[FOCUS ON PEDIATRICS: A SUPPLEMENT FOR PEDS THERAPISTSThis workbook is intended specifically for pediatric therapists who are starting a private practice. It is written by Carrie Strauch OTR, a pediatric therapist with over 25 years of experience along with Iris Kimberg, MS PT OTR. It is available as a downloadable PDF($55) CD ($65) or hard copy($75) * This is a 55 page supplement to the first workbook, Starting a Professional Practice and focuses specifically on issues relevant to setting up a pediatric practice including information on early intervention, school based practice, billing for pediatrics and consult time, FERPA, family based practice and complementary service inclusion in the pediatric arena.

2011

Focus on Pediatrics, Written by Carrie Strauch

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ABOUT THE AUTHOR

Carrie Strauch, OTR is a highly regarded occupational therapist with over 27 years of experience treating infants and children with a variety of developmental and behavioral challenges. She has lectured in NYC and Spain at both the university and continuing education level. She has been a key member of the Lenox Hill Neonatal Follow Up Program for premature infants for the past 15 years. Ms. Strauch is certified in NDT and Sensory Integration. She is also a Reiki Master and an advanced level practitioner of Esoteric Healing. She has integrated complementary healing modalities into her Manhattan-based pediatric private practice for the past 9 years. Ms. Strauch consults with families, schools and other professionals related to conventional therapy and/or other forms of healing. She is also a published writer, on both professional and human interest subject matter.

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© 2011 Carrie Strauch. All Rights Reserved.No part of this workbook may be reproduced in any manner without the expressed written consent of Carrie Strauch and NYTHERAPYGUIDE.

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OTHER WORKBOOKS AVAILABLE

PRACTICE ANALYSIS AND STRATEGIES FOR SUSTAINED GROWTH AND SUCCESS This workbook is geared to those therapists already in practice who want specific strategies to bolster their long term viability, growth and success to help reach the full potential of their therapy endeavor. The workbook presents concrete ways to analyze a practice to determine strengths and weaknesses and then develop strategies for continued growth and success. Ideas on how to adapt to the changing business conditions we face are discussed. Considerations for opening a second location, starting a contract agency, bidding on school contracts, writing EI proposals as well as the sale, acquisition, merger and valuation of a practice are also covered. ($125 hard copy, $110 CD, $95 PDF). POLICY AND PROCEDURE MANUAL All practices are unique and reflect the individuals that are their creators. Yet there are commonalities that must be present in all practices by virtue of the fact that we are all compelled by similar professional practice acts, work and professional ethics as well as state and federal regulations including OSHA and HIPPA. The purpose of this book is to offer generic guidelines, policies and forms from which a therapist can then customize their own policies. procedures to best meet their individual practices. Remember that policy and procedure manuals should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations and any changes in state and federal law. Upon request, anyone who has purchased this book can request a copy to be sent via e-mail so that all materials can easily be down loaded and customized for the individual practices. A detailed table of contents follows. ($195- hard copy, $175 CD, $165 PDF)

TABLE OF CONTENTS – POLICY AND PROCEDURE MANUAL SECTION ONE: FORMS FOR DIRECT PATIENT CARE:Introduction to a Policy and Procedure Manual1. Initial Intake Form- One for Adults and One for Pediatrics2. Generic Evaluation Forms (Pediatric and Adult Practices)3. Generic Progress Re-evaluation Note4. Generic Discharge Form5. Assignment of Benefits /6. Notification of Billing/Cancellation/Discontinuance Procedures7. Medicare Beneficiary Form8. Authorization for Release of Confidential Information9. Notice of Patient Privacy / Patient Information Consent 10. Patient Satisfaction Survey11. Referral Source Satisfaction Survey

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SECTION TWO: FORMS AND POLICY STATEMENTS FOR GENERAL OFFICE PROCEDURES

1. Incident Reporting and Form2. Child Abuse2. Confidentiality, Release and Handling of HIV Information 3. Confidentiality for Emails/Faxes4. Emergency Preparedness Plan5. Health and Safety Issues Including Universal Precautions, Hand washing Procedures, infection Control6. HIPAA Policy and Procedures/FERPA7. Rehabilitation Update/Documentation for Medicare Patients8. Clinical Chart Review Form9. Photo/Video Release Form/ Waiver Form for Classes/ Permission Slips for

Caregivers

SECTION THREE: FORMS FOR HIRING THERAPISTS1. Application /, Orientation /Requirements of Therapists2. Reference Forms3. Clinical Competency Review Form4. Employee Health Assessment5. Hepatitis B Consent/Decline Form6. Freedom from Impairment Form7. On Site Clinical Competency Form8. Sample Employee Handbook9. Code of Ethics - OT, PT ST10. Employee Application including EOE regulationsSECTION FOUR: GENERIC CONTRACTS1. Sample Temporary Personnel Services Agreement2. Sample Home Care Personnel Services Agreement3. Sample Contract for School District Service Provision4. Sample Independent Contractor Agreement5. Sample Employee Contract

TAKING CARE OF BUSINESS – 50 Reprints from OT ADVANCE COLUMN 2004-10 Hard Copy only $45

Written by Iris Kimberg, MS PT OTR

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FOCUS ON PEDIATRICSSupplement to “Starting a Professional Private Practice”

TABLE of CONTENTS

1. Introduction pg. 6-72. Basics of Pediatric Practice pg. 83. Treatment Settings pg. 9-104. Federal Laws Impacting Pediatric Practice pg. 115. Early Intervention pg. 12-166. Collaboration with Family pg. 17-197. The Inside Scoop on Home Based Treatment pg 20-218. Pre school, School age and Teens pg. 22-249. Considerations in Setting up an Office pg. 25-2710. Office Forms pg. 2811. Documentation pg. 29-3012. Billing and Reimbursement pg. 31-3213. Marketing in Pediatrics pg. 3314. Expanding your Practice pg. 34-36

APPENDICESAppendix A to F: Sample Forms and Letters pg. 37-44Appendix G: ICD Codes pg. 45Appendix H: CPT Codes pg. 46-47Appendix I: Resources pg. 48Appendix J: Facts for Therapists in NY pg. 49-50

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DISCLAIMER: The information presented represents the view of this author and/or presenter and is offered for educational purposes only. While intended to provide accurate information on the subject matter listed, this is sold and /or given out at workshops with the understanding that the author and/or presenter is not engaged in offering financial or legal advice, which can only be obtained from professionals credentialed in these areas.

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Introduction

This workbook is for therapists interested in starting a pediatric private practice. It was written as a supplement to workbook 1 - “Starting a Professional Private Practice”, the first book in the series. Information from that book will not be repeated since the books are to be used together.

Pediatric practice is a complete world of its own. Options for service delivery and treatment, administration, set up and payment all differ greatly from an adult therapy practice. This book will provide you a with a greater understanding of the scope of pediatric practice today – across the disciplines of occupational, physical, and speech therapy.

There has been a dramatic increase in the numbers of therapists working in pediatrics since the early 90’s. Much of this can be attributed to an increase, or redistribution of public funding sources for pediatric therapy. In turn many therapists switched to pediatrics to take advantage of new job opportunities, greater economic benefits and flexibility in work schedules.

The economy is cyclical as is the provision of health care services - and they are not always linked equally. Funding for services for the adult and elderly population was the trend twenty plus years ago, while the pediatric population was largely ignored. Currently the health care cycle still favors funding in pediatrics, but this is clearly changing.

