THE DETERMINATION OF RELEVANT THERAPY TOOL (DRTT) OVERVIEW

Transcription

1 THE DETERMINATION OF RELEVANT THERAPY TOOL (DRTT) OVERVIEW Susan W. Cecere, PT, MHS Jodie K. Williams, OTR/L, MHA Cecere & Williams School OT/PT Consultants The DRTT was created as a means to establish a starting point for determining frequency and duration of therapy sessions once an IEP is completed by the team. The scores created through the use of the DRTT provide objective support to service decisions made for a student who is eligible for special education and related services. The tool assumes the use of evidenced based practices in support of the mandate of IDEA (best evidence practicable); recognizing the body of literature for many OT/PT interventions is sparse, the use of individualized data to support decision-making is expected. DRTT is not meant to be prescriptive nor can it take into consideration the number of variables which may exist that impact frequency and duration decisions. Despite the objective information provided by DRTT, the user must also recognize the IEP team as the ultimate decision maker regarding needed services. The tool also assumes that whatever placement decision is made as part of the IEP process will be the student s Least Restrictive Environment (LRE). From a practice perspective the DRTT addresses areas of clinical and educational relevance an OT and/or PT might be asked to address as part of a student s educational program with a focus on student performance and participation. The DRTT is not an assessment tool but rather a summation of information that represents all factors, including the curriculum and expertise of other team members. The tool addresses the continuum of services, such as those on behalf of a student (supplementary aids and services) i.e. equipment management and the training of personnel, which require ongoing support over the course of an IEP cycle without significant direct intervention, as well as services to a student to address the development and/or refinement of a skill necessary for instruction and/or functional activities. The original individual components of DRTT were generated by a modified Delphi technique to achieve consensus of the expert opinion of the OTs and PTs working in Anne Arundel County Public Schools and Prince George s County Public Schools in Maryland. Accepted pediatric practices for OTs and PTs, such as the use of the International Classification of Function, the Occupational Therapy Practice Framework and Domain as well as natural environments, motor learning theory and universal design for learning were also factors in the decision making regarding the areas addressed within the tool. The DRTT in its current form has been reviewed and edited by experts in the field of school based occupational and physical therapy using a Delphi technique via Google Survey Purpose: The intent of this research is to establish whether the Determination of Relevant Therapy Tool (DRTT) represents educationally relevant, necessary services and supports professional practices. This will be done by using a nominal group technique with a pool of chosen experts in the fields of occupational and physical therapy school based practice. The pool of experts will be chosen by the investigators and based on professional organization recommendations. The DRTT is a decision-making instrument in establishing a starting point for discussing the frequency and duration of services in the school based setting for children/students ages three to 21. Currently, schoolbased therapists lack a clinical reasoning instrument supported by research or expert opinion that encompasses the full scope of their roles and responsibilities and aids in decision making while maintaining the tenets of IDEA Objective

