MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH

DIVISION OF NURSING HOMES AND RELATED FACILITIES

Sample Agreement for Occupational Therapy Services

I.

Purpose:

The purpose of this agreement is to arrange for occupational therapy consultation for the (name of facility) and to provide for direct occupational therapy services upon written referral by a physician to any patient served by the above facility.

II. Occupational Therapy Qualifications:

An occupational therapist (0.T.R.) is currently registered by the
American Occupational Therapy Association.

III. Statement of Functions:

A.

B.

C.

Consultation

1.

2.

3.

4.

The occupational therapist provides consultation to administration regarding program planning, policy development and priority setting regarding occupational therapy service.

Provides consultation to allied professional service workers
regarding occupational therapy which includes case finding and
case review.

Provides inservice education to the staff of the facility, i.e.:

a.

b.

C.

philosophy and role of occupational therapy

general restorative techniques

physiological and psychological reaction to activity

Maintains a summary of consultation activities in the facility.

Direct Service

1. The occupational therapist provides treatment to any patient in the facility in accordance with physician's orders.

2.

3.

Instructs members of the facility's staff concerning the patient's maintenance program.

Maintains records and reports in accordance with the policies of the facility.

Supervision

1.

Provides clinical supervision to other health team personnel, i.e.: (certified occupational therapy assistants and activity directors) in accordance with accepted professional practices.

Provides suitable space and equipment.

Provides services of an activities director to meet the suggested standards of the Massachusetts Department of Public Health, Division of Nursing Homes and Related Facilities.

Cooperates in arranging for consultation and direct service.

Makes available case records and provide for recording services for the occupational therapist.

Provides general orientation for the therapist to facility as well as its policies, recording systems, etc.

Mutual:

1.

Provide periodic review of the occupational therapy program,
policies, and future considerations.

Terms of Agreement:

The facility agrees to pay the occupational therapist at the rate of
per hour for (number)
hours of consultation per month.

A.

$

B.

Direct service will be reimbursed over and above the hours of consulta-
tion at the rate of $
per treatment.

VI. Termination of Agreement:

Should either party wish to terminate the foregoing agreement, thirty
days written notice must be given to the other party.

O.T.R.

Administrator

Date

OCCUPATIONAL THERAPY

TREATMENT PLANNING OUTLINE

(Use this as a work sheet and attach other pages as necessary.)

Adapted Equipment Necessary: (wheelchair, splints, etc.)

Position for Activities:

Neuromuscular factors:

Passive and active range of motion:

Sensory factors:

Functional status level:

Psychosocial factors:

Other pertinent data:

0.T. GOALS: Referring physician:

Team evaluation:

Individual therapist:

Patient:

TREATMENT PLAN:

Be specific about activities, position, equipment, etc.

(use other side if necessary)

Reference

American Journal of Occupational Therapy, Vol. 152, 1961, American Occupational Therapy Association, 250 West 57th Street, New York, New York, 10019.

Bengson, Evelyn, O.T.R. Guide to Planning and Equipping a Handicraft Facility for a Nursing Home Activity Program, Education Service, Washington State Department of Health, Olympia, Washington.

Howe, M. R. Professionally Guided Occupational Therapy in a Nursing Home,
Hospitals, January 16, 1964.

Maryland Department of Health, Guidelines for Establishing Occupational Therapy and Activity Programs. Maryland State Health Department and Maryland Occupational Therapy Association, July, 1968.

Case prepared by:

Mrs. Elizabeth S. Cornelius, O.T.R.
Occupational Therapy Consultant

Nursing Homes and Related Facilities Program
Division of Medical Care Administration
Public Health Service

CASE STUDY

COMPREHENSIVE PATIENT CARE IN EXTENDED CARE FACILITIES
AND NURSING HOMES

Job Description, Director of Nursing Service
Employment Application, Director of Nursing
Memorandum to Administrator from Director of Nursing
Service Attaching Plans and Suggestions for In-
Service Education Program

Hypothetical Case History Illustrative of Nursing
Service Problems

Patient's Functional Status Chart

Nursing Care Plan

Patient Transfer Form

Note to Instructors, Discussion Leaders, and Resource Persons:
For this case study, the instructor and/or group leader should
know the subject matter as well as have experience in training
as indicated in the general guide. The following minimal
credentials and requirements are desirable:

Registered professional nurses, preferably those who have a
Bachelor of Science in Nursing

Knowledge and capability to provide competent patient care in
nursing homes and other long term care facilities
Experience in teaching, administration, and consultation in
nursing homes and long term care facilities

Highly desirable educational and experiential requirements:
Registered professional nurse who has a Masters Degree in
Public Health, a Masters Degree in Medical Care or Long Term
Care Administration, or a Masters, post Masters, or Doctoral
degree in a medical, surgical, or geriatric specialty
Experience in the care of geriatric persons, anthropological
or sociological gerontology, or related fields such as mental
health and sociopsychology.

The latter group, if available, should be used in training
the Instructor group.