Making decisions about providing related services

1. MOCASE CONFERENCE 2019 Presented by: Jeanne Rothermel Sally Becker, OT Kim Nevins, PT (ret.), PhD Making decisions about providing related services September 2019

2. Purpose of Presentation • Define Related Services • Outline Decision making processes for providing related services • Determining Educational relevance • Identify critical questions when determining service provision (OT and PT) • Describe Education model vs. Medical necessity • Focus on OT/PT use of Best Practices for providing effective service provision

3. Related Services: Defined Related services are supportive services as are required to assist a child with a disability to benefit from special education. Federal Reg. 300.34(a) A related service is recommended when the service is required for a student to benefit from his/her specially designed instruction

4. Who is eligible for related services? • Any student who is receiving special education under IDEA is eligible for any related service that is deemed necessary for the student to benefit from the specially designed instruction. • The provision of any related service is an IEP Team decision. The necessity of OT and/or PT is determined after the student’s IEP goals have been developed. • IDEA does not require goals to be written to include each specific discipline or to have goal outcomes based on specific assessment tool items.

5. Eligibility continued (OT/PT) • There is no medical diagnosis that automatically ensures the provision of OT or PT • There is no “test, assessment, or score” that will automatically ensure the provision of OT or PT • OT and PT may be provided as a related service under section 504 and included in Service Plans

6. The General Scope of Related Services Although most services are tied to curriculum goals, some related services are not directly linked to specific learning outcomes; instead,they may support access to the education curriculum, transportation, and/or certain health care procedures Examples: 1.The use of sign language interpreter for a hearing-impaired high-school student 2. Air-conditioned bus with chair lift for field-trips 3. School-nurse instructing student who uses catheter

7. Related Service Possibilities • Physical Therapy • Psychological Services • Recreation • Rehabilitation Counseling Services • Social Work Services in School • Speech/Language Pathology Services • Transportation • Interpreter Services • Transition Specialist • Vocational Trainer/Counselor • Audiology/Interpreter Services • Braille • Counseling Services • Early Identification & Assessment of Disabilities • Medical Services (To determine eligibility) • School Health Services(for health-related needs) • Occupational Therapy • Orientation & Mobility Services • Parent Counseling & Training ”This is not an exhaustive list.” — US Dept. of Education IDEA and IDEA regulations

8. Educational Relevance of Related Service Provision • Exists when a proposed service can be explicitly linked with an identified component of the student’s Individual education program (IEP) • The related service MUST BE required in order for the student to demonstrate progress toward meeting his/her specialized instruction goals

9. Determining Educational Necessity • IEP goals are to be written in a manner which clarifies the outcome and assists the student to complete the goal. • Once Related Services are identified in the IEP as necessary, they exist to concurrently support the student’s learning and goal completion.

10. Why Educationally Necessary? • There may be services that have relevance for a child, but ‘relevance’ is not sufficient to necessitate the need for a school-based related service • School-based related services must be educationally necessary and informed by the student’s IEP team-determined goals

11. Determining Educational Relevance • Some related services considered desirable by parents and therapists may not meet the educational relevance and necessity criteria to be considered a “related service” under IDEA • This does not mean the service is unimportant. Rather, it could mean that it is not a responsibility of the public school

12. Example: When is OT/PT necessary? • To ensure FAPE which “emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living” (sec. 300) • The IEP team decides related service necessity. It may not just be academics, but could include mobility in the school building (or job site), self care skills, self-advocacy, or use of assistive technology.

13. Evolution of OT/PT as a Related Service • In order to describe contemporary practice patterns and the adoption of “Best Practices Recommendations”, a short historical review! • Prior to 1970s, OT and PT in schools was limited to hospital-based schools or specialty schools/districts, primarily in urban areas.

