Title: Introduction to OT 677
1Introduction to OT 677
- Foundations in Low Vision Rehabilitation I
2Instructors Information
- Mary Warrens contact information
- Email address warrenm_at_uab.edu
- Phone number 934-1800
- Office Hours by appointment
- Office 340
- Beth Barstows contact information email
addressbarstow_at_eyes.uab.edu - 325-8115
3Class Materials
- Required Books
- Understanding Low Vision Jose
- Macular Degeneration The Complete Guide to
Saving and Maximizing Your Sight Mogk - Additional Readings
- Required readings will be posted in Resource File
on WebCT - Must obtain copy of the following free catalogs
- Independent Living Aides (800) 537-2118
www.independentliving.com - LSS Group (800) 468-4789 www.lssgroup.com
- Maxi-aids (800) 522-6294 www.maxi.aids.com
- Ruler with cm markings
4Lectures/Class Assignments
- Lectures will be posted in WebCT at least one day
before the class - Out of Class Learning Activity Assignments must
be typed and submitted in WebCT - Forms will be posted on the website in word
format - Due dates for Learning Activities are listed on
the topic outline - In class learning activities will be due at the
end of class
5Submission of Class Assignments
- Must be type written and submitted in the
required format in WebCT - .5 deduction for all mis-spellings, grammatical
errors - 10 point deduction for turning in a late
assignment
6Absences
- Notify me by phone or email if you will need to
miss a class. Because this class relies on class
lecture and demonstration with little outside
reading, attendance is very important. - One excused absence is allowed
- Additional absences result in 15 pt deduction
from test grade - In the case of bad weather (ice, snow) class will
be cancelled-( I will send an email out to the
class via WebCT) although the information you
will be taught is very important it doesnt
warrant risking life, limb and car.
7Learning Activities
- 1. Complete the eye anatomy coloring book.
- 2. Select 2 eye diseases from the list provided
complete a written summary on each disease using
the form provided to describe the etiology of the
disease, population affected, visual functions
affected by the disease and occupational
performance limitations. - 3. Spend one day without driving cannot be a
Sunday or a day with few activities to complete.
Write up experiences obtaining transportation
8Learning Activities cont
- 4. Design male and female signage for restrooms
that can be reliably identified by a person with
20/200 visual acuity at a distance of 10 feet.
Can be completed with a partner - 5. Observe a low vision examination by an
optometrist or ophthalmologist in either the low
vision service at the Optometry school or at the
UAB Center for Low Vision Rehabilitation and
complete the summary form describing the
evaluation process and the results of the
evaluation. - Observations must be scheduled through
- Lee Test at 488-0736
- Identify yourself as an OT student taking Marys
class - Only one student may observe at a time
9Learning Activity 6
- Observe 4 hours of occupational therapy
intervention provided at the UABCLVR - A minimum of 3 patients must be observed
- Complete a written summary on each patient using
the format provided - Observations must be scheduled through Beth
Barstow - 1 student may observe a pt session at a time
- Observations will be scheduled as pt/therapists
are available-you may not be able to observe at
the time you want - This assignment can be completed this semester or
during 679 - 20 points will be added to your total in the
semester it is completed - 20 points will be deducted from your point total
in 679 if the learning activity is not completed
by the final.
10Observing in Low Vision Clinic
- Clinic is located on the third floor of the
Callahan Eye Foundation Hospital - Directly across the street from RMSB
- Suite 380
- Schedule OT clinic observations with Beth
- Schedule Physician observations with Lee
- 488-0736
- Sign in and out on the clipboard each time you
observe
11Dress Code/Behavior
- A professional dress code is enforced at the
Center - No jeans, sandals, flip flops, excessive jewelry,
non professional clothing - Cover tatoos
- If your grandmother would be embarrassed to see
you wearing that-dont wear it in the clinic! - Display respect for patients, staff at all times
- HIPPA guidelines are enforced
12Student Evaluation
- Two written exams 60
- Short answer, multiple choice
- One practical exam 20
- Demonstrate correct test procedure
- Demonstrate understanding of test mechanics
- Demonstrate understanding of test modifications
- Learning Activities 20
- 5 outside learning activities
- 3 in class learning activities
- Learning Activity 6 20 points
13Grading Scale
- A 90-100
- B 80-89
- C 70-79
- F 69 or below
14Dates
- Exams
- Exam 1 February 4th
- Practical Exam March 4th
- Exam 2 March 10th
- Exam 3 April 21st
- NO Class March 24th
15Lecture One
- Introduction to Low Vision Rehabilitation
16Learning Objectives
- Understand the role of vision in occupational
performance - Understand the framework for evaluation and
treatment of persons with visual impairment - Understand the characteristics and demographics
of low vision - Understand how low vision rehab services are
provided in the US
17What does vision contribute to occupational
performance?
