How to Document Co-Treatments in IEP’s

GUEST BLOGGER: Kathryn Biel.

Marcia submitted this clinical question:

We’ve had some discussion around co-treatments and how best to document them in IEP’s — I’d love to get some input as to what is happening in other districts — is it being specifically documented on the service delivery page, additional information, and if so how?? (ie: for a 1 hour co-treat small group with PT & SLP — how is that documented in the IEP?? Is it in the grids as 30 minutes for each?? 1 hour for each??). Thanks in advance — I look forward to getting feedback from this group! 

This one I think will vary, depending on state regulations and reimbursement issues. I’m in New York, so I can only speak to what we’re doing in my region. This is also my understanding, so please feel free to jump in and tell me if I’ve got it wrong. I’ve never been allowed to put a co-treat on an IEP, mostly due to Medicaid reasons. Medicaid does not allow co-treats. According to most districts I’ve been in, if the service is on the IEP, it should be reimbursable. I’ve worked in districts with a very high Medicaid-eligible percentage, so every IEP was treated as if it were being submitted to Medicaid (also because you can retroactively claim Medicaid as well).

So, let’s try this example: A PT/SLP co-treat that is 1 hour long, which takes place one time per week. PT sees the student one more time individually and speech has two more individual sessions. On the co-treat day, PT and SLP would each bill for 30 minute individual sessions but at different times (10-10:30 for PT, 10:30-11 for SLP). The Related Services would be listed at PT two times per week, individual, 30 minute sessions, and SLP would be listed as three times per week, individual, 30 minute sessions.

Personally, I would then add in a PT and an SLP consult under Support for School Personnel and describe the consult to include the co-treat. This way, you have the accountability in the IEP to carve out the time in your schedules to include the co-treat. I would also state the need for/purpose of the co-treat somewhere in the Physical Development Section of the IEP.

Co-treats are a vastly underutilized service, in my book. Sometimes, to get around this, the OT and PT staff (because we share treatment space) will plan one activity that we do together with our students. This doesn’t help with the PT/SLP or SLP/OT co-treat. Obviously, scheduling becomes another issue as well.

I would love to hear how other therapists would or do document co-treats. Please let me know, and Margie, I hope this helps! 

~Kathryn Biel, PT, DPT

 

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The AEIOU Systematic Approach to Pediatric Feeding – Dynamic CEU Course for OT’s, SLP’s and Dietician’s

Nina Johanson Nina Johanson[/caption]

We are thrilled to offer this dynamic pediatric feeding course, presented by Nina Ayd Johanson a highly regarded clinician and renowned teacher.

This course teaches a step-by-step approach for helping children learn to explore food, enjoy eating, and participate independently in social mealtimes. The AEIOU approach – acceptance, exposure, independence, observation and understanding – offers a new and highly successful method for integrated treatment of infants and young children with challenging feeding disorders using sensory, oral motor, biomedical and environmental strategies. Five factors in this holistic approach emphasize active participation, independence and shared control. This course will arm participants with knowledge and practical information to achieve functional outcomes for complex etiologies, improve quality of mealtime, manage tube dependency and transition to eating solid foods, treat sensory aversions, improve oral-motor skills, achieve home carryover, and more. This course is presented in a dynamic learning environment, using case studies and videos to engage and instruct participants. Extensive resources are provided. Many special populations are discussed including: prematurity, GERD, allergies, autism, failure to thrive, tracheostomy, picky eaters, and children with various syndromes.

Courses coming up:
March 27-28, 2105 – Las Vegas, NV
September 26-27, 2105 – Hartford, CT
October 23-24, 2015 – Edison, NJ
December 11-12, 2015 – Lafayette, LA

Please click here for course information, to download a brochure or to register

What others are saying:

I learned so many applicable treatment and evaluation strategies that I am excited to implement in practice…..Brittany, OT

This was a wonderful educational course. I like the way this approach addresses the “Whole” Child and family, and not just a symptom. Nina was an engaging presenter and very capable of sharing her knowledge and experience in an easy to understand way. I would recommend this course for all clinicians who work with children with feeding disorders. – Jordan, SLP

Fantastic feeding course – it really focuses on treating the whole child and family dynamics, whilst respecting both and moving at an appropriate pace….. picked up some tips on sucking, drinking, chewing and messy mealtimes. Thanks Nina – Rachel – dietician

 

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"Get Ready to Learn" with Anne Buckley-Reen Recently Featured on ABC News

We are thrilled to share this piece that recently aired on ABC news. Anne Buckley-Reens program “Get Ready to Learn: Yoga therapy in the Classroom” is successfully being implemented into schools in the US  and the UK, with great results. 