14. Evolution of OT/PT School-Based Practice • Following passage of P.L. 94-142, the majority of OT/PT typical practice was characterized by: • Reliance on a medical model for evaluation, goal writing, service provision, and team interaction • Use of a “bottom-up” (underlying pathology) approach to evaluation which was primarily milestone-based, deficit-based, and used comparisons to established norms • Test scores may not be relevant to class performance

15. Evolution continued: • IEP Goal Development was discipline-specific (OT or PT goals) with outcomes often developed from failed items on developmental assessments. • Service provision (intervention) was most frequently individual or small group pull-out, 30-60 min/week, and isolated from the classroom and the curriculum

16. Evolution continued • Only limited time was available for PT/OT to collaborate with teachers and/or to consult with other school staff members to support student participation and/or achievement of a student’s educational goals (the actual role of the OT and PT)

17. Evolution of OT/PT role • None of the practices noted in the previous slides, regularly seen in typical practice by PT and OT in the public schools was in alignment with IDEA regulations. Because of this, the AOTA and APTA developed best practice guidelines to align with IDEA and to support student centered, educationally relevant intervention.

18. Best Practice Adoption Educational model vs. Medical model A recommendation from an outside provider or a related service provider does not automatically mean that a related service is educationally relevant and necessary for a student

19. Characteristics of Medical Model Patients span all age ranges Payment is expected Services are provided year round and focus on continuity of care Goals are developed and reviewed per institutional expectations Re-evaluations are developed/completed per Institution guidelines

20. Characteristics of Medical Model • Medical team recommends and prescribes focus, frequency, and duration of therapy. Third party (insurance carrier) may be the ultimate decision maker. • Therapy focuses on treatment to alleviate or cure specific underlying medical pathologies and remediate the disability. • Treatment settings may include clinic, hospital, daycare center, and/or home-based. • Treatment is one-on-one in a clinical or home setting.

21. Characteristics of Educational Model • Services are provided primarily on school grounds. • Services are provided in the student’s educational environment and are authentic and task-oriented • Student’s ages range from 3-21 • Services are provided at no cost to parents • Services are provided during the school year • Goals are reviewed or updated every 12 months • Reevaluations are completed once every 3 years

22. Characteristics of Educational Model • Educational team includes parents, educators, and therapists. Using therapists’ evaluations (formal or informal), the team collaborates to determine focus on service as well as frequency and duration based on the student’s educationally-related therapy needs • Therapy focuses on intervention to improve the student’s ability to learn and function in the school environment

23. Which Model for OT/PT in Schools? Schools are to use an educational model when determining the need for related services. Student goals focus on educational outcomes, not medically related outcomes OTs and PTs follow the educational model when providing services in the public schools to the extent the model guidelines don’t interfere with state licensure laws.

24. Best Practices OT/PT during Evaluation • Students do not ‘qualify’ for related services because of numbers/score on a test. • Decisions regarding which students truly need the provision of a related service needs to be based on comprehensive information from a variety of sources. • Can be gathered at the time of an initial or a re-evaluation (this would be best practice) but can also be determined based on information gathered informally.

25. Best Practices of OT/PT during Evaluations IDEA tells us that evaluations should be based on functional abilities and needs should be assessed as a team in the context of the educational environment • Assessment tools for gaining information about how a deficit may be affecting a student’s progress in special education may include observations, rating scales, checklists, and/or standardized assessments. The assessment should ideally happen within the environment in which the skills would naturally occur.

26. Best Practices of OT/PT in Evaluation • To focus on functional skills and routines required of the child across the school day in multiple locations. Use a Top-down Ecological approach during the evaluation Focus on the environmental and curricular barriers to school participation

27. Ecological (Top Down) Approach • Bottom up • Targets discrete component abilities (e.g., hopping on one foot) • Relies heavily on developmental milestone tests • Emphasizes normalization of underlying processes to improve function

28. Ecological (Top Down) approach Top Down • Defines the skills/activities required of the student • Defines the contextual expectations (the environmental barriers) • Does not focus on impairment/disability

29. Benefits of Ecological Assessment • Aligns with IDEA expectations of student evaluation • Supports development of functionally relevant special education goals • Supports Educational relevance in terms of identifying classroom participation and barriers • Supports Best Practice in terms of team collaboration and communication