2 Therapists recognize the difficulties with the arbitrariness of service decisions; dosing has become a topic being investigated in all practice settings and a focus of research for the professional organizations (AOTA and APTA). This study is intended to determine whether the DRTT is a tool reflective of expert consensus opinion of educational relevance and accepted professional practices. This would be accomplished through the use a nominal group technique (NGT) considered a useful consensus methodology that has been successfully used in physical therapy research (Potter et al., 2004). Hypothesis The realities of the current educational environment require school-based therapists to balance their clinical judgment with programmatic constraints such as staffing shortages, pressure from school teams and parents, and funding when determining the amount of therapist intervention required to meet the needs of special education students. As a result, OT and PT services have been rendered that are not educationally relevant, not necessary and / or have been duplicated by other team members. It is hypothesized that by establishing DRTT as a clinical reasoning tool reflective of educational relevance, necessity and professional practices, school based OTs and PTs will develop confidence in their service determination; they will be able to articulate that their decision was not arbitrary but made using a tool grounded in expert opinion and, therefore, defendable. Clinical Relevance: Informed clinical decision making in the school setting is challenging from multiple perspectives. In an article written by Wainwright, et al. the authors identify clinical experience as the greatest determinant in shaping how and to what extent clinical decision-making skills evolve. Self-reflection is another must in the development of clinical decision-making skills in order for the therapist to achieve autonomy and expertise in this area. Generally these two critical steps in the development of clinical reasoning are easily accomplished given practice settings such as hospitals, outpatient clinics and rehabilitation centers. However, in the school setting, many OTs and PTs work in isolation and/or are not supported by other OTs and PTs within their jurisdictions; therefore they do not have the collegial support which would assist therapists in the development of clinical decision making abilities (Cecere & Williams, 2014). About the Determination of Relevant Therapy Tool Based on special education processes, service determination of any one provider is established following team approval of the present levels of performance, supplementary aids and services, and goals and/or objectives of the IEP. (However, the DRTT may be used with a draft IEP to help establish where the expertise of an OT and/or PT is needed). The DRTT was created as a means to establish a starting point for determining duration and frequency of therapy sessions once an IEP is completed by the team. It represents the continuum of service delivery from the support of supplementary aids and service only (services on behalf of student) to intensive intervention that requires services to a student delivered extensively. Through the application of the International Classification of Function and the Occupational Therapy Practice Framework, school based OTs and PTs look beyond student impairments to linking impairment and activities with the ultimate goals of participation in educational programs and achievement of student outcomes. The DRTT is not an assessment tool but rather a summation of information that represents all factors, including the curriculum and expertise of other team members that might impact decision making regarding educationally relevant services requiring the expertise of OT and/or PT. From a practice perspective the DRTT addresses areas of clinical and educational relevance an OT and/or PT might be asked to address as part of a student s educational program. The DRTT addresses the continuum of services such as those on behalf of a student (supplementary aids and services) i.e. equipment management and the training of personnel, which require ongoing support over the course of an IEP cycle without significant direct intervention, as well as services to a student to address the development and/or refinement

3 of a skill necessary for instruction and/or functional activities. The scores created through the use of the DRTT provide objective support to decisions made regarding frequency and duration for a student who is eligible for special education and related services. *Although the DRTT is intended to support students eligible for special education and/or related services, an OT and/or PT could reference the different sections while making decisions about modifications and other supports that might be needed as part of early intervening services and/or 504 plans. The individual components of DRTT were generated by a modified Delphi technique to achieve consensus of the expert opinion of the OTs and PTs working in Anne Arundel County Public Schools and Prince George s County Public Schools in Maryland. Accepted pediatric practices for OTs and PTs, such as the use of the International Classification of Function, the Occupational Therapy Practice Framework and Domain as well as natural environments, motor learning theory and universal design for learning were also factors in the decision making regarding the areas addressed within the tool. Definitions of Terms Used in the DRTT: For the purposes of this study, the operational definitions of DRTT are as follows: Accommodation: An environmental adjustment such as modified paper, early dismissal from class, or other assistive technology used to enable a student to access the curriculum or perform an activity that enables them to participate at a par to students without disabilities Accuracy: Agreement between the actual time a therapist spends implementing a student s IEP with the recommended frequency and duration of the DRTT. Clinical reasoning: An inferential process used by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems. (Lee & Ryan-Wenger, 1997, p. 101) (Lee & Ryan-Wenger, 1997, p. 101) Duration: The length of each session of intervention in minutes that are needed to meet the needs of the student. Episode of care: The length of time needed to address a specific problem; in school practice that is generally the IEP cycle. However the episode can be shorter (such as a semester or quarter) depending on the concern that is being addressed and its impact on the student s participation in the curriculum. Exploration: The process used by a therapist to determine the most appropriate strategy to meet the unique needs of a student based on review of collected data and clinical judgment. Extensive: Three or more therapist-directed interventions a month in order to meet the unique need of a student Frequent: One to two therapist directed interventions a month that are delivered at regular intervals in order to meet the unique needs of a student Frequency: The total number of sessions of intervention that occur between the therapist and student over the course of the IEP cycle or other specified episode of care. Intervention: The design and/or implementation of a strategy that requires the expertise of an OT and/or PT Direct intervention: The design and implementation of strategies that require the presence of the student (services to a student)

