Saturday, February 17, 2018

What the One Task of Toileting Taught me about Occupations

I walk into work today. A physical therapist comes up to me to inform me that they asked the physician for an occupational therapy order to assess a client’s ability to independently toilet themselves.

I think ok... there’s a few things going on in my head at the moment (which I can leave to your experience when you hear a co worker advocate for our services).

So I review the chart:

Without disclosing too much information or place identifiers to protect privacy of the client,  I will mention co morbities and conditions of their circumstances more generally than specific.

Chart review:

The client lives alone
The client is in their 50-60s
The client has a condition where they are wheelchair bound
The client has incontinence due to the use of medication to treat another medical condition ( This condition was only diagnosed in the past six months)

The reason for admission to the hospital is “non-compliance” in taking medication for recent diagnosis of their medical condition, resulting in complications of the severe symptoms of the condition

What are some thoughts that come to mind to assist the client?

Well here’s what came to my mind (at first):

They need a medication management system; assess what’s in place then go from there for what to implement for intervention. (NOPE, I WAS WRONG).

They need health literacy retraining for the importance of adherence to taking the medication...after all, this is a new diagnosis with new routines and understanding to it  (NOPE I WAS WRONG AGAIN).

So when I resolved those not being the concerns, I sat down beside my client to conduct their occupational profile interview:

The client has their own home business and takes great pride in their profession
The client is active in the community on a social level
The client has a condition that damaged the bladder many years prior
The client is modified independent in IADLs and ADLs

Here’s the barrier to their meaningful occupations:

Incontinence... consuming their time.

They would spend hours cleaning their bedding, multiple times in the night.
They would transfer to the toilet and incontinence would occur on the transition.
They would spend time cleaning the bathroom of the aftermath.
They would find minimal sleep and lots of time in the morning spent just cleaning up after them selves.... hours of time.

Not able to get out into the community
Not able to spend time with their clients
Not able to go to the grocery store
Not able to enjoy their coffee in the morning and read the newspaper (their most favorite thing to do).

So what did the client do? They  intervened with the barrier getting in the way of their most meaningful occupations; the medication causing the inconvenience. Problem resolved right?

What toileting taught me about meaningful occupations is these 3 things:

it’s not just about toileting; it’s about all the things that are impacted by that one thing. It taught me to dig deeper in what meaningful activity truly means to my client.

when reading the chart and the doctor’s interpretation of the clients “problem” on a medical level, it is our instinct in a medical model of treatment to focus on the diagnosis unintentionally... this circumstance reminds us as Occupational Therapy practitioners that we assess the occupational barriers, not the medical problem. We treat the client’s access to meaningful activity, not resolving the issue for why they are in the hospital.

I was out of my comfort zone with how to assess my client and ultimately treat them or provide intervention strategies. In finding out more about their story, their occupations of meaning, I can truly help them achieve their goals to break down occupational barriers. That’s why I firmly believe our clients are our answers to intervention. I spent over two hours with this client on eval; it was well worth the results to overcome their barriers

In closing, I hope this inspires you to face the discomfort to come in contact with something incredible.

 When did you feel out of your comfort zone with a client diagnosis or condition that you found unfamiliar?

What stories do you have about occupations teaching you something new about how to serve your clients on an elevated level?

Love, Lex

Tuesday, October 31, 2017

Changes to CMS. Changes to future OT licensure: Why I am Not Worried

Whether you have heard about proposals related to future OT and OTA students requiring higher level degrees or changes to how therapy services will be paid (i.e. Medicare coverage within skilled nursing facility settings) or Concerns about Medi-Cal coverage cutting therapy access...proposals will cross our practice path many times in our lifetime...and more change will call for adaptability within the lifetime of our practice.  

Some practitioners are worried, angry, and scared.  Practitioners are asking: "What will this mean for me?" "Will I be able to practice?" "Will I have a job?" "Will there be enough diversity in our profession?" "What about all the baby boomers receiving rehabilitative and habilitative services?" 

"What does this mean for the future of the profession?" 

To be honest, I'm not worried. I know, I know, some of you are thinking: what! Is this woman crazy?!

Yes, you heard right. I'm NOT WORRIED. SO why? Why am I not worried?

