Adjusting our sails to the storm: The resiliency of hand therapists.

Our profession now faces unprecedented challenges. The impacts of the COVID-19 pandemic have been acutely catastrophic and the uncertainty of the effects of value-based healthcare also raises concerns. However, while the state of the world as we know it is turbulent and uncertain, our profession has a long-standing history of resilience, can weather this storm, and has great potential to thrive. The purpose of this lecture is to highlight the profession's history of resilience, feature the many commendable and resilient acts of hand therapists, explore the traits of adaptable people, and offer perspectives on how we, as individuals and a profession, might "adjust our sails" and navigate our way to a stronger presence, improved practices, and unparalleled outcomes.

2020 Nathalie Barr lecture

Let me first begin by extending my sincerest thanks to those who nominated me for this lectureship, Drs Virgil Mathiowetz, Virginia O'Brien, and Erica Stern. Each has contributed so much to our profession, to my development, and to my personal life. I have been so blessed to have these kind, genuine, and brilliant people in my life and I am deeply thankful to each. My deepest gratitude must also be extended to the board and members of this society. This organization and its people have given me more than I could ever possibly return.

Lastly, I would like to dedicate this presentation to my family including my wife Marianne, Children Logan (17) and Avery (13), parents Kay and Terry, my brother Sean, and my Uncle Dr Ron Roberts, a professor of sociology and advocate for social justice who just 2 weeks ago lost his battle with COVID.

I must admit that I'm not the historian that I would like to become. However, every recipient of this award should do their personal research on Mrs. Nathalie Barr, and so I did. She was a pioneer and one of the numerous broad shoulders upon which our strong profession stands. If you aren't familiar with her contributions, please take a few minutes to read the tributes written by the late Mary Kasch and late Dr Wynn Parry.

I have to be honest with you all upfront. I believe that so many of you in this audience deserve recognition such as this award and I will be singing some of your praises today. I'm no more deserving than so many here and thus, I would like to offer that my contributions are merely representative of some of our collective many good works. Another disclaimer is that I'm exhausted. I don't know about you but I've never worked harder in my life than I have for the last 8 months. And I mean no disrespect to the audience or the Society when I say that I have the worst imaginable case of “Zoom Fatigue” on record. As I checked in the PhD students taking my “Intro to Rehabilitation Science Class” this Monday (by zoom of course), one student shared that they “were a shell of their former self” and while this was good comic relief for this all, this comment resonated with me, I'm sure it did with all others in our class, and I'm sure it does with many of you at home. But, I suppose that it's a good kind of tired because it's the tired you feel when, at the end of the day, you know you made an impact and/or gave it your all. Everyone here can relate.

As I deliberated on the topic of this presentation and after reading the Nathalie Barr lectures of the past, I came to realize that my experiences pale in comparison to so many of the past and present giants of our profession. For those who aren't aware some of these past recipients include but aren't limited to Jane Fedorczyk, Terri Skirven, Caroline Stegink-Jansen, Paul LaStayo, Maureen Hardy, Susan Michlovitz, Joy MacDermid, James King and Judy Colditz.

Upon reflection, I wouldn't call myself a master clinician. I'm not a gifted motivational speaker and, now that I'm in this early-to-mid career transition, I'm finding that I know so much less than I thought I might by now. The list of my inadequacies goes on. As you now know, one thing I am skilled at is the art of self-deprecation but as I reflected on my numerous failures and few successes, it became evident to me that maybe I'm good at staying afloat when I should be sinking. Maybe my capacity to find renewed strength amidst failure and heavy workloads is something that warrants some introspection? Maybe my ability to ‘weather the storm’ is something I can speak about?

While I've had a rather privileged life including a rather trauma-free childhood, having all of the affordances of being a white middle-class male, and being a member of a supportive/loving family as an adult, I've come to know many failures. A list of my professional and pre-professional failures includes, but is not limited to:

Taking 7 years to complete a PhD, which, by the way, resulted in me shattering the metrics of my graduate program

Having only 1/3 of my grant applications receive funding

Numerous journal article rejections

Being a two-time nominee for this award

Being stretched so thin that I find myself being an underqualified jack of all trades and master of few

Having to retake an organic chemistry course as an undergrad given that I had prioritized the college experience

The list goes on

However, given all of my aforementioned supports, my stubbornness and my adaptability have sustained me throughout these challenging times, guided my response to new obstacles and adversity, and have perhaps even allowed me to excel in some areas. Staying afloat after failure after failure coupled with the curveball that was 2020, proved to be a calling for me to speak on the topic of “adjusting our sails.”