18The Role of Vision in Occupational Performance
- The overall function of the brain is to filter,
organize and integrate sensory information to
make an adaptive response to the environment. - All neural structures of CNS are devoted to
taking in sensory input, analyzing it and
responding to it
19Vision is the primary sensory system used to
acquire information about the environment
- 80-90 of all learning occurs through the visual
channel - 90 of all sensory information supplied to the
CNS is visual
20Vision is the primary system because it is our
most far reachingsensory system
- First to alert us to danger or pleasure
- See a car coming straight at you
- See your food before you taste it
- Enables us to be anticipatory
- Looks like its going to rain
- And plan for situations
- Guess Ill take along an umbrella
21Contributions of Visual Input
- Supplies information needed for cognitive
processing problem solving and decision making - Use vision to size up situations
- First impressions ARE important
- Avoid persons who are acting strangely or oddly
dressed - Use vision to make decisions
- Where to sit at a meeting, what to eat at a salad
bar - Facilitates problem solving
- Want to see the problem so we can solve it
- Visual memory of a previous event helps solve a
new one
22Contributions of Visual Input
- Supplies information needed to interpret social
interactions - Facial expressions convey a lot of subtle
information - Supplies input for motor and postural control
- Impetus for motor development
- Child sees a toy and attempts to reach it
- Warns of upcoming challenges to postural control
- Surveys the line of travel and prepares the
person to navigate around objects - Rarely collide with objects (and always surprised
when you do)
23Contribution of Visual Input
- Supplies speed in information processing
- Instantly identify objects with vision
- Can identify with your other senses too but not
as quickly - Information supplied instantly by one image on
television would take several minutes to describe
in print or over the radio and never have the
same impact - Example Challenger or Columbia explosions, fall
of the world trade towers
24Contribution of Visual Input
- That speed is critical to the ability to adapt to
dynamic environments - Move in two types of environments
- Static environment
- Nothing moving but person
- Must make spatial but not temporal adaptation
- Person decides when to start and stop movement
- Dynamic environment
- objects are in motion independent of the person
- Must make both spatial and temporal adaptation
- Must match movement to movement of other objects
25To Summarize Contributions of Vision to
Occupational Performance
26To Summarize Contributions of Vision to
Occupational Performance
- Anticipates/plans
- Drives decision making
- Interprets social interactions
- Supplies speed in information processing
- Dictates motor actions
- Early warning system for postural control
27Visual Impairment Can Occur From
- Disease
- Trauma
- Aging
- Combination of any or all of the above
28When Visual Impairment occurs it
- Alters the quality and quantity of visual input
to CNS OR alters CNS ability to use incoming
visual input - The result is a decrease in the ability to use
vision for occupational performance - Observe deficiencies in activities dependent on
vision for completion - Reading, driving etc.
- Observe a decrease in speed of information
processing
29Visual Impairment.
- Alters cognitive performance
- Errors made because person doesnt get enough
input and/or accurate input for decision making - Can cause changes in way person responds to their
environment and daily activities - Anxiousness and uncertainty
- Decreased confidence
- Increased passivity
30If vision is so important to occupational
performance, why is visual impairment so often
overlooked in evaluation and treatment?