We do not know what the future holds relative to public funding and/or third party insurance reimbursement. It is important to plan for options or “safety nets” in your practice so that when the cycle does change – you still will come out ahead. Keep up with changes in the economy and trends in health care. This is an important time for you to be an informed consumer! Here are some questions to think about regarding pediatric practice:

How much experience do you have in pediatrics? Do you have more experience with a specific age group or disability? Have you worked with other pediatric therapists? Were these

experienced therapists? Have you ever worked with infants? Premature infants? Do you have any specialty certifications? Have you done extensive continuing education in pediatrics? Do you prefer working with a specific population? Have you ever worked in a public or private school? Have you ever worked in isolation (home care) with a pediatric client? Would you like to be a solo practitioner or are you interested in having

other therapists working in your practice?

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How do you think you will relate to parents and family members? How about your own parents and family members?

What other questions come to your mind? Write them down here -

Basics of Pediatric Practice

Basic information for pediatric practice in all the professions include:

Typical treatment settings can be in the home, office, school or within a center-based program.

Payment sources are either from private or public funding. Private funding includes individual payment from clients or private insurance. Public funding includes all funded government programs such as Early Intervention Program, Medicaid, and funding through school systems.

The field of pediatric therapy is divided into 3 main categories both in terms of expertise and funding sources for therapy.

o Early Intervention - birth to 3 years oldo Pre-School – 3 to 5 years old o School-age – 5 to 21 years old

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Therapists tend to specialize in specific age groups, clinical issues, disabilities and treatment philosophies.

Referrals can come from a range of medical disciplines such as: developmental pediatrics, dentistry, gastroenterology, neurology, orthopedics, osteopathy, otolaryngology, pediatrics, physiatry, psychiatry or rheumatology.

Word of mouth among physicians, parents, therapists, and teachers often generates more referrals than most advertising.

Communication with team members (parents, therapists, teachers, etc.) is necessary on a frequent basis through meetings, email, telephone or a common notebook. Effective communication is time consuming and can be quite difficult to do well.

Think long range across age groups – opting for many referral and payment sources. A narrow based practice is always more limiting.

Treatment Settings

How do you decide what type of treatment setting is right for you?

Some people know exactly what they want, and others don’t – like in life. Initially, you may choose one model, and then change as you become known in the community. You may also find that certain options don’t suit your temperament such as home care or working for another therapist. Often economics is the deciding factor that dictates the service delivery model. First on the list is to research the possibilities in your geographical area – ranging from referrals to competition to economic considerations. This may dictate what type of practice you set up more than your subjective clinical experience that you prefer infants over 5 year olds.

Options for treatment or service delivery model include: Office – Rent an office, use a room in your home or sublet from

another therapist.

Home care – Treatment of infants and children in “the most natural environment” such as home or community (i.e.; day care center)

School-based – Treatment on an hourly basis at public or private nursery, pre school, elementary, intermediate or high school.

Center-based – Treatment on an hourly basis in an already established center providing services to children.

Evaluations – If you are experienced in this area you may choose to just do evaluations. Private evaluations command high fees because

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they are comprehensive and time consuming with lengthy reports. Evaluations for the older child are even more complex with formal standardized testing – especially in OT and Speech. Videos of evaluation and follow up are a great way to see progress. Fees are significantly less for funded sources, but at certain times of the year many evaluations are needed – so potential for volume is there.

Consultations and/or consulting – There are various options for consulting available to experienced practitioners. Consulting to a school with a specific purpose such as improving the gym program or handwriting curriculum. A private consultation with a family referred by their MD to determine a plan of action for delayed toddler.

Therapists working in a hospital or center-based program often begin with home care clients after work. Gradually as they develop a case load they leave full time employment. Home care provides a relatively easy way to make more money than the hospital without the costs of a private office.

If you are just starting out as a self-employed therapist it is usually easier to contract with an agency to get a caseload. Plus you will learn how an agency functions thereby providing you with useful information for future expansion of your practice.

It is usually easier to get private referrals once you are well established in the community. However you don’t want to have more than 50% of your referrals from one source.

Frequently, therapy may still need to be funded if your target population does not have the economic means to pay privately, or there are not enough therapists available to meet the needs of the community.

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Federal Laws Impacting Pediatric Practice

In 1975 federal law PL 94-142 was enacted for “handicapped children from ages 5 to 21.” This monumental public law mandated that individuals with disabilities are entitled to a “…free, appropriate, public education…” and related services, including physical, occupational and speech therapy in the least restrictive environment. “Least restrictive” in this context means - the setting that most appropriately meets a student’s educational needs.

In 1986, PL 99-457 expanded services to infants and toddlers (Title 1) and children age 3 to 5 (Title 2). In 1990 the law was updated, including changing “handicapped” to “disabled”, and then renamed the Individual with Disabilities Education Act or IDEA. Another IDEA revision took place in 1997 as PL 105-17, and most recently in 2004.

These laws radically changed the way therapists provide services and greatly expanded the possibilities for earning money in pediatrics. Suddenly every child had the opportunity by law to receive free evaluation and treatment if determined eligible, and many agencies were started to assist in the process. The numbers of children receiving therapy greatly increased across the nation, and a natural division into early intervention, pre-school and school aged was created – especially for funded treatment.

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) - Please note that therapists working with EI/pre-school and school aged children that receive federal and or state funding for the services they provide might have to comply with the FERPA regulations listed below.

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.

FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students."

Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies.

Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student

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then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.

Generally, schools must have written permission from the parent or eligible student in order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31):

o School officials with legitimate educational interest;o Other schools to which a student is transferring;o Specified officials for audit or evaluation purposes;o Appropriate parties in connection with financial aid to a student;o Organizations conducting certain studies for or on behalf of the

school;o Accrediting organizations;o To comply with a judicial order or lawfully issued subpoena; o Appropriate officials in cases of health and safety emergencies;

ando State and local authorities, within a juvenile justice system,

pursuant to specific State law.

Schools may disclose, without consent, "directory" information such as a student's name, address, telephone number, date and place of birth, honors and awards, and dates of attendance. However, schools must tell parents and eligible students about directory information and allow parents and eligible students a reasonable amount of time to request that the school not disclose directory information about them. Schools must notify parents and eligible students annually of their rights under FERPA. The actual means of notification (special letter, inclusion in a PTA bulletin, student handbook, or newspaper article) is left to the discretion of each school.

For additional information or technical assistance, you may call (202) 260-3887 (voice). Individuals who use TDD may call the Federal Information Relay Service at 1-800-877-8339.

Or you may contact us at the following address:

Family Policy Compliance OfficeU.S. Department of Education400 Maryland Avenue, SWWashington, D.C. 20202-5920

CHILD PROTECTIVE SERVICES

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In a pediatric practice it is a good idea to have a formal policy that everyone in the office is familiar with regarding child abuse and child protective services. All suspected cases of child abuse/neglect (CA/N) must be reported as per the guidelines outlined by the state in which you practice. This includes when you suspect that a child is abused or neglected or when a parent or caretaker makes a statement to you based on personal knowledge which if true would deem a child abused or neglected.Usually you can either call in the statement directly (you would then be considered the mandated reporter) or contact the designated person at the practice to call in the report ( you would then be the source of the report, and the designated person would be the reporter.Make sure you have the telephone number for either the Child Protective Service or the Central Register of Child Abuse and Neglect of your state posted in your office. In order for the report to be accepted the child must be under 18 and live in your state. Included in the report:Name and address of child, their age and genderNature and extent of injuries, maltreatment, abuseChild’s behavior and conditionPerson responsible for injury, maltreatment, abuseSource of report

Usually, within 48 hours, a written report form must be sent in to your state’s Child Protective Services. Any photos, x-rays can be included in the report.The mandated reporter is immune from civil or criminal liability when the report is made in good faith. Without the written permission of the reporter, Child Protective Services must maintain confidentiality about the source of the report. Failure to report cases of suspected child abuse or neglect is a class A misdemeanor with criminal and civil sanctions possible.

