Exam 1 Flashcards
vision 2025 pillars
Effective: Occupational therapy is evidence based, client centered, and cost-effective.
Leaders: Occupational therapy is influential in changing policies, environments, and complex systems.
Collaborative: Occupational therapy excels in working with clients and within systems to produce effective outcomes.
Accessible: Occupational therapy provides culturally responsive and customized services.
Equity, Inclusion, and Diversity: We are intentionally inclusive and equitable and embrace diversity in all its forms
policy
management of affairs based on material interest
goals/procedures that guide decisions
US healthcare system
most expenditures #45 in life expectancy
six domains of healthcare quality
(SEPT-EE)
Safe Effective Patient- centered Timely Efficient Equitable
IHI Triple Aim
population health
experience of care
per capita cost
how a new law works
congress passes bill, president signs as a statute, write regulations, state proposals for implementation, pass state laws/budget, approve or disapprove
affordable care act
increase access and quality of health insurance
can remain on parent’s insurance until 26
NIFIB vs. Seleblius
- ruled in favor of the ACA
- obamacare declared a tax and not a mandate
- *states can opt out of expanding medicaid
King v. Burwell
- ruled in favor of the ACA
- upheld subsidies declaring them legal
Tax cuts and Jobs act
- reduced the amount of the individual shared responsibility payment to $0 for months
- healthcare insurance coverage no longer reported on IRS documents
habilitation services
help keep, learn, or improve skills and functioning
rehabilitative services
get back previously learned skills
scanning the healthcare horizon
continued AOTA member, promote value of OT
long term goal of any organization
sustainability
survival
revenue - expenses = profit
business aspects of practice
who, what, where, when, how, why
traditional business
- ownership by sole proprietor, partnership, corporation, or shareholders
- may or may not have a board with bylaws
- typically have a business plan
- NOTTTTT eligible for tax deductible charitable donations
- expenses typically tax deductible for owners and staff with limitations
non-profit
- 501 c-3 tax category
- initial and ongoing application to IRS
- bylaws and board provide oversight
- typically have a nonprofit business plan
- typically 1+ paid staff to run it
- eligible for tax deductible charitable donations
employees
- W2/W4
- insurances typically covered by employer
- structured work schedule, hourly or salary
- eligible for worker’s comp
- taxes take out of each paycheck
- 50+ employees must provide benefits
independent contactor
- 1009 contractor
- self employed, operates independently under own or company name
- responsible for own taxes
- own hours, own insurance
sustainability 4 things
clients
staff
location
LIFT
LIFT
- legal regulations
- insurance/liability
- financial management
- taxes
expenses
mortgage/rent admin/staff marketing/promotion utilities/insurance communications/tech
revenue
insurance grants corporate sponsorships individual donors state/nat gov cash/out of pocket
business administration
- process of organizing business personnel and resources to meet goals and objectives
- human resources, operations management, finances, marketing
- ability to evaluate and make strategic business decisions in changing environments
business development
- pursuing strategic opportunities for an organization
- cultivating partnerships and identifying are markets for products/services
differences between business admin and development
admin - in education, skills to manage the process, evaluate/approve business dev
dev - process, any level of business, growth, sustainable and profitable
8 essential steps in business development
- plan
- management
- project
- investment
- research
- strategy
- marketing
- innovation
branding
- the value, emotion, and reputation a consumer gives any organization, product or service
components of branding
promise, trust, engagement, longevity, positioning, projecting, preference
traditional 4 Ps of marketing
Place
Promotion
Product
Price
principles-based marketing for OT services
- internal marketing
- benefits development
- program/product dev
- targeting
- channels
- differentiation
- setting
- positioning
medicare part A
- covers care for 65+ with in patient stays
- hospitals, hospice, home health, SNIF
medicare part B
- supplemental insurance, which covers out patient, some AE
- need for skilled care
- AOTA offers a faulty payment program (QPP) and merit based incentive payment system (MIPS)
- 8 min rule for CPT codes for OP therapy
eligibility for parts A and B
65+
OR
- receiving social security disability benefits for 24 months
- dx of ALS or end stage renal disease w/ dialysis or kidney transplant
medicare part C
- medicare advantage, extra supplemental insurance
- higher payment rates
medicare part D
- covers drugs (not OT)
medicaid
- covers aid for disabled and low income individuals
- early intervention 0-3
- COBRA safety net insurance
- funded and regulated by federal and state gov
medicaid eligibility
disabilities
low income
early intervention
0-3 with developmental delays or diagnosis
- federal gov regulation
- IDEA part C
- home environment
private pay
typically follow medicaid and medicare guidelines
networks of preferred providers
(blue cross, aetna, united healthcare)
Tricare
- federally funded insurance for active duty service members and families
- highly regulated policies for provision of services
budget
- a plan for income and expenses
financial terms
income - any financial transaction that comes in from sales of goods/services
revenue - total amount of income from sales
expense - any financial cost of doing business
profit - difference between amount earned and spent
can OTs diagnose?
