Introduction to OT 677

1
Introduction to OT 677

• Foundations in Low Vision Rehabilitation I

2
Instructors 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

3
Class 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 [phone]
  www.independentliving.com
• LSS Group [phone] www.lssgroup.com
• Maxi-aids [phone] www.maxi.aids.com
• Ruler with cm markings

4
Lectures/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

5
Submission 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

6
Absences

• 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.

7
Learning 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

8
Learning 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

9
Learning 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.

10
Observing 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

11
Dress 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

12
Student 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

13
Grading Scale

• A 90-100
• B 80-89
• C 70-79
• F 69 or below

14
Dates

• Exams
• Exam 1 February 4th
• Practical Exam March 4th
• Exam 2 March 10th
• Exam 3 April 21st
• NO Class March 24th

15
Lecture One

• Introduction to Low Vision Rehabilitation

16
Learning 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

17
What does vision contribute to occupational
performance?

• Lecture Objective 1

18
The 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

19
Vision 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

20
Vision 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

21
Contributions 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

22
Contributions 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)

23
Contribution 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

24
Contribution 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

25
To Summarize Contributions of Vision to
Occupational Performance
26
To 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

27
Visual Impairment Can Occur From

• Disease
• Trauma
• Aging
• Combination of any or all of the above

28
When 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

29
Visual 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

30
If vision is so important to occupational
performance, why is visual impairment so often
overlooked in evaluation and treatment?
31
A 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
32
Because 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

34
Framework for Evaluation and Treatment

• Lecture Objective 2

35
General 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

36
Viewed 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

38
OT 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

39
Criteria 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

40
Two 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

41
Education 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

42
Goal 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

43
What criteria dictate whether visual impairment
will be addressed in therapy?
44
What criteria dictate whether visual impairment
will be addressed in therapy?

• A whether visual impairment has caused a
  limitation in occupational performance

45
What is the purpose of the O.T. evaluation?
46
What is the purpose of the O.T. evaluation?

• A To link the presence of a visual impairment to
  a limitation in occupational performance

47
What are the characteristics and demographics of
the low vision population?

• Lecture Objective 3

48
Definition of Low Vision

• A visual impairment severe enough to interfere
  with occupational performance but allowing some
  usable vision

49
Definition 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

50
To 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)
52
Use 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

53
Instead 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

54
WHO 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

55
What 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

57
Low vision is primarily an acquired condition

• Most persons with low vision grew up, worked,
  reared their families and retired as sighted
  persons

58
Three 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

59
Macular 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

60
Glaucoma

• 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

61
Diabetic 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

62
These 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

63
What is the leading cause of low vision in the US?
64
What is the leading cause of low vision in the
US?A Macular Degeneration
65
What population cohort makes up the majority of
people with low vision?
66
What population cohort makes up the majority of
people with low vision?A Adults over 65 years
of age
67
Low 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

77
Most 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

78
Lecture Objective 4What two systems provide
low vision rehabilitation services in the United
States?
79
Professions 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

81
Blindness 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

82
Primary 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

83
Primary 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

84
Reimbursement 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

85
Reimbursement 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

86
Reimbursement 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

87
Healthcare 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

88
Primary 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

89
Primary 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

90
Reimbursement 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

91
Provision of comprehensive low vision
rehabilitation services through the healthcare
system has been occurring for just over 10 years
92
Critical 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

93
in 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

94
Between 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.

95
May 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

96
March 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

97
Which system is better prepared to work with
older adults with low vision?
98
Healthcare 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

99
Healthcare 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

101
Challenges 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

102
How 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

103
OTs 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

105
November 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

106
Current 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

107
OT 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