Early Intervention

The term early intervention is currently used for children from birth to three years of age. PL 99-457, the federal public law mandating free services for children from 0 to 3 years of age uses a family centered approach. It is important for you (and consumers) to distinguish between the publicly funded Early Intervention Program and early intervention which simply indicates therapy before three years of age.

Early Intervention - Treating Children Privately

Many infants are referred for private evaluation and treatment from pediatricians, neurologists, NICU follow up programs or other therapists.

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These referrals may include the following situations: therapy is needed while awaiting approval for a funded program, the child has specific, short term needs or they do not have enough of a delay to be eligible for a funded program but still require therapy or parents do not want funded therapy.

You determine frequency and length of treatment session per your evaluation, and discussion with the MD. Increasing or decreasing the number of sessions, or extending the duration of treatment is easier when working in the private sector. The family can pay out of pocket or you can bill their insurance company directly - provided there is coverage.

Clinical judgment is used to decide if the child will be better served in the home or office once your evaluation is completed. These are often better options than the local hospital out patient department but sometimes this is the only choice because of insurance coverage. Oftentimes, children begin in private therapy and then are referred to early intervention because their needs are more long term.

Early Intervention Program (EIP) - Government Funded

Early intervention is a federally funded program. However, each state interprets the law as they choose, and then sets up an EI program in accordance with their interpretation. The programs have dual administration on the state level through the department of Health, and through each municipality. The municipality ultimately determines how to organize the EI program in their county. There is a wide variation in the provision, and fee structure, of these funded programs from state to state, and county to county within the same state. For example, in some states the family must have a low income in order to qualify for the funded program.

Use these guidelines when inquiring about the administration of EI services in your state and county:

Does your state allow individual practitioners to have contracts with EI for service provision?

Can you be a solo practitioner or do you have to form a corporate entity (such as a PC or PLLC) to be approved?

What is the application process for approval on the State level? Is it the same for the local county level?

Determine if the process will be worthwhile for you before you begin. Some states have a very comprehensive application process, such as requiring a board of directors plus a full policy and procedure manual on vital issues. For center (office-based) practices you may need approved fire and health safety plans. It is usually an easier process for individual practitioners.

These documents are generally needed whether contracting directly with the state or through an agency: current CV, state license, malpractice insurance

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for self employed, employment history, record of legal actions, letters of reference, health form, fingerprints, copies of certifications, and listing of continuing education courses and other mandatory coursework.

How do you find a list of approved agencies to work for in your area?

Are applications for new agencies being accepted by state and county officials? For example, NYC is not accepting applications but NYS is.

Request the latest fee schedule from your state to be up to date on the different fees for evaluations, treatment and specific rates for ½ hour, 45 minute or hour sessions. Is there an official policy for payment for meeting times, missed visits, cancellations on same day, note writing etc or is that determined by the agency.

Third party insurance and Medicaid are supposed to be billed, as per the law, but it doesn’t seem to be a consistent practice. The law stated that “…funding was the payment of last resort…” but that clearly isn’t happening in NYC. Some states make greater use of ICHAP, the infant child health assessment program, rather than direct intervention by therapists.

Clinical Aspects of Funded Early Intervention Program

An intake evaluation is done once a referral is made to the EIP. The child receives a core evaluation based on this information, and supplemental evaluations in certain disciplines are requested. You can ask to do evaluations only, and receive an evaluation fee through the early intervention program.

Some Evaluation Tools Approved by NY State Early Intervention:

AIMS (Alberta Infant Motor Scale) DAYC (Developmental Assessment Young Children) PDMS (Peabody Developmental Motor Scales) PEDI (Pediatric Evaluation of Disability Inventory) PLS (Preschool Language Scales) ROWPVT (Receptive One Word Picture Vocabulary Test) EOWPVT (Expressive One Word Picture Vocabulary Test) SICD (Sequenced Inventory of Communication Development ACBC (Achenbach Child Behavior Checklist) CARS (Childhood Autism Rating Scale)

There are other tests, charts and clinical observations for each discipline that are valid, standardized and valuable adjuncts to those listed here.

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All states and major cities have telephone numbers for making referrals. In NY the “growing up healthy hotline” is 1-800-522-5006, and in NYC it is 1-800-577- baby. Find out the number in your city.

In order to be eligible for funded services, a child must demonstrate a certain percentage delay in the different domain areas (i.e., gross motor, fine motor, language, etc.) following the evaluations.

There are children who still may require therapy but do not qualify for funded services through the state department of health.

The EIP program is not usually based on financial need although it seems to function that way in certain states. For example, two neighboring states have very different regulations relative to treatment and payment. In NJ, services are limited to 2 hours per week no matter how disabled the child is, and parents pay on a sliding scale basis. In NYC, some children receive up to 20 hours of funded services, and some of these parents are very wealthy.

Under the terms of most early intervention programs, the infant can be seen in their home or in a day care center for the same rate. However if you are seeing the child in your office – it is considered “center based” and the rate drops considerably. This is not equitable but has not been changed to date.

Many therapists who work out of their own offices do not treat infants enrolled in EIP for this reason, or take only a percentage of their client base with this reduced rate. You are not allowed to charge money or bill insurance for these visits (or any portion of…) and your license is at risk if you do.

Ultimately, you have to work within the framework of the early intervention system if you choose this model. However, there are families that will pay for treatment in an office and/or home with experienced therapists while still having therapists at home through EIP.

Formal Meetings in EIP

Every child in the funded early intervention program has an Individual Family Service Plan. Find out if you get paid for time spent in these meetings.

The IFSP is defined as “a written plan for providing early intervention services to a child eligible for the EIP and the child’s family that must be developed jointly by the family and appropriate qualified personnel, be based on the early intervention evaluation and assessment, and include matters specified in the early intervention regulation”. An official meeting is set up between the county, the family and the service providers to establish therapy needs and goals for the child for a 6 month period following the initial evaluation. The IFSP provides the opportunity for therapists to collaborate with parents to best meet their needs regarding the child.

During the IFSP meeting the family can push for the numbers of sessions they think are appropriate if they don’t agree with the recommendations. Services

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are provided for 30, 45 or 60 minutes. Many programs insist on 30 minute treatments - but I feel that 60 minutes is the best from a clinical and professional perspective. There needs to be enough time to treat the child, provide natural breaks and still have time to teach the parents. NYC has consistently given 60 minute sessions but in recent months they are cutting back to 30 minute sessions (especially for children under one year) This enables the city/county to save money but the therapist has the difficult task of treating the child for only 30 minutes, and the agency has a smaller margin of profit for this abbreviated session.

It is harder (but possible) to increase and/or decrease frequency of service within the EIP because it requires additional paperwork, and sometimes new evaluations. Justification letters must be written by treating therapist.

In NY State the website for early intervention information, laws and forms is http://www.health.state.ny.us/community/infants_children/early_intervention/ See Appendix J for more information.If you substitute the abbreviation for your state like this: www.mass.gov or www.nj.gov, and search “early intervention” - you will find the information.

The National Dissemination Center for Children with Disabilities at www.NICHCY.org provides invaluable listings of all state agencies and related resources. If you live in a county that requires an intermediary agency, you will have to find an agency that services children through EI. The state department has a listing of all the approved EI agencies. Ads are often placed in “Advance”, local papers, yellow pages, direct mailing or by talking to other therapists.

Collaboration with Family

A child is a part of a family system, and ideally should not be treated in isolation. It is possible to treat an adult and never meet their spouse, or other people in their family. However, this same situation would be rare, and more significant if you did not meet any other people in a child’s family.