So, although my intent is to be uplifting, let's talk briefly about something we all can't wait to put behind us, namely the year 2020. I'll start. Due to the pandemic, my roles in service to my employer and profession, instructing, fieldwork education, research, and being a son, brother, father, and husband have been turned upside down.

Teaching anatomy, kinesiology, MMT, goniometry, sensibility testing, PAMS, clinical reasoning, biomechanical interventions, interpersonal and interprofessional skills during a stay-in-place order is not as easy as one might think. Redesigning an OTD program, currently in development, and simultaneously delivering it to allow students to progress in a best-practices manner yet still keep them/instructors safe has also not been easy. Having all non-COVID-related human subjects research shut down has put a huge damper on most of my projects, all of the time being shifted towards curricular redesign is requiring that I, along with my colleagues, spend 60-80 hr. weeks to deliver a curriculum. This has shifted my work away from committees and pulled me away from family. The OTs among us would call this occupational imbalance and/or role imbalance.

What else have we, as a collective, faced? Well, to name a few things, 2020 has brought a harsh political and social climate, fewer visits due to restrictions on elective surgeries or patients electing to delay seeking care, layoffs, furloughs, and other effects of an increasingly economically burdensome health care system. Although outpatient visits are now approaching their pre-pandemic values, some specialties like orthopedics have not experienced the same uptick and we've not yet recovered from the deep and wide downtick.

According to the Centers for Medicare and Medicaid (CMS), health spending is projected to grow at an average rate of 5.4% from 2019-28 which is nearly twice the average annual growth in the Gross Domestic Product (GDP) in recent years. The Centers for Medicare & Medicaid Services (CMS) is the single largest payer for health care in the United States. Nearly 90 million Americans rely on health care benefits through Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP). As a result, it's possible that we might see 8-9% reimbursement cuts for Medicare plan b patients as per the 2021 Medicare physician fee schedule in response to increased physician payment for their outpatient evaluation and management codes.

Additionally, with the introduction of value-based payment structures to our non-hospital-based Medicare B beneficiaries, hand therapists may, in the future, experience physician pay schedule deductions if not enrolled in the Merit-based Incentive Payment System or MIPS. Additionally, some therapists are findings clients to have increasingly higher copays, and some have experienced orthotic denials by CMS. I'm sure that I don't yet have my finger on the pulse on various additional issues that we are facing.

I'll be sharing success stories on how our profession has adapted to the COVID crisis and some thoughts about how we might adapt to and thrive due to CMS value-based programs in a bit but I wanted to offer some perspective on the many other obstacles we've adapted to and overcome throughout the decades.

To appreciate some of the numerous obstacles our profession has faced, consider the following crude timeline that is depicted in Figure 1 . Please keep in mind that this is not all-encompassing; I've likely left out numerous hurdles that we've overtaken.

Fig. 1

Professional obstacles.

During WWI, reconstructions aides chose to enter the military without rank and commission and agreed to accept a position inferior to that of all enlisted males. As we progress down the timeline, our predecessors continue to face and break through gender barriers. Military rehab therapists continued to be paid less than soldiers until after WWII where pay finally became comparable after we demonstrated our value in restoring the upper limb function in our injured veterans. Thanks to the fine work of these women, hand therapists now enter as commissioned second lieutenants. The Late Judy Bell Bell-Krotoski, Dr Enrique Smith-Forbes, and Kate Baker are a few of our fellow hand therapists who have become ranking officers and we thank all of you for your service to our country and profession!

Additionally, while the reconstruction aid of WWI and rehab therapist of WWII worked under the direction of an orthopedist, some hand therapists now have direct access to their patients, 13% of CHTs own their own practice, some, like Dean Rebecca Neiduski, have ascended into highly ranked positions!