Number one: Graditude
Number two: I can’t afford to worry 

Is it scary? Of course. Will I settle for it? No. 

Graditude: I get to practice this profession! I love what I do as an OT too much to accept what doesn't align with my practice priorities. I cannot do as others say or back down if my gut says this isn't right. I have to take action instead with what aligns with my professional priorities. 

Don't get me wrong, it is initially worrisome when I hear the news because my first reaction like anyone else to any news of change is fear.  Fear that someone else has control over my profession. There's a fear that comes over us that we will lose a job, have less opportunity for work if others take over and more work to be done to show our worth. 

Any change is scary but here's the good news: We don’t have to settle for changes we are not comfortable with. We can take action towards what we need and want, always. When it is not perfect in result, we can and will adapt around them.  

Let's back up a bit before I tell you what you can do to take action for yourself: I want to define my definition of the word adapting because to some, adapting is interpreted as settling and dealing with change.  The kind of adapting I am referring to is not one where I settle or having that belief of "that's just how it is." 

Instead, adapting will mean reflecting on myself to convey a message more effectively, in order to pursue what I want.  Okay, let's get back to some good things to possibly reassure you at this time of scary things happening.

Here are some reasons why I am not worried:

* Because when I walk into a state OT conference annually, I see our state association giving us tools to breakdown barriers we face in daily practice.  

When I talk with OT's at these conferences (who spend their free time being representatives in governing affairs), I am not worried.

When I also see the lobbyists at these conferences who believe and advocate for our profession, on our behalf on the state and national level, I am not worried.

* When I run into other practitioners and speak one on one with those OTs and OTAs who have a differing perspectives on the things I cannot see, I am not worried. I have faith each practitioner will follow suit in helping to speak up, just as our representatives do.Their passion for their practice gives them the courage to speak up in time of need; it also gives me the strength to keep going too. 

I have faith each practitioner's passion for what they do will speak louder for action in advocacy, in turn, overriding acceptance or settling for what is or what might be their future. 

I see what happens when we are greater in numbers; coming together as a community of occupational therapists.  It is stronger than standing alone in our clinics or facilities; our voice is louder together.  The more dynamic it is, the more comprehensive our message is for getting things done. Perspectives from all angles brings inclusivity of everyone's concerns, which breaks down the barriers we are facing today. 

I have to say, bluntly, I believe these roadblocks are there because we were not more involved when things were and are going right.  The barriers are exactly what we need to push back.  

If the changes being proposed pushes therapists hard enough, they will fight back.  There will be no settling as long as we do it together as a unit. 

I am not worried because all therapists will get involved.  There will not be lurkers watching and reading the updates of proposals, only waiting on the sidelines for all things to crumble. Practitioners will comment on proposals, convey their wisdom from their personal experiences and will get engaged with the effective people who influence these decisions.

I am not worried.

* I am also not worried because there are ways to intervene. After all, would I have a job if I didn't have an intervention to address my client's occupational barriers? 

Sure sometimes we have to try another way of doing things to get the results we need. There is always another intervention to the barriers we face if we don't succeed in the first try.
Not one intervention fits all barriers so that's why I want to share a few of the interventions that improve the ability to be heard and minimize concern for changes that we may not see so optimal.

Here is why I cannot afford to worry and three ways to adapt to the proposed changes. 

(credit for my motivation to write a post about this goes to one of our very own occupational therapy colleagues who is an advocate on a governing level for my state, Sabrena McCarley):

1. Become Besties 
with your Local Legislators:


They don't know you and they most certainly do not know what a occupational therapist is. In fact, every legislator, senator, governor, and representative on a governing level do not know who you are, what you do and why it is valuable.  

They also would think you are stalker-like and creepy for coming out of no where when all of a sudden you have a favor to ask of them like a little thing of needing their vote on a decision that impacts our professional future.  

That's why we have to build a relationship with them first by becoming their bestie. 

It's like dating: we don't traditionally walk up to the door of someone we are crushing on and ask them to marry us before introducing who we are, getting to know about them and sharing a part of you and your history, your passions, your interests, your daily life.  Of course we wouldn't rush to the alter right away, that's why we would treat those who can help us get things done on a profession end the same way as our potential partner.