- must use clinical judgement to select tx dx codes that correspond to the client’s condition and intervention
- support medical necessity
ICD-10
WORLD
official system of assigning codes to diagnoses and procedures associated with hospital utilization
- alphanumerical list
Level I of healthcare common procedure coding system (HCPCS)
- identify medical services and procedures furnished
by healthcare professionals for billing public or private insurance - numeric system (5 digits)
- some are “untimed codes” at least 1 unit
low complexity eval code
untimed
- OT profile and history
- brief
moderate complexity eval code
untimed
- OT profile and history
- expanded review and additional review of aspects of functional performance
high complexity eval code
untimed
- OT profile and history
- extensive additional review of related functional performance deficits
re-eval code
untimed
- assessment of changes in patient functional or medical status
- update to the initial occupational profile that reflects changes in condition that affect goals
- revised plan of care
Level II of healthcare common procedure coding system (HCPCS)
- coding for orthotics, prosthetics, and DME
- ambulance
process of OT documentation
Referral –> entering services –> continuing services –> exit services
AOTA guidelines for documentation/common types of OT reports (4)
- screening
- evaluation/reevaluation
- intervention
- outcomes (discharge/discontinuation)
AOTA perform screening, eval, and assessment documentation
- medical and therapy history
- occupational profile
- analysis of occupational performance
- intervention/plan of care
screening
- initial brief assessment to determine client’s need for OT evaluation or referral to another service (e.g.- PT, SLP, psych, etc.)
•Includes professional judgment on appropriateness of need for a complete OT evaluation
•Not considered an OT evaluation
evaluation
Show the patient’s functional limitations at baseline and relate to the patient’s functional goals
•Documents referral source and data gathered through the evaluation process in accordance with payer, facility, state, and/or federal guidelines
•Four primary elements: Medical and therapy history, Occupational profile, Analysis of occupational performance, Intervention Plan/Plan of Care
Selecting Assessment Tools and Methods
•CMS requires practitioners to include in their documentation of evaluation:
•Results of a specified performance measure tool or an explanation of certain factors that describe the patient’s status in relation to goals to be achieved.
***•Clinical observation is an important assessment tool.
re-evaluation report
-similar to evaluation in terms of analysis of occupational performance
•Typically conducted when required by insurance or if a patient has a significant change in status
intervention plan
documents occupation-based goals, intervention approaches, discontinuation criteria, and discharge
contact/treatment note
record types of interventions used and client response/progress•Frequently uses “SOAP” Note format •Treatment activities should always be tied back to functional goals from most recent assessments
progress report
Summarizes intervention process and documents client progress toward goals
•Typically conducted after ≤10 visits; may be monthly or quarterly in some settings
•Initial assessments re-administered to measure progress toward goals
•Goals modified/updated to reflect patient progress or if all goals met with no additional goals
transition plan
- discharge report
- summary, recommendations
- consider continuum of care*
strategies for documentation
- if it is not documented, it did not happen
- appropriate abbreviations
- insurance limitations
- do not delete errors (cross it out, initial and date it)
DME codes
orthotics and prosthetics
durable medical equipment
ACA impacts on OT
- Increase in the number of potential clients as formerly uninsured persons gain access to health insurance coverage for OT.
- In participating states, increased access to OT services–which in most cases will have to be covered as essential health benefits.
- Provide habilitative services, which will have to be covered to some degree for most of the newly insured population
business development what, how, and why
What: Create and implement innovative OT ideas that affect service provision, policy change, product design, educational curriculum, access to services, financial outcomes, and patient outcomes
How: Activities extend across different departments including sales, marketing, project management, product management, and vendor management. Networking, negotiations, partnerships, and cost-savings efforts are also involved. Business administration skills are used to manage and combine all of the interdisciplinary management aspects to drive business towards a common goal.
Why: The ideas, initiatives, and activities aimed towards making a business better. Includes increasing revenue, growth in terms of business expansion, increasing profitability by building strategic partnerships, and making strategic business decision
exiting OT services reasons
meet all goals
geographical move
progress plateaus
facility change
internal marketing
Training and support of organization employees to ensure achievement of marketing goals
benefits development
Distinguishing between features and benefitsis a key component in marketing and advertising activities
program/product development
Programs and products are developed and reevaluated on a cyclical basis, usually part of a continuous quality improvement program.
targeting
the portion of the marketplace that the marketer wishes to influence
channels
sets of people and institutions that perform the functions necessary to move a product or service from a producer/provider to an end-user—the consumer.
differentiation
Differentiation distinguishes one’s company or organization’s competitive advantage over another. Demonstrating higher technical quality, improved outcomes, increased accessibility, innovation, service, lower cost, or better value are all ways to achieve differentiation.
selling
The ultimate goal of marketing is to make a sale.Occupational therapy practitioners often have a problem with the ideaof selling their services, but to promote the benefits of the profession,we must maintain a stance of providing positive outcomes for ourclients at a fair market value
positioning
designing a company’s image so that the target market understands and appreciates what the firm stands for, in relationship to its competitors