31A Because it is a hidden disability and its
symptoms are often attributed to other
causes Unless person has a white cane or a dog
guide you cant tell h/she has a visual
impairment
32Because of the importance of vision to
occupational performance, a person with vision no
matter how limited will attempt to use vision to
adapt
33- Therefore it is more natural to train a person to
use his/her available vision more efficiently
than to learn to use sensory substitution
34Framework for Evaluation and Treatment
35General Approach
- In working with patients, vision must be viewed
as part of a unified process used by the CNS to
adapt to the environment and circumstances - Not a singular, simple modality
- Not just the ability to see the letter on an eye
chart - Used with motor, cognitive, auditory, verbal,
vestibular, memory etc to produce an adaptive
response
36Viewed as part of a unified process
- A patients visual performance is not significant
in terms of how it deviates from the norm but how
it interferes with occupational performance - Whether or not a patient has a visual deficit
that requires remediation depends on his/her life
demands
37- A patient has a visual deficit if his/her ability
to obtain and/or process visual information has
been altered to the extent it prevents completion
of a necessary activity of daily living - Viewing it from this perspective helps determine
medical necessity - Determine if treatment intervention is required
and justified
38OT Evaluation has 4 Purposes
- Identify the limitation in occupational
performance - Link the performance limitation to the presence
of an impairment - Determine if treatment is necessary
- Identify the most appropriate treatment
intervention
39Criteria for Treatment Intervention
- A person has a visual impairment that merits
treatment intervention ONLY if it interferes with
completion of a necessary activity of daily
living - Therefore observation of the patients functional
performance is the cornerstone of evaluation
40Two Treatment Approaches
- Person centered approach
- Emphasis is on changing the person
- Improving ability to take in and process visual
information - Environment centered approach
- Emphasis is on altering the environment to
achieve a better person-environment fit - Enable the person to respond with remaining
capabilities
41Education of Patient and Family is a Critical
Component of Treatment
- Education is critical to success because insight
is critical to persons ability to adapt - Education is particularly important for persons
with visual impairment because we dont typically
question the accuracy of our vision - One reason why it takes a long time for persons
in their 40s to realize that they need reading
glasses for presbyopia
42Goal never changes.
- Goal is always occupational performance
- Same as for any disability
- Only the method changes
- Instead of treating a patient with function
limitations from a motor deficit, youre treating
limitations from a visual deficit - You will continue to provide occupational therapy
- This is NOT vision therapy and you are NOT a
vision therapist or a low vision therapist - No such category for insurance purposes
- Vision therapy is equated with treatment provided
for learning disability
43What criteria dictate whether visual impairment
will be addressed in therapy?
44What criteria dictate whether visual impairment
will be addressed in therapy?
- A whether visual impairment has caused a
limitation in occupational performance
45What is the purpose of the O.T. evaluation?
46What is the purpose of the O.T. evaluation?
- A To link the presence of a visual impairment to
a limitation in occupational performance
47What are the characteristics and demographics of
the low vision population?
48Definition of Low Vision
- A visual impairment severe enough to interfere
with occupational performance but allowing some
usable vision
49Definition of Legal Blindness
- Term coined by federal government to describe
visual impairment criteria qualifying persons for
benefits and services - Best corrected visual acuity of 20/200 or less in
the better eye or - A visual field of 20 degrees or less in the
better eye
50To Experience Low Vision Place Your Low Vision
Simulator Over Your EyesBefore Viewing the Next
Slide
- Without removing the simulator see if you can
identify the following faces
51(No Transcript)
52Use of the Term Legal Blindness Creates Confusion
Regarding Low Vision
- Persons who are defined as legally blind have
varying degrees of vision loss ranging from
ability to read print to no vision at all - Individuals who are blind are also included in
the definition of legal blindness - But blindness is NOT synonymous with legal
blindness - Many persons who have low vision but who are not
legally blind have significant limitations in
occupational performance
53Instead of Legal Blindness
- In an effort to establish more precise
descriptions of visual impairment the world
health organization established a range of visual
impairment - IDC 9 codes are assigned to each level and used
for diagnostic and billing purposes
54WHO Visual impairment Levels ( for medical
coding)
- Normal vision 20/20 - 20/30
- Near normal 20/30 - 20/60
- Moderate impairment 20/80 - 20/160
- Severe impairment 20/160 - 20/400
- Profound impairment 20/400 - 20/1000
- Near blindness 20/1000 - 20/2500
- Blind no light perception
55What is the difference between low vision and
legal blindness?