Get on their email list ( they will not spam you) This is to stay informed of their local events so you can attend. This is were you will shmooze, say hello and build a relationship over time.  Soon enough they will know what you do and who you are and realize you are the reason why they will still be able to do self care when they have a barrier get in their way one day.  Be sure to get on each of these representative's lists to be there before you need to be.

1. Google: "find your legislature" followed by typing in your state

2. Type in your zip code 

3. Click on their site

4. Join their email list

5. schedule out their events when they inform you to attend

6. schmoose, get to know them and let them get to know you

7. repeat #6 over and over again

I also recommend identifying who is your point of contact federally as well for your county. Go here as well: 

To be your accountability partner in this, I need you to do me a favor:
When you finish step one, I will know you did this by tweeting me a screenshot of your newsletter request completion at my twitter handle here and say in the tweet "I'm their go-to OT." 

Don't have twitter? That's okay post your screenshot on Instagram instead with the same comment ( do not forget to tag me so I know you did it).

2. Comment on the proposals 
(sent to you by your state and national associations that ask for your comments).

This is not only an email you find from your association but this applies for those facebook group posts and newsfeed shares that have your state or national association indicating a memo or link about the topic of interest.  


because if no one comments on the proposals from our profession, it is assumed no one has an opinion about followed by the assumption that the proposal must be fine and dandy to more forward. 

If you comment, the more diversity in perspective regarding the issue can be considered.  That is why your voice counts, every single one of your voices. 


ALL can comment! You do not have to be a member of an association to have access in the proposal comments; this is put out to the public. The OT association acts as the messenger of these because they have to be on alert of anything that impacts change in our profession. 


Anytime you see a link provided by state and national OT associations for opinions and comment requests for proposals, take the five minutes to fill them out, FIVE MINUTES!  That's .003% of your day every once in a while to contribute your valuable opinion on the subject matter 

Accountability moment: tweet me #OTadvocacy each time you do this.  The proof is in the pudding, do your part in creating the mixture.

3. Email your state and national associations 
(to comment on their proposals or course of actions):


see the "why" in #2


Everyone!  Being a member of your state and national association is critical....however, you are a OT or OTA practitioner who has a valuable opinion in the matter of decisions.  

It is spoken by the wise Lena Llorens at the most recent OT conference (during her Q and A session I attended):  

"I hope they think about this wisely" while sharing her thoughts about the concern for diversity in the decision to upgrade the degree level for incoming OT and OTAs.  

Share your unique perspective on the items of discussion that causes you to have questions, concerns or otherwise. 

Our association representation will not know how you feel if you do not speak up about it or share your solutions.


Because there are many states with all types of contacts combined for each, I cannot list them all here so these are the chair titles you need to find:

* professional development and leadership chair
* Advocacy and Governmental Affairs chair
* practice and ethics chair
* political action committee chair

To locate them, 

1. Google your state OT association

2. Find the contact us button.

3. Search for the contacts above

Then contact national: Contact here

Now it says in their description that non-members are encouraged to join to support the future of OT (where messages typed there by non-members cannot be answered by staff).  

I of course would love for you to be a member too for many reasons but, that is not the point of my post today.  WHAT YOU NEED TO DO - Call and leave a typed message on that form anyway; it does not mean they ignore your inquiry if you do not get a response back. Your voice does influence their decision making.  It shows you care about your profession and you have an additional voice speaking up for change.

Accountability moment: you know what to do

Closing thoughts:

When the alarm goes off that there is smoke indicating a fire in our professional pathway, we rush around to find the fire extinguisher ( we react to danger).

More real talk for you today is: It is more of an alarm to me for practitioners to react rather than proactively respond. 

It is important to be in the know before there is a problem or a decision made.
To be involved in your future when things go scary is essential but do you know what is more important than that?  

BE THERE when things are going good too. BE THERE ALWAYS.

Proactivity from each of us will support our ability to practice. 

It’s never too late to get involved, get connected and support the validity in your worth.

- with hugs and support, 


PS: If I can ask for a favor of you: Please share this post with your colleagues who are feeling defeated about changes that come their way. They may find one of these interventions to be useful.

