Vol. 20 Issue 10
New California Regulations Allow PT Oversight
Should the law be repealed?
Golden State OTs breathed a sigh of relief nearly four years ago when Governor Gray Davis ended their 24-year battle for licensure, signing a bill leading to the establishment of the California Board of Occupational Therapy (CBOT). The board was the first to fully regulate the occupational therapy profession in the state.
Now, many California practitioners are hopping mad. A new law passed in 2002 took full effect March 9 of this year, and OTs who work in hand therapy and dysphasia treatment must seek special certification from CBOT to continue their practice.
Applications for "advanced practice" certification must be postmarked on or before September 30 of this year. Those not receiving certification, or those awaiting certification, must be supervised (not on site) by a certified OT, a physician/surgeon or a PT for hand therapy and/or PAMs (including ice and hot packs), or a speech therapist with expertise in the area for swallowing.
Babak Amali, OTR, senior director of rehabilitation at Consonus HealthCare Services in Sacramento, said she understands the need for continued education. "[However,] I don't think requiring a PT's co-signature on my notes is the best way to get me motivated to attend more training seminars," she told ADVANCE. "It is an insult to me as an occupational therapist."
In a strongly worded letter to CBOT on May 11, Amali called for repeal of the the law. "For years we have tried to prove to the rest of the industry that we are a strong force in health care and rehabilitation–that we are needed as much as PTs or SLPs," she said. "Now that we finally have gained their respect, [CBOT] has single-handedly undermined what we as occupational therapists have strived to achieve."
Amali, who works in a long-term care setting, sees several patients for contracture management every couple of months. "I don't think I need 240 hours of on-the-job supervision or 30 contact hours to apply ice or a hot pack when treating my patients!" she said.
Not only does she believe that the hours required are unnecessary, she is also concerned as to how she will find the time to acquire them.
"How am I going to be able to get the hours of supervised on-the-job training as required for modalities certification while working full time?" she asked. "That is 30 days worth of supervision and/or internship. Isn't that just outrageous?"
Other OTs are concerned about just how long it will take to receive their certification once they have applied to CBOT. Will practices be interrupted, and is interim certification possible as the September deadline nears?
ADVANCE attempted to contact CBOT regarding these questions but no one returned our calls. However, Amali said that Janet Yagi, associate program analyst for CBOT, told her that the certification process should take about two to three weeks "if all the documentation is complete."
Senate Bill 1402 became law on Jan. 1, 2003. OTs must now demonstrate their competency in any of these arts not covered in their undergraduate education through post-professional education and training. The legislation demanded that CBOT develop regulations concerning such requisite education and training. The regulations are in place and were implemented March 9.
Applications for certification must go directly to CBOT and can be obtained free of charge at www.bot.ca.gov. Click on the 'application' link, and download the appropriate form (hand therapy, PAMs, and swallowing each have their own). Along with the application, practitioners must also provide written portfolios documenting their education and training in the specific area(s) of advanced practice.
A CBOT panel will review the application, checking for compliance with the Occupational Therapy Practice Act (OTPA) and applicable regulations. Applicants are told they will be notified "as quickly as possible" as to whether or not they qualify for certification.
There is a loophole for those certified by the Hand Therapy Certification Commission (HTCC) prior to Dec. 31, 2003–automatic qualification for advanced practice certification in hand therapy and PAMs. Submission of an application is still required by CBOT, along with the HTCC certificate. However, people who received HTCC certification after January 1 of this year must complete the application process for CBOT certification in full.
The PT Factor
Though many California practitioners celebrated the licensure victory in the fall of 2000, they were worried about a looming battle with physical therapists over hand therapy practice. The licensure law stated that OTs "providing hand therapy services" had to be certified by the Hand Therapy Certification Commission by 2005.
At the time, OTAC leaders said they intended for only those practitioners specializing in hand services to require a CHT, even though the law itself seemed to read otherwise.
A few vocal therapists told ADVANCE they felt that the CHT requirement would lead to a demise of practice for uncertified OTs who provided hand services. One of them was Arlie Haviland, OTR, director of rehab services at Arrowhead Regional Medical Center, Colton, CA. Haviland, who had 17 years in the profession, was running his own private hand practice at the time without a CHT. Haviland said he was receiving plenty of referrals from physicians who trusted his work. (see "Long Road Home," Oct. 09, 2000) The law, in his opinion, would be "selling out a large segment of OT," and he was worried that "people are going to lose their jobs over this."