56- Low vision describes the visual functioning of
someone for whom regular eyeglasses or medical
procedures cannot correct vision to within the
normal range - Legal blindness is eligibility criterion used to
qualify persons for services
57Low vision is primarily an acquired condition
- Most persons with low vision grew up, worked,
reared their families and retired as sighted
persons
58Three Diseases Account for 90 of Referrals to
Low Vision Clinics
- Macular degeneration
- 60-90 of all referrals
- Glaucoma
- 13 of referrals
- Diabetic retinopathy
- 9, leading cause of blindness adults
59Macular Degeneration
- Also called
- Senile macular degeneration
- Age macular degeneration (AMD)
- Age related macular degeneration (ARMD)
- Primarily seen in Caucasians
- NEVER results in blindness
- At best takes only 20 of vision
- But central vision is damaged significantly
reducing visual acuity
60Glaucoma
- Often most feared because it can result in
blindness - But usually can be better controlled
- So less vision loss occurs
- Higher incidence in African Americans
61Diabetic Retinopathy
- Side effect of diabetes
- Caused by elevated and fluctuating blood glucose
levels - Most dangerous
- Can quickly lead to blindness
- Higher prevalence in African Americans, Native
Americans, Hispanics, Pacific Islanders
62These Diseases Share Common Characteristics
- Age related
- Incidence of the disease increases with age
- 1 out of 4 in the plus 80 age group
- Vision loss is permanent
- Treatment consists of management NOT cure
63What is the leading cause of low vision in the US?
64What is the leading cause of low vision in the
US?A Macular Degeneration
65What population cohort makes up the majority of
people with low vision?
66What population cohort makes up the majority of
people with low vision?A Adults over 65 years
of age
67Low Vision Demographics
- For persons over 70, vision loss ranks 3rd among
chronic conditions causing a need for assistance
in ADL - 2/3rds of low vision elderly have a secondary
chronic physical impairment that affects
occupational performance
68 Vision loss is
69 Vision loss is a womans issue
70 Vision loss is a womans issue
- Ratio of women to men with vision loss is 21
- Reason women outlive men vision loss is age
related - Women with vision loss are more likely than men
to live alone without in-home support available
to them - Reason women outlive men
71 Vision loss is
72 Vision loss is a race/ethnicity issue
73 Vision loss is a race/ethnicity issue
- African Americans, Hispanic, Native Americans,
Pacific Islanders experience higher rates of age
related vision loss than the overall population - African Americans are 5x more likely to
experience glaucoma and 6x more likely to
experience blindness from this condition - Experience higher rates of diabetes and as a side
effect experience - Diabetic retinopathy
- And elevated rates of glaucoma
74 Vision loss is
75 Vision loss is a socioeconomic issue
76 Vision loss is a socioeconomic issue
- Diabetic retinopathy and glaucoma can be held in
check with good access to quality health care and
eye care - Lack of preventative care can lead to severe
vision loss
77Most older adults with low vision live in their
own homes
- Despite age and impairment 70 live in their own
home - The goal of O.T. is to help them age in place
78Lecture Objective 4What two systems provide
low vision rehabilitation services in the United
States?
79Professions Providing LVR
- Ophthalmologists
- Optometrists
- Orientation and Mobility Specialists
- Rehabilitation teachers
- Certified Low Vision Therapists
- Vision Teachers
- Occupational Therapists
80- These professionals provide services through two
distinct and separate systems - Blindness system
- Healthcare system
81Blindness System
- Traditional provider of low vision services to
older adults - Well developed network of private, state and
federal services - Has been in existence for over 100 years with
comprehensive services beginning after WWII - Uses an educational/vocational framework
- Most appropriate for retraining veterans and
preparing children
82Primary Service Providers
- Rehabilitation teachers
- Degree in rehabilitation teaching
- Certified by Academy for Certification of
Rehabilitation and Education Professionals - Address ADLs affected by vision loss
- Often experts in Braille, assistive technology,
diabetic management, blind technique - Orientation mobility specialists
- Masters degree in orientation mobility
- Certified by Academy for Certification of
Rehabilitation and Education Professionals - Address travel needs of persons with visual
impairment and blindness - Long cane technique, dog guide
- Some OTs obtain this masters and hold dual
certification
83Primary service providers
- Certified Low Vision Therapist (CLVT)
- Certification recently introduced and granted by
Academy for Certification of Rehabilitation and
Education Professionals - Rehab professionals with various backgrounds can
take the exam for certification (given 2x yearly) - Including OT
