Of California Brown Bag Lunch Series A statewide training series on health and policy topics affecting children and youth with special health care needs.

of California

Brown Bag Lunch SeriesA statewide training series on health and policy topics affecting children and youth with special health care needs. This series is geared towards diverse stakeholders including families, youth, professionals, parent-to-parent staff and advocates.

The voice of familiesthe vision of quality health care

the future for children and youth with special health care needs

Family Voices of California is locally based, nationally connected

A statewide collaborative of locally-based parent run centers working to ensure quality health care for children and youth with special health care needs. As the State Affiliate of National Family Voices, we are California’s federally funded “Family-to-Family-Health-Information-Center” providing statewide support to families of CYSHCN. For more info, visit www.familyvoicesofca.org

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All PowerPoints & materials posted online following the webinar.www.familyvoicesofca.orgMargaret Mary [email protected]

Educationally Related Occupational and Physical Therapy Services

Family Voices of California Webinar

October 3, 2012

Carol Cohen, Parent Health Liaison, FRN Alameda

Pat Louie, Assistant Chief Therapist, CCS Alameda

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California Children’s Services

How can my child qualify for Occupational or Physical Therapy

The question to ask is NOT “Does the student qualify for OT or PT in school?”...but rather… “Is an occupational therapist’s or physical therapist’s skills and expertise a necessary component of the student’s educational program in order for him/her to achieve his/her IEP goals?”

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Related Services• In order to receive any related service including physical

and/or occupational therapy in the school setting a child must be found eligible for Special Education in any of the 14 categories

• When a child is found eligible for Special Education services, the IEP team will determine what additional services a child will need. Related services should enable a child to:

– Make meaningful progress towards meeting their annual goals– Be educated in the least restrictive environment– Make progress in the general education curriculum

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Rules of the IEP Process

Assessment and Eligibility determination

Goals

Placement

Educational Benefit

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Assessments

• Establish a child’s need and must be as complete and accurate as possible.

• Should be completed in all areas of a child’s suspected disability.

• Documentation of all the child’s needs is absolutely essential.

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Goals

Goals establish reasonable expectations of how much your child will progress. Think in terms of where you want your child to be at the end of the year.• If goals are set too low, services can be set very low.• If goals are set too high, a child may not have success• If goals are reasonable, yet a child is NOT making

adequate progress, you have a reason to request additional services be put in place

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Placement

• Description of all services and supports that are needed as well as WHERE a child will receive these services. Placement should include everything that is necessary for a child to have a reasonable chance of achieving his or her IEP goals

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How are OT and PT defined by IDEA?Occupational Therapy services must be provided by a qualified occupational therapist and include:

• Improving, developing or restoring functions impaired or lost through illness, injury or deprivation

• Improving ability to perform tasks for independent functioning when functions are impaired or lost

• Preventing through early intervention initial or further impairment or loss of function

Physical Therapy means services provided by a qualified physical therapist Note: this is all that IDEA says about educational PT

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What is Educationally Related OT?

According to the American Occupational Therapy Association (AOTA), OT is concerned with a person’s ability to participate in daily life activities or “occupations.” In the school setting, an OT:• Uses their expertise to help children to be prepared for and perform

learning and school related activities and to fulfill their role as students.

• Supports academic and non-academic outcomes, including social skills, math, reading, writing, recess, sports participation, self-help skills, and prevocational/vocational participation for children and students with disabilities, 3-22 years of age.

• Is skilled in facilitating access to curricular and extra-curricular activities for all students.

• Trains parents, staff members, and caregivers in educating students with diverse learning needs

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The School Occupational Therapist works with:• Students to improve their performance in a variety of learning

environments (e.g., playgrounds, classrooms, cafeterias, bathrooms)

• Parents to help them support their children’s learning and participation in school

• Educators and other school support staff to plan and develop activities and environments that include all students

• Para-educators to support child success and promote child safety within the school environment (e.g., physical and behavioral assistance needs)

• Administrators to provide training for student, staff and parents, as well as to recommend equipment for schools and ways to modify existing classrooms, buildings and curriculum

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What is Educationally Related PT?• According to the American Physical Therapy Association

(APTA), physical therapy services support the educational team and help the student perform successfully in school.

• Physical therapy addresses the ability to move parts of the body, assume and maintain postures, and organize movement and functional gross motor skills.

• The PT works with students to build strength and endurance for functional mobility (e.g., climbing stairs, opening doors, mobility in and about the school, carrying materials, accessing the playground, participating in field trips and work experiences).

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OT and PT are Designated Instructional Services (DIS) under IDEA

• DIS shall be available when the instruction and services are necessary for the child to benefit educationally from his or her instructional program.

• To receive any DIS a child must be identified as having a disability under IDEA.

• California Ed Code, Section 56031 defines DIS as special education. In California, therefore, a child who has been determined eligible for special education may have an IEP that contains DIS as the only special education service provided, if an assessment demonstrates such therapy is needed.