In 1966, female PTs earned, on average 122 dollars/week when compared to the male-dominated trade of plumbing who earned, on average 190/week. Additionally, I'm told that 1997 was a rough year for many therapists as were numerous years to follow. The Balanced Budget Act was passed at this time and this resulted in significant cuts to Medicare and caused massive disruption to the rehab therapies. Changes included moving to a prospective payment system for inpatient rehabilitation facilities, home health, and skilled nursing facilities and expanding the cap on private practitioners to therapy in all settings, except hospital outpatient departments, at $1,500; and placing all Part B payment for therapy under the Medicare Physician Fee Schedule. Due to the advocacy of ASHT, AOTA, and APTA, this CAP was repealed in 2018!

In 2017, the American Health Care Act (AHCA) was introduced as the replacement for the ACA. This would have resulted in individual and group plans which excluded “Essential Health Benefits” such as rehabilitation and habilitation. Thanks to our professions’ advocacy, this didn't pass in the senate.

Also introduced in 2017 was the Medicare Orthotics and Prosthetics Improvement Act. If passed, this would have required state licensure or approval by an orthotist board for hand therapists to be paid for the fabrication and fitting of custom orthoses. This was also not passed due to our advocacy.

Today, while still a female-dominated field, our earnings as CHTs have ascended to an annual average of $88,720 which is now some 30K more than the average salary of a plumber. As reported by the US Bureau of Labor Statistics, , the professions of PT and OT are expected to continue with “faster than average” growth for the next decade and impressive median salaries.

Although a male hand therapist, the work of the trailblazers during the formative years of our profession has opened doors for me that would have never existed if not for their commitment and excellent outcomes.

Dorit Aaron, in her presidential address, touched on the strengths and qualities of our profession and stated the following and I wholeheartedly agree:

“When I look around at who we are, I see three distinct qualities that make us hand therapists. First: A scientific, scholarly quality that pushes us to ask why and to prove that what we are doing today will have an effect tomorrow. Second: A tangible creative quality, one that helps us mold each plan to meet specific needs. Third: An adaptive quality. We adapt our approach to meet the individuals' unique situation that is sitting in front of us.”

So what is it about us that has and will continue to push this profession forward? How will we weather the storm? I'd like to think that the answer, as suggested by the title of this talk, is that we “adjust our sails”. This will require that we be scientific, creative, and adaptive. Additionally, I'd like to add a quality to this list. That quality is that we are or will strive to be informed. Dr Brent Braveman, when amending the old adage “If you don't have a seat at the table talking with them, they are talking about you” to say “If you want to keep your seat at the table, you have to understand the conversation!” We'll come back to being informed in a bit, but, for now, let's focus what it means to be adaptive.

There are many definitions of “adaptation”. From the perspective of the biological sciences, adaptation is the “evolutionary process whereby an organism becomes better able to live in its habitat or habit” or is “Any alteration in the structure or function of an organism….by which the organism becomes better fitted to survive and multiply in its environment.” What is common to both definitions is that the environment drives the process. Likewise, adaptability is “the quality of being able to adjust to new conditions” or “the capacity to be modified for a new use or purpose.”

Adaptation occurs when there is a demand and/or motivation for such and it occurs at the intersection between what we know through our didactic learnings and what we know through experience. For example, in 2020 the global health and economic environments have necessitated some pivoting by our profession. As we will come to see in a bit, we have responded to the environment by applying the key characteristics of the hand therapist and building from what we know. Let's talk about the key characteristics of an adaptable person.

Adaptable people tend to possess the following qualities. , You should note that these characteristics align with those described by Mrs. Aaron and likely define the way each of you functions as clinicians, educators, or researchers. They are as follows:

We are flexible. We aren't afraid to try something new and will pivot as necessary.

We are reflective. We examine our competencies and areas for development. We make plan strategies for success, altering accordingly.

We are responsive. We anticipate and face problems, strive to do better, and apply our learning to new situations. After reflecting, we make plans accordingly, whether it be for our own development or in our client's intervention plan.

We are curious. We are keen consumers of the literature, seek to understand the body and how it responds to injury and intervention, seek to understand our clients and what influences how they respond to hand therapy, etc.

We are optimistic. We identify opportunities in our failures. Adaptable people don't have one solution set in stone. They have a wide variety of ideas and resources to pull from, and because of this, they are more likely to reinvent the wheel in real-time.

We are team players. We partner with our clients, referral sources, our parent organizations, other providers, our students/mentees, and other hand therapy investigators.