Family centered service is an integral part of any program addressing infants and children experiencing developmental delays. It is important to facilitate a discussion with parents about what is meaningful to them in relation to the child’s treatment. This is an important part of the therapeutic process when treating children of all ages. However, your interaction with the family will vary depending on where you do the service. In reality, you have 2 clients – the child and the family. The “voice” of the family must be reflected in goals, treatment and documentation. Early Intervention is mandated by law as a family centered program, and funding for approval as a provider is contingent on the therapists providing this type of care.

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A clear understanding of therapeutic goals is necessary for all members of the team – child, parents, siblings and therapist. You will quickly learn that if you don’t incorporate the parents into your treatment plan, your work with the child will be less effective. Changes in function rarely occur just because of an hour or two of therapy a week. Plus these changes cannot be promoted or sustained without instruction, repetition and integration of these skills into daily life.

Parent’s interest in their child’s therapy programs differ for many reasons. As a therapist there is only so much you can only do to alter this within the context of your relationship. There is often less direct contact with parents in an office or school setting. Therefore you will have to make more of an effort to contact the families through notes, phone calls or emails.

In home care the relationship with the family is more immediate, consistent and often quite intense – even if they are not always present at therapy. The energy, tension and dynamics of a household are especially evident when you are in someone else’s home. Always remember that you are in their home with specific therapeutic goals and keep boundary lines clear from the start. In some homes the contact with the parents is minimal secondary to work, timing or unavailability on their part. Your expectations regarding home programs will change as your outlook becomes more realistic about what a parent and/or child can realistically do in a day. The therapist needs to be aware of the impact of having a disabled child on the family’s life, and the natural stressors of everyday life even for a typically developing child.

In the long term, your patience and effort in collaborating with the family will pay off. Remember, word of mouth is the best marketing tool.

Setting Limits

Many of the families you will meet have extraordinary emotional needs because of the recent discovery that their child has a problem, illness or disability – whether at birth, delays in development or after an accident. You may be the first point of contact following these events, and can easily become their main support system – sometimes by default, and not choice.

Parents often confide in pediatric therapists in a very intimate way – sometimes bordering on the inappropriate. Setting limits is key to your work. It helps to be aware of how you relate and communicate in your personal and professional relationships. This knowledge will help you to decide whether you or your client needs the limit setting, and how to do it.

If you find that a parent always wants to talk at the end of a session you must determine how to handle it. It is easier in an office when your next client is waiting than when you are in the client’s home. Rules should be set up when you start with a client, especially regarding talking or note writing. If you get in the habit of calling parents outside of treatment time, you can easily spend your evenings talking to parents. It might be better to set up rules from the

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beginning such as: set up specific times for phone calls one night a week to avoid evening and weekend calls or end your session 10 minutes earlier to speak to parent. There are always a few needy parents on everyone’s caseload, and at these times compromise and caring go a long way.

Integration of therapeutic goals into the home and school environment is the ultimate goal for the child, and often the most challenging to accomplish. It is your responsibility to work with the parents in a way that will best benefit the child within the context of his family.

There will be situations that clearly merit referral to a mental health professional – either for the parent, or parent(s) and child. This may be difficult to bring up in private practice depending on your relationship with the family – and is often best done in collaboration with the MD. In many of the early intervention programs, the service coordinator is often a social worker and will be able to help with extreme family dynamics.

Over time you will learn what works best for your personality and client base. It is important for your health to separate your work and home life – or it will ultimately impact on your practice.

The Inside Scoop on Home-based Treatment

You will learn a lot about yourself in the first months of doing home care - working in someone else’s home, scheduling, commuting hourly, communicating with other therapists and other after hour administrative work that is necessary in home care but not billable. It is impossible to truly understand the scope of this service delivery model until you experience it!

Family centered care is the cornerstone of early intervention programs, as stated in the federal law. The most natural environment to see a child under 3 years old is in their home. Having therapists come into the home is also often the easiest for the parent – both physically and perhaps emotionally, because it is the least clinical and therefore less stigmatizing environment. However, it can also be more difficult emotionally for other reasons - often seen as an invasion of privacy. Setting limits on someone else’s turf is not always easy, but it must be done. This is often very difficult for parents.

In home care, you have to be adaptable, flexible and learn to go with the flow. If not, you are headed for multiple hours of frustration. Unfavorable conditions can exist in any home – a rural trailer park, country estate, inner city project or luxurious apartment. The home environment may be chaotic –

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siblings or other people in and out of the room, dogs, television, loud music etc. One house is overflowing with toys and the other has no toys. One parent restricts your therapy to a tiny room even though the apartment is big, and the child is learning to crawl and needs space.

If you are used to working in a clinic with 5 different sized balls or rolls, it is a challenge at first to adapt. I remember having to use a 20 lb bag of rice to position a baby in his crib in a Chinatown apartment. Sometimes you feel satisfied, and at other times you are tired of always “making do” with what you have. People working in rural areas may have to drive long distances but it is easier to bring a ball in a car than on a bus or subway. Some therapists may loan the family balls, rolls or benches if they do not have the finances to invest in basic equipment. Certain early intervention programs will even pay for specific equipment such as bath chairs, therapy balls or benches.

Parents are an integral part of the pediatric team along with the other professionals. You must be able to deal with a variety of personalities and situations which are often greatly intensified in the intimate setting of a home – and more so when it isn’t your home. Some mothers choose to participate in every session while others want to take care of household chores. It is clearly important for the parent to stay during treatment, but sometimes they need a break. However, you should not be alone in the house.

Some parents expect you to stay longer than the designated session time to talk, or to make up time for when the child cries or goes to the bathroom. It is important to explain that you aren’t punching a clock. For example I will stop treatment 15 minutes earlier to talk with a parent, and explain that this is part of the treatment. I either save a few minutes at the end of the treatment session to write a note or stay a few extra minutes. This enables you to keep on top of the written work. The EIP in NYC has many forms that must be submitted, and if you aren’t mindful you can spend quite a few unpaid hours completing them at the end of the month. Check with your EIP regarding billing for documentation time – daily, justification or progress.

It is not unusual to spend a lot of time commuting between clients since it is not always easy to schedule children within the same geographical area. Transportation will very depending on where you live - car, bus, subway, bicycle or foot. The numbers of clients you can see in a day is limited if you have to commute long distances between clients. Scheduling is often hard because of nap times, other therapy or school – and you can find yourself with a lot of down time. This time can be used efficiently if well planned – i.e.: tape recorder in car to record observations, neighborhood café to write reports, using cell to contact therapists, internet cafes, blackberry to send emails, library to research or just enjoying this “down time” by eating a nice meal, taking a walk, going shopping or getting quiet time to restore yourself.

By 2 to 3 years old many children do better in the more challenging office environment. Each case is individual, so it will depend on the child, treatment goals and the home set up. Older children with fine motor, handwriting or

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language issues often can be seen at home but this varies. There are also times when children need specific training with equipment in the home.

Pre School, School-age and Teens

Pre-school and school aged children can be treated through the public or private sector just like infants and toddlers. Publicly funded sources fall under the Department of Education rather than the Department of Health as in Early Intervention.

Guidelines, provisions and funding vary from state to state. For example in NY a child will get more services from EIP, while in NJ they get more from the department of education. Private, religious and home schooling usually falls under the Department of Education.

In most states the following options are available: contract with an agency to work with specific children or schools contract directly with the Department of Education to service a child in

their home or your office employment by the Department of Education.

Contact your local school district or department of education to find out how related services work in your district and/or state. Get a list of approved agencies or find out how you can become an approved provider.

PRE SCHOOL

A referral is made to the CPSE (Committee on Pre school Education) if a child is receiving services through the Early Intervention Program, and it is anticipated that he will continue to need therapy services after he turns 3. Evaluations are scheduled to determine eligibility for related services.