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PT and OT under Section 504A child who has a disability as defined under Section 504, but who does not meet eligibility criteria for an educationally disabling condition under IDEA may still be eligible to receive federally defined related services pursuant to a 504 planAn OT or PT may be involved in providing accommodations to the educational environment and/or curriculum. Such accommodations may include: • Accessibility to classrooms, schools, rest rooms and transportation• Provision of simple adaptive devices such as pencil grips, specialized

tools and lap trays • Adaptations for written communication • Positioning or meeting specialized health care needs• modifications of assignments and curriculum

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Indicators for Educationally Related Occupational Therapy Referral

• Difficulty in learning new motor tasks• Poor organization and sequencing of tasks• Poor hand use (including writing and tool use)• Difficulty in accomplishing tasks without the use of adaptive

equipment, environmental modifications or assistive technology• Unusual or limited play patterns• Deficits in adaptive self-help or feeding skills in the educational

setting• Poor attention to tasks• Notable overreaction or underreaction to textures, touch or

movement

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Indicators for Educationally Related Physical Therapy Referral

• Delayed Gross Motor skills• Difficulty in learning new motor tasks• Unusual walking or movement patterns• Difficulty in moving or moving unsafely in the school environment• Difficulty in maintaining an appropriate sitting posture• Poor balance or falling frequently• Difficulty in accomplishing tasks without the use of adaptive

equipment, environmental modifications or assistive technology• Postural or orthopedic abnormalities• Reduced endurance or fatigue

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Requesting an Evaluation• A parent should request in writing that they would like

their child evaluated for Occupational and/or Physical therapy. In the letter, request “prior written notice if the district plans on denying the request.”

• A district may not require an Adaptive Physical Education (APE) assessment or services before referring for an assessment by an OT or PT. A child does not need “to fail” in APE before an evaluation is offered. They are different services.

• A district cannot require that the child be first evaluated by California Children’s Services prior to a district evaluation.

• Only a Licensed OT or PT can assess a child for services, or determine educational need.

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Levels of Service• Direct services (either group or individual)• Consultation to staff and/or parent• In some cases services may be provided by a special

education teacher (especially if they are OI credentialed) or by the adapted physical education (APE) specialist if it determined the child does not require the expertise of a physical or occupational therapist to to receive educational benefit

• On the IEP, therapy services should be specified for type (individual or group), level, duration and frequency, not “as needed.”

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Adapted Physical Education• Credentialed APE specialists

have training in basic body mechanics, kinesiology and other medically oriented subjects that assist in teaching the basic concepts of movement, speed, force, rhythm, complex motor skills and sequences, play and leisure skills, and social and group interaction skills. APE can augment OT or PT services

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Orthopedically Impaired Credential

It is recommended that children with severe orthopedic impairments have a teacher with an OI credential as their case manager. OI teachers have expertise in collaborating with medical professionals and in adapting equipment. They are trained in augmentative communication and assistive technology. They are also able to provide APE, positioning and seating adjustments, and sensory integration activities.

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California Children’s Services (CCS)• CCS provides medically necessary PT and OT through the Medical

Therapy Program (MTP). Therapy must be prescribed by a CCS approved physician. Active therapy services and prescriptions are reviewed every 6 months.

• Eligibility for CCS services is limited to children ages 0-21 with specific neuromuscular, musculoskeletal or muscular diseases such as cerebral palsy or muscular dystrophy. Please visit the CMS website for more information. http://www.dhcs.ca.gov/services/ccs/Pages/MTP.aspx

• Children under three years of age may be served, if they are at risk and show signs that they may have an eligible condition, but don’t yet have a clear diagnosis. A medically eligible condition must be diagnosed by age three in order to continue to receive services.

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California Children’s Services (CCS)• The IEP team determines

where to record CCS therapy services.

• Frequency and duration of CCS services should be recorded on a child’s IEP

• For more information on recording CCS therapy on the IEP, see this publication: www.disabilityrightsca.org/pubs/512401.pdf

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Can a child receive therapy from CCS and the school district concurrently?• School district therapy must be educationally

necessary and CCS therapy must be medically necessary, so it is possible to receive services from both.

• School therapy services can not duplicate or conflict with the CCS therapy plan. Goals and objectives from the CCS and school district therapists must be different.

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For example:• If a CCS Occupational Therapist is working on self-

feeding and dressing, and the school district OT is working on keyboarding and handwriting skills needed to complete school work, this is not a duplication.

• If the CCS Physical Therapist is working on balancing on one leg and lifting the opposite foot to step over a threshold, and a school district PT is working on balancing on one leg and lifting the other to kick a ball, this is a duplication of services as both therapists are working on the same muscle groups and movements.

• Please visit the CMS website site earlier to view CCS Numbered Letter 11-1600.

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Other options for therapy

Request a physical or occupational therapy evaluation referral from your child’s pediatrician. If your child is not eligible for CCS, but still has a medical need for therapy your insurance may agree to provide this service. If denied the evaluation or recommended therapy, you may need to file for an independent medical review through Department of Managed Care or Department of Insurance, depending on your medical coverage.

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Medi-Cal• For children with Medi-Cal,

therapy services may be covered through EPSDT (Early Periodic Screening, Diagnosis and Treatment).

• EPSDT provides medically necessary and ameliorative supplementary medical services

• Visit this site for more information: www.dhcs.ca.gov/services/Pages/EPSDT.aspx

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Beyond TherapyThere are many opportunities for children to develop physical skills outside of a medical or educational setting. Your child can participate in a special needs programs like E-Soccer, Challenger Little League, or wheelchair basketball. Also look for inclusive programs offered by local recreation departments or at private gymnastics, swimming, yoga or martial arts programs.

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• Fine motor skills can be worked on in arts or music programs. Many programs are open to all children if requested, and offer your child a chance to gain appropriate social skills with typically developing children. Don’t be afraid to ask if your child can be included.

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Therapy doesn’t just happen with a therapist. If your child is receiving therapy, continue activities at home by requesting a home therapy program. Many exercises can be completed with low cost items or things you might already own.

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Sources and Resources• Guidelines for Occupational Therapy and Physical

Therapy in California Public Schools CDE, 1996• A Composite of Laws, www.cde.ca.gov• Special Education Rights and Responsibilities, CASE

and DRC www.disabilityrightsca.org• Family Resource Network Alameda, Recreation list

available by download at www.frnoakland.org• Get help with insurance from Office of the Patient

Advocate (916) 324-6407 www.opa.ca.gov• Medi-Cal Managed Care Ombudsman (888) 452-8609

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