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Practice Analysis of ABC Credentialed Orthotic Fitters

American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc.330 John Carlyle Street, Suite 210Alexandria, VA 22314–2747

ORTHOTIC FITTER PRACTICE ANALYSIS

Practice Analysis Task ForceMichael Allen, CPO, FAAOPNelson LeMarquand, MS, CO, LO, FAAOPBrad Mattear, MA, CFoJack Richmond, CFoRobby Tardell, CFoSteven Whiteside, CO, FAAOP

American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. (ABC)Catherine A. Carter, Executive DirectorStephen B. Fletcher, CPO, Director of Clinical Resources

Professional Examination ServiceSandra Greenberg, Ph.D.Carla M. Caro, MA

© 2011 by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. All rights reserved. No part of this document may be reproduced in any form without written permission of the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc., 330 John Carlyle Street, Suite 210, Alexandria, VA 22314


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Table of ContentsAcknowledgements ..................................................................................................................................................... iiIntroduction ................................................................................................................................................................ iiiExecutive Summary ................................................................................................................................................... iv

SECTION ONE 1 Results Related to Professional Background, Work Setting, and Demographic Information ..................... 1SECTION TWO 6 Results Related to the Domains ........................................................................................................................... 7 Results Related to the Tasks ................................................................................................................................. 8 Results Related to Knowledge and Skills .......................................................................................................... 11SECTION THREE 15 Results and Discussion Related to Practice Areas, Devices and Activities .................................................. 15 Highlights of Results Related to Qualitative Responses ................................................................................. 22

Table of TablesTable 1 Years of Experience as Orthotic Fitter................................................................................................ 1Table 2 Years of Experience in Ranges ............................................................................................................. 1Table 3 Type of Facility ...................................................................................................................................... 2Table 4 Number of Orthotic Fitters at Work Location .................................................................................. 2Table 5 Supervisors ............................................................................................................................................. 3Table 6 Highest Level of Education Completed ............................................................................................. 3Table 7 ABC Credentials Held .......................................................................................................................... 4Table 8 Year CFo Credential Earned ................................................................................................................ 4Table 9 Other Credential(s) Held ..................................................................................................................... 5Table 10 Gender of Respondents ........................................................................................................................ 5Table 11 Age of Respondents .............................................................................................................................. 5Table 12 Racial/Ethnic Background of Respondents ....................................................................................... 5Table 13 Domains and Tasks ............................................................................................................................... 6Table 14 Percentage of Time and Criticality in Each Domain........................................................................ 7Table 15 Task Frequency and Criticality ........................................................................................................... 8Table 16 Knowledge and Skill Statements ....................................................................................................... 11Table 17 Percentage of Time in Each Practice Area ....................................................................................... 15Table 18 Detailed Percentage of Time in Each Area ...................................................................................... 16Table 19 Orthotic Devices: Percentage of Respondents Performing Each Activity ................................... 18Table 20 Percentage of Patients in Each Age category ................................................................................... 21Table 21 Percentage of Patients with Each Type of Pathology ...................................................................... 21


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AcknowledgementsOn behalf of the American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc. (ABC), I am pleased to present this Practice Analysis of ABC Credentialed Orthotic Fitters. This report describes the contemporary practice of ABC credentialed orthotic fitters practicing in the United States. It represents the culmination of seven months of planning, execution, data analyses, and writing.

A project of this scale depends on the hard work and commitment of many professionals, and I am pleased to acknowledge their contributions to the final product. We are indebted to the five member Practice Analysis Task Force for the direction it provided. Its members—Michael Allen, CPO, FAAOP, Nelson LeMarquand, MS, CO, LO, FAAOP, Brad Mattear, MA, CFo, Jack Richmond, CFo, Robby Tardell, CFo, and Steven Whiteside, CO, FAAOP—worked with us diligently throughout the study process.

This project represents a substantial investment of ABC’s financial resources and personnel and supports ABC’s efforts in continuing to develop exemplary examination programs as well as providing information to primary and continuing education programs. I am grateful to Catherine A. Carter, Executive Director and Stephen B. Fletcher, CPO, Director of Clinical Resources for their support and guidance during this project. They provided thoughtful and consistent support for the study and developed a highly effective communication program in support of the study.

John M. (Mo) Kenney, CPO, FAAOPPresident


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IntroductionThe American Board for Certification in Orthotics and Prosthetics, Inc. (ABC) contracted with Professional Examination Service (PES) to develop and implement a practice analysis and validation study for those credentialed as a Certified Fitter-orthotics (CFo). To accomplish the objectives of the study, PES worked with ABC’s Director of Clinical Resources and a Practice Analysis Task Force over the course of a seven-month project during 2010.