- Not required for OT and not a benefit to practice
- Vision Teacher
- Have special education degree and additional
certification in vision - Work with children who have visual impairment on
issues of literacy and inclusion in the classroom
84Reimbursement Sources
- Private Sector
- Local charitable organizations will provide
services for a certain state, city or region - Example Lighthouse International and Jewish
Guild for the Blind in New York, Alphapointe in
Kansas City etc. - Some have a more national agenda
- American Foundation for the Blind
- Services provided vary
- Most concentrate on younger and severely visually
impaired
85Reimbursement Sources
- Veterans Administration
- Following WWII, VA played a pivotal role in the
development of vision rehabilitation services
especially orientation and mobility - Has its own network of comprehensive services
- 5 blind residential tx centers
- 3 blind rehab clinics
- 3 low vision rehab centers-VICTORS
- Services are restricted to veterans
86Reimbursement Sources
- State Vocational System
- Established with Rehabilitation Act of 1973
- Created one system for persons with disabilities
and a separate system for blind and visually
impaired - State commissions or divisions for blind
- Focus is on working age adults, competitive
employment - 1978 amendment added independent living stream of
funding - Covers older adult homemaker
- Funded at 11 million dollars for entire nation
- Approximately 250,000 per state
87Healthcare System
- Services reimbursed through medical insurance
- Requires physicians and licensed health care
providers - OT, PT, Social Services, Nursing, etc.
- Restorative not educational
- New player in low vision field
- Service delivery is not yet as comprehensive as
blindness system
88Primary Service Providers
- Ophthalmologists
- Medical doctors (M.D.)
- Trained to diagnose and medically manage
conditions causing visual impairment - May specialize
- Retina
- Glaucoma
- Cornea
- Vitreous
- Neuro
- Often have very little awareness or understanding
of rehabilitation - Largely function in consultative role providing
information on diagnosis and prognosis
89Primary Service Providers cont..
- Optometrists
- 4 years of post graduate training in optometry
- Graduate with doctorate of optometry
- Not physicians but instead healthcare providers
who diagnose, treat and manage conditions causing
visual impairment - Provide almost 2/3rds of primary eye care
services in the US - Led the development of the field of low vision
rehabilitation - Occupational Therapists
- Have always treated persons with low vision
- Formally re-entered low vision field in 1991
- Educational preparation is sporadic
90Reimbursement Sources
- Medical insurance
- Since most persons with low vision are over age
65, Medicare is the primary reimbursement source - Medicare Part B covers physicians, occupational
therapists in private practice and employed by
outpatient clinics - Medicare Part A covers home health OTs
- Other insurances may cover depending on
conditions for coverage - Workmans compensation
- May cover services on case by case basis
91Provision of comprehensive low vision
rehabilitation services through the healthcare
system has been occurring for just over 10 years
92Critical Milestones in Development of LVR in the
Healthcare System
- Prior to 1991
- Primary providers
- Ophthalmologists
- Diagnosed and medically managed the diseases
causing low vision - Did not provide treatment or rehab
- Optometrists
- Prescribed optical devices for persons with low
vision - Did not receive reimbursement for training and
had difficulty obtaining coverage for evaluation
93in 1991..
- HCFA (now CMS) unofficially acknowledged visual
impairment as a physical impairment meriting
rehabilitation - Enabled reimbursement for services provided by
licensed health care providers when prescribed by
physicians - Brought O.T. into the field
- Coverage of OT services was interpreted on a case
by case basis by regional Medicare fiscal
intermediaries (FIs) - Some FIs imposed very restrictive guidelines,
others were more lenient and generous - Did not cover orientation and mobility
specialists or rehabilitation teachers - Not classified as licensed health care providers
- Optometrists were not allowed to refer patients
to OT as they were not recognized by Medicare as
physicians
94Between 1991 and 2002
- Hospital based outpatient clinics opened using
occupational therapists to provide rehabilitation
services - Ophthalmologists interested in low vision served
as the medical directors of the clinics and other
ophthalmologists provided referrals - Optometrists were minimally involved because they
could not make direct referral to OT - A few OTs provided services as independent
practitioners and others provided services
through home health agencies - Coverage for services varied by state depending
on the regional Medicare fiscal intermediary - 26 regional fiscal intermediaries had established
guidelines for coverage of OT services by spring
2002.