Friday, May 12, 2017

Wait...You Can Pull Off Over 90% Productivity??

If this is you and you are an Occupational Therapist, please speak now or forever hold your peace in this mastery of an unheard skill.

New value-based OT evaluation codes were released in January and some occupational therapists claim they are able to meet 90% productivity (and higher) when being asked to accomplish this at some settings! Can you believe it?

I am scratching my head at the confusion...this is so 2016 shenanigans.

We have been reminded that we get the permission to go back to our roots of what occupational therapy truly is, as well as being able to have the say of:

HOW LONG we spend with clients for evaluation sessions

AT WHAT COMPLEXITY LEVEL we evaluate them at (based on the complexity of their case) and....

no other non-OT person has the right to make this decision.

(and if you are a OTA, hang in there with me, this applies to you too!)

I was curious about the claims I read in social forums related to pulling off 90% + I explored the break down (seen below) for the time allotted in a typical day to do evaluations and/or treatments for clients in a post acute setting:

8 hours in a shift (480 minutes)

90% productivity met would be 432 minutes in a shift which would equal 7.2 hours

For California therapists: add on two mandatory 10 minute breaks to that - now we are hitting 452/480 minutes in the shift leaving us with 28 minutes to do a few un-billable things:


1. SELF CARE: water and pee ( or #2) breaks

2. EDUCATION and information gathering where the client is unable to be present:

This could be discussing education or occupational performance with:

The client's nurse who is running around the floor getting medication for their other patients

The doctor who is not in the building

Other disciplines working directly with this client who is not immediately present in the room at exactly the time you are having your session or caregiver/family involved.

3. SUPERVISION AND GUIDANCE: of OTAs you supervise...and for the OTA themselves:

-the time for the OTA to be able to ask for guidance
-the time to provide feedback to the OT supervising them regarding upgrading and downgrading (or meeting) goals
-the time to receiving the coaching they are allotted as well

am I missing any scenarios?


4. DOCUMENTATION and INTERPRETATION OF ASSESSMENTS that cannot be completed when you have your hands on treatment with your client

If you are able to physically master documentation on an IPAD while doing ADL treatment in a bathroom... or in the patient room while treating them, you MUST share your secrets with us. As OTs we have impressive talents including adapting devices and their user-ability.

...I wonder how this so when the patient requires contact guard assist for standing balance while progressing their dynamic access to grooming at the sink side

...or needs MAX redirection cues for safe participation in lower body dressing at the edge of the bed

...or needing to monitor their vitals while the client takes that rest break.

...or is impulsive in their movements during a cooking activity at stove top/ meal prep and needs the therapist to have two hands ready at any moment

...or that hands on assist for that safe shower transfer training

...or they have an aspiration risk that needs our eyes on them for the whole meal they are being trained to feed themselves with.

...or it's their first time handling that razor to shave themselves for grooming and their cognitive awareness isn't quite up to independent standards.

Other additional things like transporting a patient to and from our evaluation/treatment space of choice (when this is not conducted in the client's room), clean up of materials and etc can likely be delegated right?....hmmm not sure if there is a designated rehab aide in all settings yet but, having an assistant is helpful when we cannot do it all.

Here's the flip side...

(I am all about seeing each side of the coin and I do forewarn you on the real talk):

1. SELF CARE: I see the burnout and lack of self compassion for my occupational therapists who are my students, colleagues and clients of mine.

They are conforming to a non-OT rule to the way of evaluation, practice and treatment. Sure there is business to be done, we HAVE to get paid to put food on the table and a roof over our's and our family's heads... and I am not even talking about this being about having "no other choice." It is to point out that some disregard themselves as even being human, imperfect and doing their best...and that human I speak of (you!) must come first to truly serve your clients.

2. CARE FOR COLLEAGUES: we want them to be their most successful in assisting their client and decrease their burnout as well. They flourish from our guidance and training to facilitate our client's access to their life occupations. Take that time to say "how are you?" "How can I help?" Connect with their human self.

3. CARE FOR CLIENTS/PATIENTS: Their occupations are at the center of our practice ...

and yet, are they getting their value's worth for the evaluation, practice and treatment we provide them?