4 Indirect intervention: The design and implementation of strategies that do not require the presence of the student (service on behalf of a student) Modification: A change to a functional activity and/or the curriculum needed due to the impact of the disability that will allow a student to participate and achieve some level of educational benefit. Activity modifications might include allowing extra time to transition between classes, a reduced number of warm up exercises in PE class or using a chair to sit to unload a back pack upon arrival in the classroom. Curriculum modifications might include a pictorial as opposed to written display of material due to cognitive challenges or having a student bend his/her knees as opposed to jumping in PE class due to a physical disability Periodic: One or less therapist-directed intervention sessions per month order to meet the unique needs of a student, generally prompted by a concern of classroom staff members Physical Assistance: Physical assistance provided by one or more adults for a student who is otherwise physically unable to complete the activity Physical Prompt: A touch cue provided by one adult Session: A period of time in where services are being delivered to a student or on behalf of a student in accordance with the IEP Supervision: Stand by assist of one adult that does not require a verbal and/or physical cue Verbal prompt: a verbal cue provided by one adult Components of the DRTT Scores and Recommendation (Summary Page page 1): The Summary Page is used to document the objective data from each section of the DRTT in order to determine the recommended frequency and duration of services. OT/PT Service Needs (page2): Sensory processing: The student s sensory needs that are related to academic and non-academic (social and/or functional skills) performance Independent living skills: The student s performance as it relates to the functional skills curriculum and their abilities/needs with self-help and independent living Fine motor: The student s management of manipulatives, writing tools, clothing fasteners, and other manual abilities relevant to the school setting Visual/perceptual Motor: The student s performance as it relates to copying (near and far point), coloring, and cutting tasks, as well as visual tracking while reading and keyboarding. Mobility: The student s performance as it relates to moving in the school setting including hallway negotiation/navigation, transfers, stairs, bus steps, and the playground, and physical education. Gross motor: The student s performance as it relates to foundational gross motor skills that facilitate participation in physical education and social interactions with other students during recess. Educational Impact (page 4)

5 This section ascertains: The impact the student s needs have on his/her ability to participate and make progress in the educational environment. Whether or not the student s needs can be addressed by another professional, other than the OT and/or PT How many years a particular goal has been addressed by a therapist. (Please note: this is not total number of years receiving therapy support but rather the number of years supporting one particular goal.) Service Frequency (page 5): This section assists with determining how often service may need to be delivered based on student need, prognosis and their ability to benefit from intervention. OT/PT Supplementary Services Needs (page 6) This section provides criteria that may influence: 1.The need for supplementary aids and services to support a student s educational program, and 2. what area(s) may need support. Conclusion: Following a review of the literature, there is little evidence to guide decision making when it comes to the frequency and duration of services. In the school setting, this poses challenges not encountered in other settings: IEP teams not understanding the model of OT and PT practice or intent of related service provision, conflicts between outside and school system providers, and administrative difficulties such as financial constraints and unwieldy caseloads. There are no tools recognized by expert opinion for educational relevancy, necessity and professional practices that school-based OTs and PTs can confidently use to make informed frequency and duration decisions for students who are eligible for special education and/or related services. Having a tool a therapist can use to articulate the process of service determination to school teams could eliminate what appears to be the arbitrariness of the decision as it relates to a student s IEP. The DRTT can be a valuable tool assisting school-based OTs and PTs in their decision-making processes and establish a starting point for team discussion not based on emotion but on objective data.