If a child has never received services, and the parent suspects a problem with his child, they can call the CPSE directly to request evaluations. There are many laws regarding time lines, procedures and strategies if the parent disagrees with the recommendations. This information is readily available on line or through your local department of education.

School-age

Under IDEA, the goal of all school based related services is to support the child’s ability to access and progress in the general education curriculum.

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All related services - PT, OT, speech - must be designed to improve school performance and achievement whether the therapist is employed by the public school, self employed or working in a private clinic.

Services are to be provided in the “least restrictive” environment which is defined as the setting that most appropriately meets a student’s educational needs. This might be in the classroom, playground, lunchroom, library, gym or specific designated therapy space. The latter being the “most restrictive” of all the other choices.

Pre-school and school aged children are mandated to receive related services with goals outlined in the IEP (individualized education plan).

Some schools prefer the “push in” model which means that you work with the child in the classroom, whereas others have a designated therapy space outside of the child’s class.

In some districts you can service the child off site at their home or your office if the family proves that the school does not have the appropriate therapists or the school is not the “least restrictive” environment. The child must be serviced within certain time frame or the department of education is out of compliance.

The NYC Department of Education awards a contract for therapy services to an agency in 3 different ways - competitive bidding, non competitive awarding of contract and individual contract. Steps needed to become an agency are covered in Book 2. There is great potential for expansion if awarded a related services contract.

Private pay is another option for treating pre-school and school aged children either at home, private school or in an office. Many parents do not want their children “identified” by the department of education, especially if their problems are minimal.

An important part of the comprehensive private evaluations done in pediatrics is observation of the child in daily life situations - home, school, and playground or after school programs. Many therapists who treat only in their offices may lose touch with how the child functions in the real world. It is usually very helpful to schedule visits throughout the year as part of the ongoing treatment process. It helps to integrate the services, and also highlights your role as a professional in the community.

When children are treated in school, the teachers have the opportunity to see what you do, and incorporate ideas in to the classroom. This also provides an informal forum to comment on other children – which educates the teacher, and may lead to referrals or invitations to lecture for teaching staff or parents.

Teens

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Adolescence has its own special issues that are only further complicated by an illness, specific challenges or disability. The adolescent with cerebral palsy, hemi paresis, learning disabilities or a spinal cord injury will have different needs than younger children with the same disabilities.

Teens with similar disabilities can be scheduled back to back to provide informal opportunities for socialization. This strategy can often lead to eventual work in dyads which reinforces therapy and may promote new friendships. Certain teens may do better in groups where the focus is somewhat more diffuse, and socialization opportunities also exist. These ideas can work across all the disciplines.

Some teens need more privacy at this age so scheduling, and the location of therapy within your clinic is an important consideration. Older teens may do better in an adult practice, especially as therapeutic needs change.

Opportunity for therapy off site within the community may take precedence at a certain point within the treatment program. Honest communication and collaboration with teens is a very important part of the treatment process. Teenagers have to learn how to take responsibility for their therapy and follow through with home programs. Contracts are a good way to do this.

Considerations in Setting Up a Pediatric Office

The multiple legal, economic and business factors addressed in “Starting a Private Practice” obviously must be taken into consideration in pediatrics. Details regarding names, budgets, cost and renting a place of business are also in that workbook. Ask questions of yourself and others as you begin your journey into the world of private practice. You never know what you may learn that will save you time, anxiety and money!

Is there a shortage of pediatric clinics in your area? Why might that be? Is there a real need for a new clinic? Is the area growing with new young families or retirees? Do the clinics only offer one discipline, or many? What types of services do the pediatric offices offer besides typical therapy? Are there specific treatment techniques you can offer so that your practice will be unique? For example: therapeutic listening for OT, fast forward for speech or pediatric Pilates for PT?

Choosing a Name – Best to have some reference to children in the name so people instantly know that it is not an adult therapy practice. Giving the practice your name limits flexibility and future expansion. Consumers often want to see the person who the practice is named after – and, at some point you may not want to treat clients.

Start up costs – are usually less for a pediatric practice than an adult practice mainly because the equipment is not as expensive. You can start out with basic equipment (balls, mats, rolls, small table and chairs, benches and toys) whether you are a PT, OT or Speech.

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Standardized testing materials, especially for OT and Speech, can be costly but it is really just an initial investment. New practitioners can join together to purchase expensive tests/equipment and then buy their own as cash flow increases.

Location Choose area near school, hospital or park (i.e. natural environment) Accessible by transportation, subway, bus, parking, easy navigation

(i.e. teenager can get from school) Elevators big enough for wheelchair and strollers

Renting or sub-letting an office has its own set of costs, considerations and requirements. Many therapists choose to use one room of their home for a start up practice. This works nicely in pediatrics because it generally is a more intimate, less clinical environment.

Physical Space Can equipment be suspended from the ceiling? This is important for

other pediatric practices besides OT since many speech therapists and PT’s are also using this equipment to assist in their therapy.

Is the room big enough for a swing to move back and forth, sideways and in a circle without the child getting hurt (generally 6 feet of excursion, 3 feet on either side).

Huge spaces are not always the best because it is often harder to contain/structure the children.

Children laugh, scream with delight, talk loud and cry! Most offices are not soundproof so try to cut down on noise by using carpet, mats on floor or hangings on wall. Make sure that office is not next door to a psychotherapist if you are in a suite of offices.

Smaller rooms for table top work, or screened off areas that are more contained for kids with decreased attention spans.

Waiting room has to be big enough for nannies, parents and siblings. Bathrooms – needs to be accessible for kids, preferably in the space.

Decoration Cheerful but not stimulating environment Light colors Incandescent lighting Create some quiet spaces Kid friendly – not clinical Chalk wall paper or felt boards on wall Few mirrors to cut down on visual stimulation

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Carpeting to cut down on noise Some areas of wood or vinyl flooring Sound proofing if in suite of offices Waiting room to accommodate strollers, wheel chairs, siblings

Equipment Commercially available suspension devices, eyebolts and rotational

devices for suspended equipment Bolster swing, platform swing, mats, scooter board, bolsters, therapy

balls, large therapy pillows, adjustable therapy benches, climbing ladder, trampoline, bean bag chair

Mats to cover floors below and around suspended equipment Hooks to hang equipment above child’s height Racks for balls or hammocks Closed cabinets and high shelves for toys Computer for children - keyboarding, eye hand, language etc Standardized Testing Materials Individual Cloth bags for oral motor toys/brushes CD or other type of music player Locked fireproof file cabinets

Websites for equipment, tests and supplies can be found in the Appendix.

Office Forms

Information Sheet General rules, FAQs, and policies regarding MD referrals, fees,

payment, cancellation, sick therapist, make up sessions, vacation, clothes or other needs for therapy session. communication book etc

Permission consent For pick up from therapy Participation in classes at the facility

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Cancellation Policy Listed on information sheet plus separate sheet that parents sign.

Cancellation within 24 hours is the norm; if child is sick that AM, then parent has to call by 8:30 to not be charged; cancellations for birthday parties etc not charged if told a week in advance; charge for no show or last minute calls unless kid suddenly becomes sick.

Agreement for Payment

If your patient has agreed to pay you privately or by credit card, have your patient sign a form that states the cost of each session, and the terms of payment (due at the end of each session, weekly or monthly).

Intake sheet for new patients Medical history, insurance, referrals sample form in appendix

Health and Safety Procedures Outline emergency procedures in a book accessible to parents so that

everyone knows what to do in an emergency. Emergency contacts centrally listed here not just on each chart. Also hand washing, universal precautions, cleaning mats/toys; if chicken pox breaks out…

Specific Sample forms can be found in “Starting a Professional Private Practice” including, but not limited to

HIPAA/Notice of Patient Privacy Practices &Patient Privacy Consent Payment Agreement/Assignment of Benefits

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Documentation

Referrals from MD

Prescription from MD for evaluation and treatment is standard, and must be updated accordingly. You must know the regulations of your practice act for this as it varies among professions. Referral should include ICD code, child’s date of birth, date, frequency of service.