However, Diane Josephs, OTR, CHT, CWS, OTAC president at the time, assured ADVANCE that she believed regulations yet to be written would put the fire out. "No one's going to lose jobs" she said. "People who believe that are misinterpreting the statute."
But California has been literally plagued with opposition to its entire licensure process, and following the passage of the licensure law, to the regulations promulgating it. The California Physical Therapy Association aggressively defends its "turf."
The Occupational Therapy Association of California submitted the legislation that became Senate Bill 1402. It made changes to the original law to satisfy the California Speech Language Hearing Association, but CPTA refused to support the bill without amending it further.
The three basic changes to the licensure law included:
• a revision of the definition of "hand therapy" from treatment of the hand, wrist and forearm to "the art and science of rehabilitation of the upper extremity that requires comprehensive knowledge of the upper extremity and specialized skills in assessment and treatment to prevent dysfunction, restore function or reverse the advancement of pathology."
• a revision of the wording "educational training and competency requirements" in regard to hand therapy to include "in specified subjects."
• revocation of the requirement that hand therapists be certified by the Hand Therapy Certification Commission by 2005, replaced by a definition that covers which "advanced practices" an OT may participate in, "to include hand therapy, the use of physical agent modalities in addition to feeding and swallowing assessment–if the OT hasÉmet educational training and competency requirements developed by the board in collaboration with the Speech-Language Pathology and Audiology, Registered Nursing and Physical Therapy boards."
Proof of Training
Applicants need to provide the name and location of the facility in which they practiced, including an estimate of the number of hours and type of training or experience they completed while there. A supervisor's verification is necessary; if the supervisor is unavailable, the employer is acceptable.
CBOT recognizes training/experience including, but not limited to, the following:
• caregiver training
• team collaboration
• patient evaluations
• chart review
If you cannot locate either the supervisor or the employer, make note of that on the application. The board may contact you for further information.
Here is a breakdown of required hours for each advanced practice area.
• 45 contact hours in the subjects identified in the hand therapy section of the application.
• 480 hours of supervised on the job training, clinical internship or affiliation (paid or voluntary) pertaining to hand therapy. OTs providing hand therapy services using PAMs also must comply with the requirements pertaining to PAMs.
• A maximum of 8 contact hours in PAMs
• 60 hours of supervised on-the-job training, clinical internship or affiliation (paid or voluntary) completed for PAMs will be credited toward the requirements for hand therapy certification.
Physical Agent Modalities
• 30 contact hours in the subjects identified in the PAM section of the application form.
• 240 hours of supervised on-the-job training, clinical internship or affiliation (paid or voluntary) pertaining to PAMs.
Swallowing Assessment, Evaluation or Intervention
• 45 contact hours in the subjects identified in the swallowing assessment, evaluation section of the application form.
• 240 hours of supervised on-the-job-training, clinical internship or affiliation, (paid or voluntary) pertaining to swallowing assessment, evaluation or intervention.
Provisions have been made to allow OTs to demonstrate competency in advanced practice areas through substantially equivalent education and training (California Code of Regulations, section 4155, c). Essentially, OTs are not required to have the exact number of hours of education and training that is required under the new law. However, CBOT suggests the regulations be used as a guide in preparing your portfolio.
The Law Is the Law
It's unclear how well the new requirements were disseminated. CBOT did at least one "mass mailing" last November to all OTs and OTAs, and the requirements appear on the board's Web site. But though the law was to be effective Jan. 1, its tenets were not mandated until CBOT had finished writing the regulations that accompanied it. Thus the March 9 deadline.
Amali said Yagi told her that hot and cold packs are covered under the statute simply because by law, they are included in the definition of physical-agent modalities. However, there are no separate billing codes for thermal therapy as there are for ultrasound, electrical stimulation, etc.
Amali intends to contact the California Department of Consumer Affairs under which CBOT operates to find out how to go about calling for a repeal of the law.
"I am one of many OTs in California who are against this law the way it is written and being executed," she told ADVANCE.
"Questioning my clinical competency and suggesting the superiority of the physical therapists is a sad and disappointing approach to the enhancement of occupational therapy," Amali wrote to CBOT.
"This law needs to be repealed."
Jessica LaGrossa is ADVANCE assistant editor. ADVANCE editor E.J. Brown contributed to this article.