Autism Review

My sensitivity for the challenges of being an Academic Fieldwork Coordinator runs quite deep; I held that position at a college for three years and experienced the difficulty with finding student placements. There never seems to be enough fieldwork placements, there are challenges with finding places that will provide a quality experience for the student, and although there have been efforts to incentivize practitioners to take students that does not overcome the practical obstacles.

The repeating theme that the occupational therapy profession is not yet grasping is that there has to be some kind of understanding that services provided by students are not the same as services that are provided by licensed professionals. This has been a recurring theme for Medicare reimbursement of services provided by students. Fieldwork educators are very familiar with AOTA's efforts to establish clarity in these rules.

There is a parallel pushback against allowing student provided services to be reimbursed in the Medicaid system. In NY State there are restrictive rules about OT students providing Medicaid services to children. This has a large impact on practitioners willingness to accept students.

Large systems like Medicare and Medicaid are obviously motivated by creating high standards that promote public trust. If public dollars are going to pay for skilled services - then the services need to be skilled. This is understandable.

Now we are seeing new legislative perspective on this issue. While NY State tightens up regulation of OTA practice this has opened up the issue of student supervision as well. Current proposed regulations are getting much more restrictive for students - and now it is being proposed that OTA students can only be supervised by OTs and not OTAs. Furthermore, the degree of supervision that is being proposed in NY for a person who has a limited permit is more restrictive than what is generally being practiced for OT students - and there is no logic in the position that any student requires LESS supervision than someone with a limited permit. This means that if the current proposals for supervision of people who have limited permits is applied downward to students - there are going to be huge problems with models of 'non-traditional' fieldwork education. Also, removing OTAs from the equation and not allowing them to supervise OTA students will place a tremendous pressure on OTA fieldwork opportunities.

The pickle that NY State is in gets even worse - part of the proposed regs allows 'physicians' (which are not statutorily defined) to provide supervision of OTAs. This is a rather large concern because it might remove OTs from the loop and encourage optometrists or foot doctors (much less regular MDs) to hire OTAs in their offices, provide 'supervision,' and begin billing for OT services. Of course most people oppose this, but the State Board of OT comeback is 'you can't be AGAINST physician supervision and be FOR supervision by non-OTs for 'non traditional' fieldwork at the same time.

The concept of 'non traditional fieldwork' is interesting but we have not had enough discussion that relates to whether or not it 'constitutes OT' or is 'just something an OT can do with their education.' These are important legal distinctions. This also raises the issue of whether or not these 'non traditional' sites provide appropriate preparedness for taking the certification examination and practicing OT. Apparently, if we don't tackle this issue ourselves we will see regulatory boards step in like in NY.

My very strong suggestion to AOTA and ACOTE is to PUT ON THE BRAKES when talking about 'non traditional fieldwork.' The notion that "one-to-one supervision, a hallmark of traditional placement models, is replaced by alternative supervision practices such as collaborative learning or distance supervision" (Hanson, 2011) is starting to look like an idea that might have some pretty big legal problems associated with it in some contexts.

The current crisis in NY should be examined and studied CLOSELY by all other states. Opening up a practice act is a can of worms, and now we are seeing some major unintended consequences. There were issues to address in NY but this is an amazing study in why it is important to open up ONE ISSUE AT A TIME - or at least to have enough eyes on the ball when multiple issues are opened that unintended consequences are held to a minimum.


Reference:
(links in text)

Hanson, D. (2011, Nov.14) Expanding practice borders: The value of nontraditional fieldwork models, OT Practice, pp.6-8.

Background fact:
occupational therapy assistant (OTA) means someone who has not passed a NBCOT certification examination or who has not renewed their certification. NY State allows these people to practice.

certified occupational therapy assistant (COTA) means someone who HAS passed a NBCOT certification examination and who HAS renewed their certification. NY State does not require this for occupational therapy assistants.

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The recent NYS Department of Health ruling on qualified professionals to provide OT in NYS schools originally stated that one qualification for practice was:

A certified occupational therapy assistant (COTA) “under the direction of” such a qualified licensed and registered occupational therapist, acting within his or her scope of practice under New York State Law.

This sent quite a few people into a panic because there are many OTAs in NY practicing without ever haven taken the NBCOT examination. After someone takes and passes the NBCOT examination they are allowed to use the initials 'COTA.' This new statement from the Department of Health seemed to indicate that occupational therapy assistants would have to pass their certification examination.