State/federal and Department of Education

Specific note writing protocols and standardized forms for evaluation, daily, progress and discharge notes are supplied by payment source. The M.D. prescription is on file with agency, state or department of education when you are treating through these programs.

Private practice

Each discipline follows guidelines for note writing according to practice act. Voice of parent should be reflected in the notes

Client chart- prescription from MD, evaluation, daily notes, home programs, discharge notes, contact info

It is very important to keep your notes up to date. Insurance companies often ask for copies of your notes when they are trying to determine eligibility for reimbursement for a private patient. Your notes can/will also be subpoenaed in the event of a lawsuit.

Storing files

NY State legally requires you to keep notes until child is 21 years old whereas for adults it is 6 years. An EI agency is supposed to keep copies of these notes but legally so are you.

Communication

Team members – Regarding treatment, goals, progress, carry over etc

Parents – Home program, updates, coordination

“Communication Notebooks” - use one notebook to communicate with parents, other therapists and teacher about the child. Incorporating these informal notes into your treatment time cuts down on emails and/or telephone time after hours. This also helps to keep all

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the information centralized and easily accessible. Names, numbers, emails of all team members should also be written here.

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Billing and Reimbursement

Your income usually will come from a variety of sources. The rate and frequency of payment is dependent on who is paying you.

For example, an early intervention agency might cut a check in the pay period following submission of progress notes, the department of education might pay with a 3 month delay no matter when you send in your notes, and a private patient may pay at each session. Rates, payment, and therefore cash flow, will influence how you choose to divide your caseload whether you are doing office, school or home based treatment.

Rates for therapy visits are usually less when an agency is the intermediary, and vary from county to county and state to state. Private rates also vary depending on the city, county or state. There is no website or book that tells you what rates to use nor is there any control on fees.

It is may be helpful to use the state fees as a guideline for “customary and reasonable” charges. Phone calls to a few practices in your area will also give you an idea of the average fees for initial evaluations and treatment. Fee structures in adult practices are usually different than in pediatrics, but the rates are usually fairly consistent between PT, OT and Speech.

I always tell parents to call their insurance company, HMO or PPO to find out the rules regarding the specific therapy. Reimbursement is often better for PT and OT than speech. Many insurance company representatives will tell the parents to choose a therapist in their area from the provider book. Typically the parents start calling, and find out that all the providers work with adults. Many insurance plans do not have pediatric therapists in their networks. Sometimes this is a plus, because the parent can fight to get out of network coverage. For example – my son needs a therapist certified in NDT with experience with premature infants under 6 months old and the insurance company does not have appropriate therapists in their network.

In the New York City area most pediatric therapists do not accept direct insurance assignment or co pays. The norm here is for the parent to give you a personal check upon receipt of the bill, and they submit the forms to their insurance company. Parents often ask if we accept “assignment of benefits” – meaning we submit forms to insurance company and take whatever reimbursement the insurance company will give. I usually explain that cash flow is a problem because the caseload for a pediatric therapist is on a 1:1 basis, and therefore much smaller with less turn over than for an adult. You can bill them for every session or once monthly - depending on your accountant and theirs. Some center based programs will hire you on a 1099 and others with a W2 depending on their business structure.

In some areas of the country it is necessary to be an approved MedicaidProvider. You have to contact the Medicaid office in your state to determine eligibility and reimbursement rates. Usually rates are very low for Medicaid but some children must be seen through this funding source.

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Specific Billing Information Once weekly, biweekly or once a month depending on your accounting

system, your client’s preferences and/or rules of agency. You should include the following on all bills: ICD diagnosis code, dates

of service, current CPT codes with units, your state license #, NPI # tax id number and professional title

Cash, check or credit card? Cash is cash. Checks are easy for both consumer and business – especially for ongoing clients. You’ll get your fee more quickly with credit cards, and they can get miles!

Best to mail bills home rather than send home in child’s backpack – worth the stamp not to lose the bill.

All bills sent by email must include specific information per HIPAA CPT Codes, or Common Procedure Codes - describe medical or

psychiatric procedures performed by physicians and other healthcare providers. A new CPT book is published by the AMA every year. Certain codes are more reimbursable than others. It is important to use all codes that apply to show that these codes are valid (i.e. SI codes in OT). If you don’t use the codes then the insurance companies will stop honoring them, and they will eventually be taken out of the CPT handbook. Also keep in mind that if PT and OT’s both bill using the same codes – the family won’t be reimbursed either.

A listing of frequently used ICD and CPT codes in pediatrics can be found in the appendix.

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Marketing in Pediatrics

The pediatric service delivery model will influence your marketing strategy.As a general rule, most adult orthopedic cases are short term, and are often treated in multiples in an office. The majority of pediatric cases are long term – an entire school year or across many years – and are treated 1:1 for 45 – 60 minutes. This clearly limits the numbers you can treat in a day but also makes it much easier to fill up your caseload if you retain children from year to year. Therapists have been known to work with children from 1-5 years or longer – depending on progress, payment source or other factors.

General marketing techniques and strategies are covered in Workbook 1

Direct Mail Pediatric therapists in other disciplines Pediatric Dentists, Osteopaths, Chiropractors Therapists who treat adults Case managers for chronic care at home pediatric patients

Community Sponsoring events in community Free screenings at head start programs, local day care center Participating in community events Street fairs Lectures at Y, gymboree , play spaces, schools, music or yoga classes Signs at stores for children- clothing, toy stores

Follow up Letters To MD’s and other referral sources To parents of discharged patients To directors of schools of kids who used to be in therapy

Make sure you ask parents to write a review of your practice online at Yelp or some of the site specifically geared toward health practices.

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Expanding Your Practice

Each pediatric client referral has the potential to expand your practice. Here is an example of this “ripple effect”.

A 3 year old is referred for evaluation, and now comes 2x weekly Parent comes to a workshop at office Child comes to after school group M.D. refers another child Nursery school director asks you to talk at school Mother tells friend who just had premature baby Therapist observes child at music class, teacher introduces you,

parent approaches you after class about her child Child comes back for re evaluation at 6 years old New sibling comes for evaluation

The potential also exists for keeping a child in your practice for many years if you can continue to meet his needs. For example, let’s say my specialty area is birth to 3 years. I hire another therapist with expertise with school age children with CP, and another with certification in “yoga with special needs children” – this immediately expands my market rather than only serving clients under 3 years old.

CLINICAL

THERAPEUTIC GROUPS – billed as therapyo For children who would benefit from working with other children

in small groups o Some general examples are: fine motor, writing, self care, ball

skills, oral motor, language, yoga, bike riding and roller blading. These ideas also can also be used for “step up” classes below.

4 to 8 WEEK CLASSES – Pay Up-Front

o “Step Up” Classes (like “step down unit” after NICU but with positive name) for children who no longer need 1:1 therapy and/or those with minimal needs who haven’t had therapy at your office. See above ideas.

o Create “day camp” classes for summer or winter/spring breako Specialized small classes for “Mommy and me” (or Daddy,

sister, brother, grandma). Can group according to disability.

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o Teens - sports, grooming/beauty, role playing, community navigation, cooking, big sister/big brother (disabled teen partners with younger disabled child)

Follow up visits with clients – every x months for first year. Send out letters/postcards like your dentist does

Incorporate specialized modalities into your practice such as: yoga, Pilates, tai chi, therapeutic listening, metronome, fast forward, prompt, keyboarding to name just a few.