Is it truly client-centered....a life occupation based practice...

...or is it a day at the rehab gym?

(is it me or have many client's taken up the hobby of cone stacking, arm biking and T-band pulling?)

What do they (your client) want to get back to? Do they want to:

Care for their dog?

Spend social time with their grandchild?

Get back into their golf swing?

Write that letter to their best friend on the other side of the coast?

Put on their make up every morning?

Pull the weeds from their garden?

Wipe their tuchus on their own despite being incontinent so they can live with their children at home and not worry about them cleaning up after themselves?

Play their favorite instrument again?

Make it to their Mah-jong game on time?

This is why I love and live off my copy of the Occupational Therapy Framework because I know if I get lost, there will always be it's guidance in getting back to my client's occupations.

I am also super grateful for my California State and National occupational therapy associations because they not only advocate on behalf of me to do be able to do my job...

They keep me in the loop about resources to use to defend my intention in everyday practice, as well as provide the up-to-date info impacting our profession AND when I need to step up and act to protect it

(and, and... let me tell you this much):

we need to protect our profession even when, and especially when, things are going right.

So here is some real talk ;) :

1. Go easy on are productive when you are with your clients working toward their occupation based goals.

AOTA provides you with a copy of an occupational profile template to use with your clients to accomplish this.

2. Stay true to your value-based evaluations in choosing accurate codes to best serve your client

Didn't get formal training at your site for this?!

Here is the OT evaluation worksheet I compiled to help you figure out the formula of what code to choose for which patient (not every client or diagnosis fits all).

3. Ask yourself when your gut instinct cries and screams at you:

"what other resources are out there that can help me shift from defeat of ethical dilemmas to champion mode?"

Here is an additional document to use in defending your case to administrators of facilities/ parties that say you should do it differently than you have decided clinically (when you in fact, are in the right):

Consensus Statement on Clinical Judgment in Health Care SettingsAOTA, APTA, ASHA

My closing thoughts about this high productivity? I go for the goal of being 100% productive:

 when in an actual session...

From the time I enter a client's presence, to the end of that session, I am accomplishing one goal: 

understanding their occupations to their fullest, jam packing my assessment and intervention with therapeutic use of self and seeing them flourish on their own to access what is meaningful to them.

REMEMBER: productivity does not equate billable time; make either effort occupation based.

Two things I kindly ask of you:

1. Leave your comments below on ways you feel productive in a one-on-one session by answering this question:

When it comes to OT, what makes your heart sing?

2. Share this with your fellow OT colleagues as we don't know what we don't know and sharing the resources is mandatory so they too can do what they do best in practice.

Thank you for stopping by,


Tuesday, December 27, 2016


HUGE ANNOUNCEMENT for my fellow Occupational Therapists! 

If you have yet to hear the news, the evaluation codes we choose to initiate our plan of care in serving our patients (in the realm of physical medicine and rehabilitation) is changing and fast! January 1st, 2017 to be exact.

Here is what you need to know before plugging in any evaluation code and how to decide on the right code to choose:

1.    It is a formula!
o   You plug the measures into each equation and come out with a result or answer. This answer indicates a level of complexity. That level of complexity determined by you is reflected as your OT evaluation code.
o   The worksheet included helps you decipher what measurement to plug in and where to get your answer to the equation. It is super simple if you go through the process in using the formula, for each and every patient. 


2.     DO NOT pay attention to the time indicated beside the code, it is irrelevant. Here’s why:
o   The code (for evaluation only not a standard visit with treatment only) is chosen based on a formula, not how long a therapist conducted an evaluation for.
o   The time is a projected or an educated guess of how long it may take to complete the level of complexity for an OT evaluation. THIS IS NOT utilized to formulate the data needed to decide on which code to choose.
o   At this time, each choice in code reflects the combined level of complexity in three categories (it is like a math problem based on three variables…consider it algebra)
o   The code is not reflective of the time spent doing any of the evaluation specifications but the “how” of deciding on which code to choose; this is determined with the step by step completion of the formula in the worksheet
o   The code costs may or may not be the same (depends on payer as time goes on and this may change in the future)
o   Each code is 1 unit; however, this does not mean choosing any code blindly or impulsively will suffice. You really have to ask yourself: how complex is this case? We will explore more why it is important to choose the right code in the next section!