We are creative. We are imaginative, artistic, and think outside of the box. We thrive on opportunities to stretch ourselves in this area.

We are emotionally intelligent. We care, are tolerant, respect others, even those who may have different views from their own.

It is because we possess these qualities that we chose this career path, have weathered, are weathering, and will continue to weather the storms. Let's shift gears and talk about the acts of hand therapists in 2020 which epitomize these qualities. After which, I will offer some closing thoughts on how we might sustain and grow our profession as we move forward.

Since March, I have made major adjustments in my academic work. I've modified how I teach, supervise fieldwork students, perform service to the program and university, and adjusted the focus of my research. From a maladaptive standpoint, I've taken to destroying my home. As a positive coping mechanism, I've been using a Karaoke App to sing with friends across the world! I've been teaching orthotic fabrication and anatomy from my basement via zoom with some help from my kids and wife and the visible body app. I have sent small kits with goniometers and edema management supplies for students to practice on others that they might be quarantining with while I demonstrate on my kids through zoom. I have been bringing students into the classroom in pods and PPE when social distancing isn't possible. In the classroom, we've administered PAMs, practice goniometric assessments, palpations, and MMT.

My fieldwork has moved from in-person job analyses and ergonomic consultations to virtual home workstation ergo consultations which involve zoom interviews, administration of Patient-Reported Ouctomes, the review of requested still photos sent to my students and me in advance of the meeting and meetings with students for interpreting and planning interventions as well as zoom follow-ups to deliver recommendations and assess outcomes.

My human subject's research is on hold so I've transitioned into writing up a few manuscripts that were sitting around, and submitting a NIAMS K23 grant application while wearing my PJs. I've also been involved with presenting my pre-COVID research findings at this conference as well as the 2020 European Federation of Societies for Hand Therapy Congress.

I did some outreach to hand therapists I know across the country to ask for stories from those who have adjusted their sails to the storm which we call 2020. I have a large response so I am featuring the stories of only several of those who responded.

The first story is that of Cindy Weinberger, an experienced OT and CHT, who prior to COVID, worked in an outpatient clinic in Florida and had been putting together the pieces to create and launch a Mobile-based and telehealth practice She was laid-off without notice on a Friday and March and put the final pieces together for her telehealth program over the weekend and launched her new business on the following Monday. Since then, she has hired a PT and 2 more OTs as contractors, her business is thriving, and she's enjoying running her own practice! Adaptation at its finest!

The next story is of Dr Kim Kraft. Kim's story is unique to that of Cindy's. The outpatient rehab department she worked for was closed on March 16th and during April and May, only one therapist would be scheduled to see urgent cases given that all elective surgeries had been deferred. At this time, her focus shifted towards project development and supporting the affiliated hospital with implementing COVID safety policies and procedures with staff and patients. Like us all, they now were masks, eyewear, and practice stringent disinfecting and hand hygiene but are now back to seeing patients in clinic. Kim has found herself using her biopsychosocial training in helping support her colleagues and clients who are experiencing the effects of social isolation and fear of the unknown. Perfect examples of flexibility and high emotional IQ.

Dr Virginia O'Brien shares a similar story. She experienced a shutdown for several months. In her practice, they gradually began introducing telehealth visits for persons with comorbidities. It has also opened the door for those who would have ordinarily, traveled long distances for the progression of exercise regimens in the clinic. She went on to state that “Telehealth via telephone or video has allowed our hand therapist providers to reach out and provide care to them from the safety and comfort of their own home. This also offers us the opportunity to work with the patient within their context, seeing them work within their home environment, and problem solve issues in real-time to allow the person to experience true occupational performance tasks with appropriate problem solving in real-time with them.” And emphasized the importance of making hand therapy available to those who are appropriate for telehealth and to those who would otherwise not get access to us and described the endless opportunities for improving health outcomes and reducing health spending through telehealth.

Saba Kamal is the Director of Hands-On-Care and as such owns two clinics. She was fully staffed prior to the pandemic and worked tirelessly to keep her employees even in the face of financial stress. She outreached to every possible referral source to convey that her therapists were essential. She reached out to government programs to support her business, quickly transitioned into offering telehealth for those at risk and for persons with simple non-surgical protocols when approved and for her in-person visits, took all of the measures imaginable to keep her patients and staff healthy including pre-visit screens, rigorous PPE wear of therapists and clients, the physical distancing of patients, hand hygiene and stringent sanitization procedures. When things were slow in the clinic, the therapists participated in journal clubs, studied the literature, and wrote articles. At present, they have almost returned to full capacity. This story epitomizes weathering the storm.