Sponsor an Equipment and/or Orthotics clinic at the office every month Sponsor an OT for splints, adaptations, seating as needed

EDUCATIONAL

Group education on generic topics for parent/caregiver/babysitter Monthly workshops for therapists and/or parents Mentoring and supervision for therapists in community Sponsor courses at your office for therapists, MD’s etc

COMMUNITY OUTREACH

Target directors of schools - lectures, screenings and/or groups for kids on site who need help but not 1:1 therapy – fine motor, language ,

Consultation – schools, neighborhood arts and crafts, gymboree, music classes, daycare center, sports programs

Obesity – fitness groups for different age groups Sports Clinics for normal kids – injury prevention etc Screenings with local pediatricians in their office Sell products to parents and/or community “Tupperware” parties for small equipment or toys

ADMINISTRATIVE

Become an approved agency for Early Intervention Program Bid for a contract with the Department of Education Specific information for “hiring additional staff” is in workbooks 1 and 2 In pediatric practice it is highly recommended that you do as thorough a

check as the law allows when hiring staff – in order to ensure that your potential employee does not have a history of child abuse or neglect. In NYS you can ask any candidate to fill out a form called the State Central Register Database Check Form (LDSS-3370). Completion and

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submission of the form indicates the person has no past documented offences.

The forms can be obtained by writing to: OCFS (Office of Children and Family Services)Forms Management Unit Room 101 South Building52 Washington StreetRensselaer NY 12144or accessed online at www.ocfs.state.ny.us/main/forms/

Contact the State Health Department in your state to find out the procedure for background checks.

APPENDICES

Appendix B: Sample Initial Intake Form for Pediatrics Appendix C: Agreement and Waiver for participation in onsite classes Appendix D: Photo/video Consent Appendix E: Permission SlipAppendix F: Sample Letters Appendix G: ICD Codes Most Frequently Used in PediatricsAppendix H: CPT Codes Most Frequently Used in PediatricsAppendix I: Resources/Equipment/Supplies/Testing Appendix J: Fact Sheet for NY Therapists

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Appendix B: Sample Initial Intake Form for Pediatrics

YOUR PRACTICE LETTERHEAD

Today’s Date ___________________Referred by_____________________________Child’s Name___________________ DOB________ Diagnosis__________________Mother’s name__________________ Father’s name___________________________Telephone @ home_______________ Work_______________ Cell_______________Address______________________________________________________________Pediatrician____________________ Telephone_______________________________

Insurance Company _____________ Dept of Ed __________E.I.P_________________ School _________________________Telephone ________Teacher_______________

Emergency Contact _____________________Telephone_________________________

GENERAL HEALTH HISTORYDescribe your pregnancy, labor, delivery__________________________________________________________________________________________________________Was your child Full term Premature Gestational Age _____Birth weight _______Has your child ever been hospitalized? _______________________________________Was your child Breast fed Bottle fed? Did child transition easily to solids_________At what age did your child: Sit ______Crawl ____Walk ___Talk________________________________________________________________________________________Who lives at home ____________Siblings ________Any developmental issues or illnesses in family ______________________________________________________________Has your child ever been treated for? Asthma Allergies Ear infections Feeding Problems Food hypersensitivities Gastrointestinal Problems Headaches Major illness or injury Seizures Sensory or motor issues Sleep Problems Other__________________________Comments_____________________________________________________________________________________________________________________________________________________________________________________________________Has your child seen any of the following specialists? Developmental Pediatrician Neurologist Psychiatrist Audiologist Occupational Therapist Physical Therapist Speech and Language Therapist Neuropsychologist Osteopath Chiropractor Homeopath Nutritionist Psychotherapist Special Educator____________________________________________________________________

Areas of concern__________________________________________________________ ____________________________________________________________________

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Please Note: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office.

_______________________ __________________ ____________________Name of Parent/Legal Guardian Signature Date

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Appendix C: Agreement and Waiver for participation in onsite classes

I __________________the parent or guardian of _________________(Thereafter referred to as "my child") give permission for my child to participate in the NAME OF YOUR PRACTICE classes to be held once weekly on Tuesdays from ____ to _____ for a ______ week period beginning ______. The cost of the program is ___________, payable in advance to name of practice. I understand that I or a designated caretaker am responsible for being an active participant and supervising my child for the entire duration of each session. Should my child have to drop out of the program, _______________ agrees to reimburse the family for the program on a pro-rated basis. There are no refunds for any missed sessions, and no make up sessions are provided. I hereby release ____________ its principal owners, therapists, employees and representatives and all other individuals or organizations acting on behalf of ____________in connection with this program from any and all claims which I or my child may have arising from, resulting from or in connection with my child's participation in the ____________ program, including but without limitation, any claim, demands or causes of action for injuries to my child, including but not limited to injuries resulting from the use of any play equipment during the program. This agreement is signed for the purpose of fully and completely releasing, discharging and indemnifying ____________ its principal owners, therapists, employees, representatives, and all other individuals or organizations acting on behalf of _____________in connection with this program from all liability as herein described. Liability for the cancellation of the group by _____________is limited to the program fee.

Signed:

___________________________________ ______________Parent or Guardian Date

Acknowledged By:

___________________________________ _____________NAME OF PRACTICE Date

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Appendix D: Photo/video Consent

PLEASE LEGIBLY PROVIDE ALL INFORMATION REQUESTED.

Photo/Video Consent for Name of Your Practice

Child's Name: _____________________________________________

Child's Age: _____________________________________________

Parent/Guardian'sFull Name: _____________________________________________

Parent/Guardian'sFull Address: _____________________________________________  _____________________________________________  _____________________________________________

Parent/Guardian'sTelephone Number: _____________________________________________

Parent/Guardian'sE-mail (optional): _____________________________________________

I consent and give permission to you and those acting under your authority to photograph/video and use the likeness of my _________ in connection with ____________________

By signing below I certify that I am the (please check) ___ parent or ___ legal guardian of the child above, a minor. I release ___________________, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. The undersigned does hereby agree to hold _____________________, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor's behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor's likeness and photograph. This permission is for use of ________________________ only.

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________________________________________________Signature Date

________________________________________________Witness Date

Print Witness Name: _______________________________

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Appendix E: Permission Slip

NAME OF PRACTICE

PERMISSION SLIP

Child’s Name: ______________________

I, ______________________ parent/legal guardian of the above named child hereby give permission for ___________________, a designated caregiver tosign on my behalf, any and all service verification forms for Early Intervention or Dept of Education, that need to be signed in the event that I am not available.

OR

I also give permission for ________________________to pick up my child from_____________________ when his therapy is finished. In the event that another person will pick up my child, I will notify this office.

_______________________Parent/Legal Guardian Name

_______________________ _______________Signature Date

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Appendix F: Sample Letters

Dear ,

I am very interested in treating students mandated for Occupational Therapy services through the Department of Education either at school, or in their homes. I have a Masters Degree in Developmental Disabilities, and have been working for 10 years in pediatrics. I am certified in NDT and the Sensory Integration and Praxis Tests. I am familiar with the delivery of school based therapy services, writing IEP’s, working in the classroom and collaborating with teachers and other team members.

Please contact me if I can be of service to any of the students in your district (or school depending on who you are sending the letter to). I am available to meet with you at your convenience, and I look forward to hearing from you. Thank you

Sincerely

_____________________________________

Dear ,

I am a pediatric occupational therapist with 15 years of varied experience as director of Occupational Therapy at the Children’s Rehabilitation Hospital including NICU, head trauma and home care. I have just opened a 2000 sq. ft. office on Willow Street with 2 other occupational therapists, and would like to tell you about the services offered.

Our experience covers a wide range of ages and disabilities including but not limited to: premature infants, brachial plexus injuries, cerebral palsy, fine motor coordination and sensory processing issues. We have all lived in this community for many years, and are committed to providing state of the art treatment to the children and their families.