95May 29, 2002
- CMS issued a memorandum outlining conditions for
coverage of services provided by licensed
healthcare providers - Set official national policy that supercedes
guidelines imposed by regional FIs - Placed low vision rehabilitation services under
the umbrella of physical medicine and
rehabilitation services - Must follow the same requirements for physician
referral and certification - Classified optometrists as physicians for the
purpose of referral and certification of OT
services - Set down the ICD-9 codes needed to justify
referral for rehabilitation services - Suggested CPT codes for OT procedures
96March 2003
- CMS eased restrictions and permitted occupational
therapists to be employed by physician practices
and bill under their own Medicare provider number - OT assigns reimbursement for services over to the
practice and is paid by practice
97Which system is better prepared to work with
older adults with low vision?
98Healthcare vs. Blindness System
- Chronic shortages in funding and manpower have
created a situation in the blindness system where
rehabilitation services for older adults are not
based on need but availability of resources - Services are generally restricted to urban areas
(get the biggest bang for the buck) - Services are often limited to 1-2 show and tell
sessions, providing person with resources and
tips rather than comprehensive treatment
intervention
99Healthcare vs. Blindness cont
- Services for older adults with vision loss are
more easily provided for through the healthcare
system and are the primary focus of this system - Funding is automatic from Medicare
- Multiple sessions can be provided
- Referral pattern is already established
- Services are disseminated widely throughout the
U.S. (compared to urban concentration for
services provided by blindness system)
100 To SummarizeHealthcare vs. Blindness
- Consistent, adequate funding
- Adequate manpower
- Elderly are primary consumer
- Widely distributed services
- Funding limited and often sporadic
- Manpower shortages
- Working age and children are primary consumers
- Services limited to urban areas
101Challenges Treating Elderly Through Either System
- Elderly have multiple disabilities
- Complicates provision of services
- Vision issues make them appropriate for the
blindness system but professionals in that system
are not trained to address other physical
disabilities - Their physical disabilities make elderly more
appropriate for the aging and healthcare systems
but professionals in that system are not trained
to address their vision issues - As a result, elders with low vision often fall
through the cracks of the two systems
102How OT Can Bridge the Gap
- OTs are trained to address issues of aging and
disability - With training in visual impairment, OTs can meet
the diverse needs of elders with low vision - Bridging the gap between the two systems
- This ability creates the potential for great
demand for services from OTs trained in LVR
103OTs Entrance into LVR
- OT has not been embraced by traditional blindness
professionals - David vs. Goliath scenario
- 2,500 traditional providers vs. 95,000 OTs
- Afraid of losing jobs to OT
- Has prompted traditional providers to seek better
reimbursement and standing - Optometry obtained physician status for medical
referral through technical amendment to the
Balance Budget Refinement Act of 1999 - Later superceded by 2002 Medicare Memorandum
104- Other rehab professionals, under the leadership
of Lighthouse International (NY) persuaded Rep
Capuano to introduce the Medicare Vision
Rehabilitation Services Act in 1999 - Original bill excluded OT from service provision
- AOTA worked to have the bill rewritten
- New bill (HR 2484)re-introduced in 2001 left OT
coverage alone and sought coverage of O/M and
Rehab Teachers, CLVT under supervision of
physician - Bill died in committee twice before being
reintroduced this year in both the House and
Senate
105November 2003
- Bill was passed as an amendment to the Medicare
Prescription Act - Orientation Mobility Specialists, Rehab Teachers
and Certified Low Vision Therapists are now
permitted to receive Medicare reimbursement - Must now qualify to receive reimbursement
- Licensure and facility issues will have to be
addressed - Will significantly alter provision of services to
persons with low vision
106Current OT Structure in LVR
- No specific restrictions on treatment settings
- Can be provided in all settings covered by
Medicare and third party payers - Most programs are outpatient, hospital based but
employment of OTs by physician practices is
expected to increase - Ophthalmology is the primary referral source
- Also expected to change as more optometrists (now
that they can refer) begin to partner with OTs
107OT Programs continued
- Older adults still make up the majority of
referrals for OT services - Most programs using OTs see both brain injury and
age related diagnosis - Persons with visual impairment from brain injury
are also more likely to fall between the cracks
of the two systems - Medicare is currently the primary payer source
- Will continue as long as older adults are the
largest group of consumers