of upper extremity burn units
ex. of tertiary care: depends on surgery, how are they going to do normal ADLs/IADLs, energy conservation; restrictions/limitations cardiac / neurosurgery
after this people typically go to home health/hospice, nursing homes, assisted livings, outpatient therapies post acute care
ex. of post acute care: clients must meet qualifying criteria, OT can not be admitting reason, patients must be homebound and can only leave for appointments or hair or church home health / hospice
ex. of post acute care: value-based care vs. volume-based; if not skilled qualify for Med B, patient has a room rate to pay nursing homes
type of nursing home: billed same as swing bed, new model does payment based on diagnosis and co-morbidities skilled nursing facilities
ex. of post acute care: similar to nursing homes, can bill Med B assisted living
ex. of post acute care: vision therapy, pediatrics, ADLs, adaptive equipment training, neuro, lymphedema, wheelchair positioning/fitting, hand therapy, driving rehab outpatient therapy
benefits: no days are the same, seeing a patient through much of continuum of care, build strong relationships with clients; challenges: do everything, advocacy to providers, difficult to determine where to focus continuing education rural healthcare
credentialing, referral process, scheduling, post-evaluation outpatient pediatric evaluation process
evaluation level: occupational profile and brief history, 1-3 performance deficits, low complexity clinical decision-making, no comorbidities, no modification of tasks, limited treatment options, few concerns low
evaluation level: expanded review of occupational profile and history, 3-5 performance deficits, moderate complexity clinical decision-making, may present with comorbidities, min to mod modification of tasks, several treatment options moderate
evaluation level: extensive additional review of occupational performance and history, 5+ performance deficits, high complexity clinical decision-making, may present with comorbidities, significant task modifications, multiple treatment options high
codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external cause of injury or diseases; reimbursement for evaluation ICD - 10
describes medical, surgical, and diagnostic services; reimbursement for treatment sessions CPT codes
program for those whose income is too high for CHIP and Medicaid but have significant health needs medically needy program
services for kids 3-21; ensures child can access education environment; part B of IDEA; no cost to family or child, state pays; OT and PT are related services; Rehab Act of 1973, Section 504 IEP
IDEA part C; infants and toddlers with disabilities, birth to 3; voluntary state program individualized family service plan
how to qualify: request/consent to eval, duration is typically a year, frequency determined/approved by team, considered a contract and legally-binding, qualify based on skill deficits identified by standardized and/or skills-based assessments OT services in schools
other roles: staff training, classroom meetings, assist teachers with lesson planning, recommendations to teachers, IEP meetings, IEP planning meetings, equipment modifications/support OT in schools
review strengths, propose frequency for OT, highlights needs/goals in order to be most successful in education program annual IEP
part of Medicare: covers medications, depends on plans, premium based on income part D
system based on volume of therapy services, patient diagnosis, and co-morbidities for reimbursement; classifies into 5 categories patient - driven patient model
designed to be collaboration score of usual performance between nursing and therapy within 3 days of admittance; typically done by OT/PT eval, gives a score to areas therapy assesses section GG
entity or private company that has a contract with CMS to determine rates for therapy services via CPT codes fiscal intermediary
Med B covers what percent of outpatient therapy services provided at clinics, residents in SNFs that are not under Med A, and private practitioners 80%
indicates documentation exists to certify medical necessity of service KX modifier
for services in excess of $3000 targeted medical review may occur threshold
pros: large number of individuals in plan, can be more affordable, more comprehensive services, may not have out-of-pocket payments; cons: frequently use HMOs, may be limited in flexibility and coverage types, may not be able to cover family members employer - based insurance
unique number that allows you to provide reimbursable OT services National Provider Identifier
reflects ongoing efforts by OT boards and advocacy groups across all 50 states; allows OTs to be licensed in all states within it; 2025 expected to start issuing privileges; OTs have to apply to be included OT compact
able to work outside insurance scope of care, allows for flexibility with referrals, clients can begin/access services rapidly, allows for a more tailored approach benefits of cash - based services