Angelica Gicalone, Nhu Wong, and Cindy Pedersen shared similar stories of the benefits of telehealth in terms of it offering a more conducive environment to evaluate function and ergonomics in natural contexts, prioritizing it for clients with comorbidities, using screen sharing functions for educating clients and for use of patient-reported outcomes. To expand the reach of their practice's telehealth, Nhu and Cindy applied for licensure in a bordering state where many of their clients would travel from pre-COVID. They also described the intra and interprofessional collaboration which took place to effectively make a telehealth visit happen. This included support from the clerical staff, other hand therapists, and surgeons. Cindy described how the home environment has also supported the use of occupation-based interventions which was ordinarily not possible in the clinic.

Last but not least is the story of Laurie Humiston. When many others were saying no to FW students, Laurie said yes to supervising level II occupational therapy Fieldwork students, and learning alongside them as they implemented the use of telehealth.

She also shared the unique perspective of being an Education Division member who witnessed the resiliency and adaptability of the division as they pivoted to create new ways of delivering workshops and an annual conference that had traditionally been delivered in person. Thank you, Laurie, for your commitment to supporting the development of future hand therapists and for your commitment to our profession and our clients!

Let's end with some thoughts about adapting and thriving in a value-based payment model. It's important for us to seek to understand the value-based payment model and Merit-based Incentive Payment System and Advanced Alternative Payment Models. We are poised to shine here because rehab has a history of being a strong predictor of how we perform.

The data coming from MIPS is how they are doing it. Rather than making big sweeping cuts based on a random decision, they are using the best information they can obtain to decide where to spend their money. This sounds logical. Dependent on quality, improvement activities, cost, and EMR usage, the extent to which we get paid will depend on how we perform in these areas:

Quality: This category covers the quality of the care you deliver, based on performance measures created by CMS, as well as medical professional and stakeholder groups.

Improvement: This is a new performance category that includes an inventory of activities that assess how you improve your care processes, enhance patient engagement in care, and increase access to care. The inventory allows you to choose the activities appropriate to your practice from categories such as enhancing care coordination, patient and clinician shared decision-making and expansion of practice access.

Cost: The cost of the care you provide will be calculated by CMS based on your Medicare claims.

Occupational therapists will receive a score of between 0 and 100 based on performance in two categories: quality and improvement activities. In 2020, scoring higher than 45 yields a positive payment adjustment. Scoring less than 45 yields a negative payment adjustment. Our parent organizations, AOTA and APTA, both offer online educational materials that overview MIPS as it relates to our services. , CMS also provides significant resources and help on its “QPP” website.

The quality category is reported over 12 months and requires that clinicians submit at least 6 measures included on the physical therapy / occupational therapy specialty list. One of those measures must be an outcome or a high priority measure. The AOTA's "Medicare Part B Eval Checklist” includes all of the quality measures reportable by occupational therapy.

Improvement activities give practices or clinics points for completing formal activities over a 90-day period that are intended to improve processes and client outcomes. This accounts for 15% of the final MIPS score.

With these three categories in mind, here are some thoughts on how we might thrive in a value-based payment model:

Advocate for Earlier visits. Early access may help in managing the opioid crisis. Colorado, California, and New York, among others, will continue to consider policies to encourage practitioners to first prescribe non-pharmacological alternatives to pain, including hand therapy, prior to prescribing opioids. Hand therapy practitioners can teach people with chronic pain how to prioritize and pace their activities, modify tasks, and complete those tasks without triggering pain. Hand therapists are also equipped to manage pain through exercise, modalities, and occupations as ends. We're relatively inexpensive. Get them to us early and we can help steer that ship away from costly surgeries.

Evaluate those with fall-related fragility fractures for balance, screen for OP risk, and collaborate to address the fracture-related risk fractures. For example, a distal radius fracture is often a sentinel event and predicts future falls, hip fractures, the risk for future hospitalization, etc. Here we can impact cost and quality through secondary prevention.