3.    The codes directly reflect how valuable the OT profession is to our clients:
o   It indicates how complex our assessments are for individual patient cases; the higher level of complexity involved in each of the three criteria levels, the greater the combined level of complexity, resulting in a determined code.
o   The code reflects that our time is valued for the level of complexity in evaluation and developing a plan of care; this means quality of care is important and highlighted in the process.
o   It encourages and allows us to remain consistent with our OT framework
o   It is a tool to communicate our distinct value
o   It directly reflects how holistic we are
o   It helps us to remain ethical in clinical decision making
o   It helps us provide evidence as to why we choose the code we decide upon
o   It helps us advocate as individual practitioners; no other individual is allowed to decide a code for us.
o   When conducting an evaluation and formulation of a plan of care for our clients, only the OT practitioner may do so, reflected in their choosing of the code for that evaluation.
4.    The new OT evaluation codes are a collection of data.
o   This data collection reflects a skilled OT need in variety of MD referrals for a patient to receive consultation.
o   Why is this important? It appears to determine where OT is needed, where OT should be continued and where services in the community are lacking (all under the umbrella of physical medicine and rehabilitation).
o   It appears it will likely be greatly utilized in the future of other OT settings (mental health perhaps? Primary care? Community based private clinics?)
o   This data collection will also likely influence payer sources in the future to determine what payment is allotted for patient therapy costs, starting right at the beginning at evaluation.
o   As time goes on, our data input (aka OT evaluation code selection) may reflect what is covered in the future; therefore, we must be accurate in selection to continue to serve patients.

5.    Code selection is (and always will be) determined by the therapist, not administrators.
o   ethical and legal standards practiced strictly by the therapist conducting the evaluation is reflective of how we serve our clients and whether we get to continue to do so
o   Our unique role and professional, skilled expertise as occupational therapists allows us to make a decision or conclusion of which code to choose.
o   Code selection is based on four components completed in the evaluation process. This can only be done by the skilled therapist, therefore, no other discipline or individual can reflect which code is chosen for evaluation. 
6.    OT evaluations remain the same; they are just broken down into levels reflected in the code we choose
o   There is specific and stated criteria to determine which is an appropriate OT evaluation code to choose (listed in the worksheet).
o   Evaluation has four components; three of which when combined and formulated effectively, determine the code we choose.
o   We normally gather data to form an:
                                               i.     occupational history, as well as medical history, to determine a patient’s prior level of function
                                             ii.     whether the client has a change in functional performance and how we are utilizing our assessments
                                            iii.     clinical reasoning/decision making ability to determine an appropriate plan of care.
o   These codes directly reflect that we are clearly doing our job in the evaluation process. Consider them check boxes to mark off your evaluation checklist; use it as you complete your formal evaluation.
o   It ensures all aspects of an evaluation are covered and it will be individualized for each patient served. How complex is our case and how complex is the process to get a thorough assessment and implement a plan?

7.    Three of four components of the evaluation determine the code you choose
o   1. Occupational profile, client history (medical and therapy) 2. Assessment of occupational performance 3. Clinical decision making
o   once the level of complexity is chosen for each of these components, a overall, comprehensive level of complexity is decided (they are plugged into the formula, which is reflected as the OT evaluation code chosen).
o   The fourth component completed in the evaluation is developing the plan of care. This is directly reflected in the holistic assessment of the three component formula.

Now it is time to conduct your OT evaluation! The worksheet formula breaks down and guides you through how to choose the accurate code for each and every individual patient you evaluate. 
Deciding which OT evaluation code to use starting Jan 1st 2017 is a several step process! 
Decipher how to rank the level of complexity in the OT evaluation code you choose! This worksheet is designed to make it simple for the therapist to breakdown. In a step by step format, you will know how to choose the code to use for evaluation. 
This will decrease some of the confusion and bring our OT evaluation process back to serving the client. Stay ethical and legal with the need to know information. 

Here is the FREE formula worksheet to determine which OT evaluation code you need to use:

References for this information are included in the worksheet