cash-based service: typical eval/assessment paired with a post-eval meeting; meetings involve entire team and provide analysis of occupational breakdown, assessment results, collaboration on goals, detailed plan moving forward evaluation bundle
cash-based service: parents are directly involved in sessions with emphasis on working with child on goals and parents observing and engaging parent - child sessions
cash-based service: not typical, for clients that do not want parent present, parents must still be in the home, must be paired with parent collaboration sessions, often used in trauma-based or teenage cases child - only sessions
cash-based service: therapist and parent only; discusses ongoing area of struggles, specific work for parent, guidance for parents; recommended for all clients at least 1x/month parent collaboration sessions
cash-based service: working with multiple people in family on relationship skills sibling and/or family sessions
cash-based service: opportunity for all to meet to get on the same page and share info/goals, best for carry over of each provider's goals into one another's sessions care / team meetings
this type of service is a good option for clients that struggled in traditional settings, struggle with transport and scheduling, want to work on skillset for family/parent relationships, need help getting team on same page, needs 1 on 1 support waiver - based
type of practice: advocates for best practice; involves caregivers & team; teaching, support, training, counseling; recognizes that best fit looks diff for diff people; supports clients with a variety of needs; more non-traditional ways to practice mobile practices
what is the fastest growing cohort of veterans women
core value of VA: act with high moral principle, adhere to highest professional standards, maintain trust and confidence of those I serve integrity
core value of VA: work diligently to serve veterans and other beneficiaries, be driven by an earnest belief in VA's mission, fulfill my individual responsibilities and organizational responsibilities commitment
core value of VA: be truly veteran-centric by identifying, fully considering, and appropriately advancing interests of veterans and other beneficiaries advocacy
core value of VA: treat all those I serve and with whom I work with dignity and respect, show it to earn it respect
core value of VA: strive for highest quality and continuous improvement; be thoughtful and decisive in leadership, accountable for my actions, willing to admit mistakes, and rigorous in correcting them excellence
Veterans Health Administration and National Cemetery Administration veterans administrations
eligibility for VA services: served in active military for 24 continuous months or full period for which they were called to active duty; exceptions could be discharged for disability, hardship, or early out veteran status
eligibility for VA services: received a discharge under conditions other than dishonorable character of discharge
eligibility for VA services: veterans who are determined by VA to be disabled due to an injury/illness which was incurred or aggravated during active military service service connected
eligibility for VA services: disabilities VA presumes to be caused by military service due to exposure presumptive conditions
eligibility for VA services: veterans must have served honorably with at least 1 during a wartime period VA pension benefits
VA priority group: 50% or more service connected, unemployable due to service conditions, Medal of Honor group 1
VA priority group: 30-40% service connected group 2
VA priority group: former prisoner of war, purple heart recipient, line of duty disability, 10-20% service connected, vocational rehab group 3
VA priority group: aid and attendance or household benefits from VA, VA determines veteran to be catastrophically disabled group 4
VA priority group: non-service connected or non-compensable service connected disability rated by VA as 0% and below income limit, VA pension, Medicaid eligible group 5
VA priority group: compensable 0%; radiation, Project 112/SHAD, in Country Vietnam, Persian Gulf, Camp Lejune, Combat Theater; eligible for 5 years group 6
VA priority group: gross household income below VA GMT limit group 7
VA priority group: gross household income above VA GMT limit group 8
America's largest integrated healthcare system, serves 9 million enrolled veterans each year, largest single employer of OTs VHA
aging in place/home safety, amputation, assistive tech, geriatrics, hand therapy, mental health, cancer rehab, driver's rehab, home-based primary care, homelessness, pain rehab, seating and mobility, SCI/TBI, brain injury, vision loss/low vision OT services within VHA
ADL assessment and training, DMEs and adaptive equipment covered, DME assessment for ADLs free for all enrolled veterans, home safety eval and training covered VHA coverage of OT
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