Putting our best foot forward with our Telehealth services and studying the impacts to justify our use of it beyond our temporary CMS approval period

Advocating for direct access

Choose the right care for clients, in the right amount, when they need it, to show documented outcomes

Additional things to consider in your day-to-day practice:

I came across this statement by William Arthur Ward and pondered about it for a bit: “The pessimist complains about the wind, the optimist expects it to change, and the realist adjusts his sails.” I'm not sure that I agree with all his sentiments. I don't think it's pessimistic to speak your mind about something and, for us to weather the storm, we must. I also feel that an optimistic outlook and hopes and expectations for change are healthy. While the realist adjusts the sails in response to the storm, we must acknowledge that the climate whether it be political, social, cultural, etc. feeds or quashes the storm. Thusly, I would suggest that, in addition to being adaptable, the hand therapist strives to change “climate” so that the impacts of the storm might be mitigated.

Tonight we discussed our past, present, and future challenges. We heard stories about resiliency, creativity, and adaptation. Although this is nothing new to us, I hope you leave this session with renewed energy and hope for our present and future paths. I know that this exercise was exactly what I needed and I hope that it has offered food for thought and helped to light a spark in a time where one might be needed.

Thank you for this honor and the opportunity to speak with you. I'm so proud to be a hand therapist and you should be too.

1) When conducting and documenting the evaluation and when intervention planning:

• Be top-down – evaluate function first and select tools that measure necessary body structures and functions next • Create a link between objective information or test scores to functional performance and participation • Add pertinent medical and/or family history that could have an impact on the plan of care • Address cognitive level if it has an effect on the intervention • Differentiate therapist-only skills from non-skilled services • Include an adequate baseline of function to measure change • Clearly state the frequency and duration of necessary therapy treatment

2) When intervening and documenting interventions:

• Indicate why the frequency or duration of treatment has changed • Document current client status by identifying the specific outcome being addressed and how the client is responding at present • Document all gains toward treatment goals, even goals for sustaining gains • Be sure the coding, descriptions, and dates within the intervention notes are accurate and consistent • Indicate whether concurrent therapy is being furnished Use a nomenclature system that is understandable by non-therapists when describing orthotic intervention and link to function • Don't use PAMs without providing purposeful/occupation or activity-based interventions • Consider the “Choosing Wisely” {AIBM, 2020, Choosing Wisely} resources available to us through our parent organization to help us intervene in an evidence-informed manner

3) When writing progress notes:

• Goals must be client-centered and measurable • Use approved abbreviations, and spell out the full abbreviation at the outset in your documentation • Indicate how your interventions achieve functional performance, participation, or another outcome, rather than just describing the activities themselves • Use therapy-specific goals to clearly demonstrate that your services aren't duplicating those provided by another discipline • Address each original goal in the progress report • Use verbs such as evaluate, fabricate, analyze, tailor, grade, develop, design, optimize, stabilize, and educate to describe skilled service in progress notes

4) When discharging and summarizing the discharge:

• Consider:○ If client is able to adhere to the therapy routine ○ Has the home been evaluated for fall safety? ○ Does the client have a list of follow-up appointments? ○ Is any needed transportation assistance to make it safely to those appointments? • Identify appropriate carryover training for the caregiver • Document progress toward all goals.

In addition to these practices, here are some additional steps you can take to prepare to weather the storm:

1. Read and learn. Understand the payment models being introduced such as ACOs and bundled payments and be able to articulate how they may impact your work setting, your organization, and the consumers to whom you provide care 2. Get aggressively involved at your place of employment. Volunteer (assertively ask to be a member) for committees and initiatives to streamline care such as early access, falls prevention, etc. 3. Demonstrate and articulate the distinct value and contribution of hand therapy practitioners to improving outcomes and limiting costs through efforts such as fall prevention, chronic pain programming, and early access 4. Advocate. If you believe as I do that that achieving the Triple Aim of improving the health of the public, improving health care, and providing quality care at a lower cost is critical to our future, then advocate for Hand Therapy's involvement at the state and federal levels. See the ASHT advocacy page and read/respond to any communications from ASHT. The parent organizations also have lobbyists who will lobby on our behalf. Be sure to communicate your concerns to all organizations when you would like support advocating. 5. Lastly, attend Capitol Hill Day and use your voice to speak at the table with your elected representatives whether it be virtually or in person