I would be happy to tell you more about my practice or discuss any children in your practice that might benefit from occupational therapy. In the meantime I am sending some information packets to your office, and look forward to hearing from you at your convenience. Thank you.

Sincerely,

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Appendix G: ICD Codes Most Frequently Used in Pediatrics 299. Infantile autism299.80 Pervasive Developmental Disorder314.0 ADD314.01 ADD with hyperactivity315.02 Developmental dyslexia315.4 Coordination disorder315.32 Receptive language disorder mixed315.39 Developmental articulation disorder334.9 Cerebral palsy343 Infantile cerebral palsy 343.0 Congenital diplegia343. 1 Congenital hemiplegia343.4 Infantile hemiplegia, post natal345 Epilepsy348.8 Cystic Periventricular Leukomalacia (CPVL)389 Conductive Hearing Loss389.10 Sensorineural hearing loss 728.85 Increased tone729.9 Muscular imbalance734 Pes planus737.30 Scoliosis749 Cleft Palate754.1 Congenital torticollis758.0 Down’s Syndrome 760.71 Fetal Alcohol Syndrome764.9 IUGR765.0 Extreme prematurity (<1000 grams)765.1 Prematurity (1000-2499 grams)767.6 Brachial plexus injury772.1 IVH – grade 4779.3 Feeding problems newborn780.91 Fussy baby781.3 Hypotonia, decreased tone 783.3 Feeding mismanagement infant783.41 Failure to thrive789.0 ColicAppendix H: CPT Codes Most Frequently Used in Pediatrics

97001 - Physical Therapy evaluation97002 - Physical Therapy Re-evaluation97003 – Occupational Therapy evaluation97004 – Occupational Therapy re-evaluation97110 - Therapeutic procedure, one or more areas, each 15 min; therapeutic exercises to develop strength, endurance, ROM, and flexibility97112 – Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing 97113 – Aquatic therapy with therapeutic exercises97116 – Gait training (including stair climbing)

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97124 – Massage 97140 – Manual therapy techniques (myofascial release, mobilization…one or more regions, each 15 minutes.97150 – Therapeutic procedure(s) for group (2 or more - report 97150 for each member of group); group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one on one patient contact by the physician or therapist97504 – Orthotic (s) fitting and training, upper and/or lower extremity, and/or trunk, each 15 minutes97520 – Prosthetic training, upper and/or lower extremity, each 15 minutes97530 – Therapeutic activities to improve functional performance direct one on one patient contact by the provider, each 15 minutes97532 – Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct one on one patient contact by the provider, each 15 minutes 97533 – Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct one on one patient contact by the provider, each 15 minutes97535 – Self care home management training (i.e. activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of assistive technology devices/adaptive equipment) direct one on one contact by the provider, each 15 minutes97542 – Wheelchair management/propulsion training, each 15 minutes92506 – Evaluation of speech, language, voice, communication, auditory processing and/0r aural rehabilitation status92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual92508 - Treatment in group, two or more individual92510 – Aural rehabilitation following cochlear implants (includes evaluation of aural rehabilitation status and hearing, therapeutic services) with or without speech processing program92526 – Treatment of swallowing dysfunction and/or oral function for feeding96105 – Assessment of aphasic (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, i.e. by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour96110 – Developmental testing; limited (i.e. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report96111 – Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, i.e. Bayley Scales of Infant Development) with interpretation and report96115 - Neurobehavioral status exam (clinical assessment of thinking, reasoning, and judgment, i.e. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report

Please note: the AMA holds all rights to the CPT codes

Coding and Payment Guide for the PT 2002www.ingenixonline.com or 800-INGENIX

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CPT Codes (document 1055) available from AOTA 800-701-7735 Fax on demand service

Appendix I: Resources/Equipment/Supplies/Testing

www.firstsigns.org **website has excellent extensive links to other sites**www.NICHCY.org www.spdnetwork.org www.zerotothree.orgwww.abilitations.comwww.alcanairex.comwww.beyondplay.comwww.equipmentshop.comwww.flaghouse.comwww.icdl.comwww.interactivemetronome.comwww.kayproducts.comwww.kinesiotaping.comwww.ncmedical.comwww.new-vis.comwww.otpt.comwww.pdppro.comwww.PsychCorp.comwww.sammonspreston.comwww.sensorycomfort.comwww.sensorysmarts.comwww.southpawenterprises.comwww.talktools.netwww.theradapt.comwww.theraproducts.com

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www.vitallinks.netwww.wpspublish.comPlease note that websites constantly change so we are not responsible for errors

Appendix J

FACT SHEET for THERAPISTS IN NEW YORK STATE

Early Intervention – New York Early Intervention ProgramBureau of Child and Adolescent HealthNYS Dept of HealthEmpire State PlazaCorning Tower, Room 208Albany, NY 12237-0618Form DOH 3736 – Application for Approval of Agencies, Incorporated Groups of Individuals as Evaluators, Service Providers or Service CoordinatorsForm DOH 3735 – Application for Individuals

In NY State, agency or individual provider approval must happen first at the State (Albany) level and then at the county level. You will not be given a county application until you are approved on the State level – 2 applications.

Decide where (municipality/county) in NYS you want to provide services. Does this county allow individuals to become a direct provider or are you required to be an agency? This will determine the form you request from Albany. You can begin providing services in one county, and then add counties by sending in an addendum to your application.

There are many counties in NYS that are not accepting applications for new providers. You can call each county municipality to find out. Even if you find out that a particular county is “closed” to new providers, it is recommended that you apply at the State level, so that when your county "opens" for new providers, you will have already been approved at the State level, and then can focus on the county level application.

Providing Services in the Public School System

As of June 2011, the only school system in NY State with a formal competitive bidding process to provide services is the NYC Department of Education (formerly the Board of Education). All other school systems in NY State provide services either by hiring their own therapists as employees or contracting with therapists directly, with pricing for services determined through negotiation and not by submitting bids. The trend for the future in school districts, particularly on Long Island is to begin to institute a competitive bidding process for the procurement of related services. Competitive bidding is a way for the school districts to keep the fee for services low, and thus is being looked at as a good option from a budgetary point of view.

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There are two mechanisms in NYC for the provision of therapy services.

(1) The Department of Education (DOE) issues a Request for Proposal (RFP) for the Provision of Related Services, and another one for the Provision of Assessments. The RFPs are rewarded for a three year period. Start off by going to this website to get on the list of vendors so you can be notified when new RFPs come out: http://schools.nyc.gov/Offices/DCP/Vendor/RFP/Default.htm

(2) Becoming an RSA provider: Historically, the DOE has never been able to provide all the mandated services through the RFP so they also issue Related Services Authorizations(RSA) allowing individual therapists to provide therapy services even though have not been awarded a contract through the RFP.

For many therapists in New York City, becoming an “RSA” provider is a way to begin a private practice. Here is the link for additional information and an application form: http://schools.nyc.gov/Offices/District75/Departments/RelatedServices/default.htm

Once you complete the application form and are approved, you will be added to the DOE MUNICIPALITY LIST OF INDEPENDENT PROVIDERS OF RELATED SERVICES FOR STUDENTS WITH DISABILITIES. This list is accessed by parents, schools, Integrated Service Centers, CSEs and Citywide Programs when an RSA is issued. The next date for the list to be updated is September 2010 .Please note that a major change for the DOE is that now in certain districts where there is a significant shortage of therapists, DOE employees are now allowed to become RSA providers – previously this was viewed as a conflict of interest.

Outside of NYC, contact the school district where you want to work to find out the procedure for providing related services. There may be a difference between doing initial evaluations and ongoing treatment. A sample contract to use with school districts is included in the Appendix.

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