30. Best Practices in determining IEP Goals • Must be Team Determined (not by individual discipline without discussion). • Must be measurable • Belong to the student – discipline free (not PT goals, OT goals, etc.) • Meaningful and Functional in the current Environment – Supports Active Student Participation

31. Best Practice: Developing Goals • Goals should not be written in a manner that can only be addressed by a therapist, the need for related services is determined after the goals are developed • Goals should Not focus on discrete skills, but relate to an authentic functional skill already identified in the IEP. • i.e. speech therapy related to a reading or fluency goal or perhaps a behavior/social skills goal

32. Example: Goal which may require OT/PT support • Team Determined IEP Goal for John: • By the end of the IEP cycle John will independently complete the morning routine consisting of traveling from the bus to the classroom, clothing/backpack management, and finding assigned spot/seat in the classroom in 5 of 5 mornings

33. Example: OT/PT support for goals,thinking through what is needed • What does school participation look like for this student? • What are the barriers to school participation? • What are the routines of the classroom/students? • What goal/goals are needed to increase participation? • Is the expertise of OT/PT required in order to achieve the goal?

34. OT/PT: What is a functional Goal? • If the student doesn’t perform the function – someone else will need to do it for him/her • Move/travel from one location to another • Eat, drink, or dress • Complete school assignments - earn a grade • Entertain self (on the playground) • Purchase or cook a meal • Earn a paycheck!

35. Functional Goals are Not… • Activitiesbelieved to help accomplish functional outcomes in the long-run, such as • Balance while sitting on a therapy ball • Lift head while in a prone position • Stand on one foot • 25 Repetitions of an exercise • Long sit without support • Increased muscle strength • (McEwen, 2015)

36. Best Practice: Determining Educationally Relevant Intervention (OT/PT) Discussing the need for related services • Build consensus through the use of data. • Make decisions based on student needs not parental wants or outside therapist medical reasons • Do not follow the inclination to say “We have always provided this service” when making a related service decision • If needed, discuss the type, amount and frequency

37. Service Provision Methods The provision of related services can be identified as a continuum of intervention: 1. Direct individualized services by the provider to enable the student to access the environment and educational activities 2. Collaboration and consultation with teachers and IEP team members to improve student participation and performance in curriculum based activities within the educational environment

38. Determining Educationally Relevant Intervention Consider whether services are educationally necessary by asking the following questions: • Will the absence of the service impede the student’s participation in his/her educational program? • Could the intervention be addressed effectively by the classroom teacher? • Is the need for considering a related service more medically based or does it have an educationally based purpose?

39. What Level of Related Services Type , Amount & Frequency • Who needs the expertise of the therapist; the teacher or the student? • What expertise does the therapist provide that the teacher cannot? • Is it necessary for a related service to be identified for supporting this goal/benchmark? • How long has the student been working on this goal or a similar goal? Progress or not with the level of service that has been provided? • Is the same type, amount and frequency required for next year? If so, why is same level of service needed?

40. Determining Effectiveness of Service? Key question: If the student does not receive a proposed related service, is there reason to believe that he or she: 1) will not have access to an appropriate education or 2) be unable to experience educational benefit?

41. Determining Effectiveness of Services • Must collect and review data to determine the impact of a related service’s provision on a student’s IEP goal achievement • Must collect and review data to determine if changes are needed in the type of service, frequency or amount of a related service

42. Need for Continued Related Service • What changes have occurred to the student’s functioning that would have an influence on the goal(s)? • How would discontinuing the service impact the student’s ability to accomplish goals and benchmarks? • Which method of related service is needed: direct, consultation or a combination of both? Why?

43. Discontinuing Service • Start reviewing data before the IEP and prepare reasons and examples for changing service(s) • Involve parents in sharing progress to see how the classroom staff works with the student on the skills (independent of the therapist).

44. What questions do you have?