Currently, NYS law only 'certifies' occupational therapy assistants and does not 'license' them. As part of this, there is no current requirement for an occupational therapy assistant to pass a certification examination - there are only educational requirements that have to be satisfied. Therapists who have failed their NBCOT examination find a haven in NY where they are allowed to practice without the NBCOT credentials. This is a concern because the purpose of initial and ongoing NBCOT certification is to ensure a basic level of competence.

Anyway, people started scrambling because there are untold numbers of occupational therapy assistants in NYS who are working and never passed the examination - and this new requirement could theoretically put a lot of people out of work and could have caused a human resources shortage. Enter NYSOTA and AOTA, who quickly responded as reported in the recent AOTA publication State Policy Update October 2010:

NYSOTA quickly went to work and, with the assistance of Chuck Willmarth at AOTA, we argued that the Medicaid agreement language far exceeded what was required by federal statute. In addition, we argued that the occupational therapy practice act provided for the certification of occupational therapy assistants by the
Commissioner of the State Education Department.

NYS bureaucrats concurred with this argument and here is a link to the NYS Department of Education memo that 'clarified' the initial requirement and stated that

Occupational therapy assistants may also be registered with the National Board for Certification of Occupational Therapy (NBCOT); however, this is not required for Medicaid reimbursement purposes. Occupational therapy assistants who are New York State certified but who do not hold national certification use the title “OTA,” not “COTA.”

The short term positive impact of NYSOTA and AOTA is that quite a few occupational therapy assistant jobs were saved - but I am not so sure if this is a net gain for the public who consumes occupational therapy services. The purpose of national certification examinations is to protect the public, and if NYS allows anyone that shows up and gets passing grades in some college courses to become an occupational therapy assistant then what does that say about the quality of OT services in NY State?

The unspoken story - one that even most Occupational Therapists in NY State don't know - is that the NYS Office of the Professions does not directly have disciplinary oversight over occupational therapy assistant practice. The reason for this is because there is a loophole in the Education Law that dictates that there is only jurisdiction over LICENSED professions and not CERTIFIED professions. The difference is that in the licensed profession (Occupational Therapist) there is a certification examination that establishes a base level of competency. There is no such requirement for the occupational therapy assistant - and that is why anytime that a discipline issue comes up against an occupational therapy assistant in NY State they go straight after the supervising occupational therapist, who is the licensed professional.

So, New York State may be the only place in the USA where occupational therapy assistants are A SUPER PROFESSION - they do not need to pass a competency examination, and they are not subject to professional discipline. If an occupational therapy assistant does something wrong their license is not necessarily in immediate jeopardy - but their supervisor's license certainly is.

There are usually only a handful of cases in New York when occupational therapists come up for disciplinary hearings so it is easy for politicians to brush aside the longstanding attempts to change this. There have been bills in the Senate and Assembly to change this for many years but they have not made significant forward progress.

Perhaps the larger issue for consumers (employers, patients, etc) is that professional misconduct may not be the most important measure of this problem. The most important measure of this problem is that we are not doing enough in NY State to ensure basic competency by passing a certification examination. Sadly, there also is no requirement in NY State that occupational therapy professionals have to participate in any continuing education.

This means that your child is sanctioned by NY State to be receiving therapy from someone who never took a certification examination and never attended any continuing education in their life. Perhaps they are not felons so the professional misconduct is not an issue - but what about their ability to deliver an occupational therapy service that has any quality?

Standards barely exist, and when they do exist they lay the blame at the feet of the supervisors. That means that in NY State it is important for occupational therapy supervisors to keep the blunt scissors in the hands of the occupational therapy assistant - if they even decide to take the risk to let them have scissors at all.

More and more we are hearing parents ask if professionals have their NBCOT certification, and in some cases parents are asking specifically that their children NOT be seen by an occupational therapy assistant. In one County where we provide early intervention services we are required to tell the family if services might be provided by an OT assistant and who the supervisor would be. In nearby Counties we are seeing OT assistants being shut out of certain areas of practice.

This is a shame for the thousands of competent COTAs who passed their exam, participate in continuing education, and practice responsibly and effectively. Their professional reputations as occupational therapy professionals and indeed their livelihood is being sacrificed on the altar for the benefit of all the people who skip the NBCOT exam, don't renew their certification, and are not following the best path.

This is a situation that is extremely problematic. It can only be fixed by appropriate policy making that ensures initial and ongoing competency. Until that happens, don't be surprised that more and more consumers will have questions about practitioner qualifications.

In all this mess, that is one good thing that is happening.