Don’t miss Anne presenting this program in July:

July 20-21, 2015 – Fairport, NY
Please click her for detailed course information, schedule, to download a brochure or to register

Barbara Joseph, NYC School Administrator and GRTL program facilitator states:
“The impact of implementing the Get Ready to Learn Program across our entire district with students with significant disabilities ages 3-21 over the past year has had tremendous results in decreasing behaviors that interfere with learning and increasing appropriate behaviors to enhance each students ability to learn more effectively. Teachers, administrators, students and parents have reported significant changes in both the classroom environment as well as student performance. Parents are reporting that their children are reacting to their environment in ways they haven’t demonstrated in the past. At the onset of the program we knew that the daily implementation of this movement program would have a positive impact on student progress but the data is reporting gains beyond our expectations.” 

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Any Ideas on How to Improve Gait and Balance in an 11 Year Old with Dystonia?

GUEST BLOGGER: Kathryn Biel.

Marcia submitted this clinical question:

Any ideas on how to improve gait and balance in an 11 year old with dystonia? Backwards gait is OK but forward stepping is very ataxic and asymmetry increases with increased speed. Nothing seems to help consistently. HELP!! 

Dystonia, for me, is one of the most difficult tone issues to work with, around, through. I always feel sort of lost and like I’m grasping at straws. Here’s where I would start: muscle length and muscle strength. What’s short and tight? What’s long and weak? I would guess that the flexors are stronger in relation to the extensors, since backward walking is better than forward. Is one side more dominant than the other? Stretch what’s tight, and strengthen what’s weak. This might be a case where, to improve walking, you take a few steps back and just strengthen. Look at the hip extensors and lateral musculature specifically.

Biofeedback and the use of mirrors during treatment can help to give the patient an awareness of his or her movement patterns, which may aid in some postural corrections.

If there is a muscle imbalance due to dystonic spasms in the opposing muscle, modalities could be indicated. This could include NMES to the antagonistic muscle groups (which oppose the dystonic, spasming muscles) to increase muscle strength. Kineseotaping to both inhibit and facilitate may be a valuable tool. Although this child is a little old (for social reasons), compression and strapping garments (like TheraTogs) may also be useful.

Tone management (like Botox injections that would specifically target muscles) may be indicated, and are often prescribed in dystonia. Patient and family education on tone management is important.

Dystonia is a very difficult condition to treat. If you have other ideas or suggestions, please feel free to comment. I’d love to hear about what has been successful for you.

 

~Kathryn Biel, PT, DPT

 

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Toe Walking – the Clinical Challenge for Therapists

GUEST BLOGGER: Kathryn Biel

As a physical therapist, and a pediatric one at that, I get numerous referrals every year for children who toe walk. Often, that is the only information provided from the physician. Early on, I would look at these children and think, “Where to start?”

As with most cases, a good history is critical. Does the birth history suggest a neurological insult? Is there a history of autism or sensory processing disorder? Is there a structural deficit?

Following the history, evaluation is next. What is the range of motion and muscle tone?

When the child has a diagnosis of cerebral palsy, the treatment path is generally straight forward, including tone management, range of motion, and bracing. However, when there is no diagnosis, things are trickier. And this is where I used to get stuck. Especially if the range of motion and muscle tone were within normal limits. With some children, it’s easy to see that toe walking is a result of sensory-seeking. Walking on the toes provides increased proprioceptive input through the leg joints, thereby giving more feedback about the child’s position in space and his or her relationship to the floor. Sometimes, toe walking is the result of sensory avoidance, as the walker does not like input on the bottom of his or her foot.

Those are the “easier” sensory things to tease out. What about the children who are intermittent toe walkers? Or those who are not apparently sensory seeking or avoiding? Another aspect to consider is the integration of primitive reflexes. Children with unintegrated primitive reflexes, especially the tonic labyrithine reflex, can demonstrate toe walking as a sign. The retention of reflexes can also indicate an immature or neurological system that is under stress. The stress can activate the sympathetic nervous system, making the child function in a “fight or flight” state. A primary sign of the fight or flight state of arousal is toe walking. Other signs of this heightened state of arousal is increased respiration, decreased attention, increased visual scanning, and agitation.

Also, in the absence of sensory issues, a suggestive birth history, or a diagnosis of cerebral palsy, other neuromuscular disorders (Muscular Dystrophies, even in females) should be considered. This is especially important to follow through with when treatment does not change the toe walking, muscle length or muscle tone.

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Why is it important to address toe walking? An equinus gait is energy-costly, as it causes the ankle and knee joints to lock out, thereby preventing the transfer of energy in the form of momentum through the legs. The forward movement of the body that is normally achieved by a heel-toe gait is absent. Additionally, toe walking causes compensatory strategies throughout the rest of the body that can lead to long term imbalances and eventually pain and dysfunction.

toe walking pathology

These postural compensations will impact lower extremity muscle length, posture, core stability, and vision. The postural implications can also play a role in scapular and shoulder function, thus setting the child up for a life time of dysfunction.

What challenges are you finding with your toe walkers? Are you getting referrals for toe walking? How are you treating it?

 

~Kathryn Biel, PT, DPT

 

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