ABC last performed a practice analysis study of the orthotic fitter profession in 2004 and 2006. In 2010, as planned, the profession was resurveyed in order to identify changes in the profession related to the delivery of care, the orthotic devices available, and the technology in use today.

WHY DO A PRACTICE ANALYSIS STUDY?

The goal of a practice analysis study is to determine current trends in patient care, technology, and practice management in the provision of prefabricated orthotic services by ABC certified orthotic fitters.

WHY DO A VALIDATION STUDY?

The goal of the validation study was to identify unique priorities in the delivery of prefabricated orthotic patient care, e.g.: What highly critical tasks are performed by all ABC credentialed orthotic fitters? What subset of knowledge and skills is essential at the time of initial certification? Which procedures are the most frequently implemented?

WHAT WILL ABC DO WITH THE RESULTS OF THE STUDY?

The results are being used to generate defensible credentialing test specifications designed for entry-level orthotic fitters. The results will also be used to identify specific topics for in-service and/or continuing education and to provide guidance for education program enhancement in regard to curriculum review and/or programmatic self assessment.


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Executive SummaryThe specific objectives of the study were to:• Conduct a practice analysis of ABC credentialed orthotic fitters to update the delineation of practice of orthotic fitters, including the domains of practice, tasks performed, and knowledge and skills utilized.• Develop profiles of practice of certified orthotic fitters, including time spent in each domain and the criticality of domains.• Quantify time spent in practice areas.• Identify the functions performed with regard to various orthotic devices. • Quantify patient populations served in reference to patient age and presenting condition.• Develop defensible test specifications for the discipline of orthotic fitting in connection with the multiple-choice certification exam for orthotic fitters.

In order to conduct the practice analysis and validation study, PES completed the following steps:

UPDATE OF DELINEATION

Subject-matter experts were identified by ABC who then reviewed and refined the existing delineation of practice to ensure the domains, tasks, knowledge and skills, practice areas, and the listing of orthotic devices was comprehensive and contemporary.

REVIEW

An appointed task force performed a critical review of the elements of the delineation. They made suggestions to further refine and update the draft delineation, suggesting additional tasks, knowledge, and orthotic devices. The task force then edited the document to ensure clarity and completeness.

SURVEY OF PRACTICE

PES developed a survey of practice, the Practice Analysis Survey of Orthotic Fitters, including the following components:• Introduction – including a description of the purpose of the survey and instructions for completing the survey.• Screening question – to ensure that the respondent was currently working as an orthotic fitter.• Section 1: Tasks – including 32 delineated tasks in association with six domains of practice.• Section 2: Domains – including six domains of practice. • Section 3: Knowledge and Skills – including 36 knowledge statements and 18 skills grouped in six general areas. • Section 4: Practice Areas and Device Lists – including percent of time spent in five areas of practice and activities performed in connection with 58 orthotic devices.


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• Section 5: Qualitative Questions – including four open-ended questions regarding expected changes in the profession over the next three years related to reimbursement, credentialing, professional status, and expansion into diabetic/wound care along with one question concerning the availability of continuing education.• Section 6: Background Information – including questions about the respondent’s patient population, educational and professional background, work setting, and demographic characteristics.

REVIEW OF DATA

PES analyzed the data, developed a description of practice, and developed empirically-derived test specifications.

SURVEY RESPONSE RATE

An invitation to participate in the survey was sent out to the entire population of 1,540 ABC Certified Fitter-orthotics via email. Two hundred forty-five orthotic fitters completed the online survey, for a response rate of 17%. The number of responses was far greater than that achieved in previous surveys of the profession and is large enough to generate a valid test content outline for the CFo examination. This response rate is very acceptable when compared with studies of other professions where potential respondents were required to respond to a detailed and comprehensive study such as that used in the current study.


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SECTION ONE

Results Related to Professional Background, Work Setting, and Demographic Information

This section provides background information for the sample of respondents. The survey included a questionnaire regarding professional history and then addressed the respondent’s work environment, educational background, and demographic information.

Survey respondents averaged more than 10 years of orthotic fitter experience. Slightly more than 11% have one to two years of experience; approximately one-fourth fell into the three to five years and six to 10 years of experience ranges; almost 17% have 11 to 15 years of experience; and the remaining 20% have 16 or more years of experience.

TABLE 1 Mean Years of Experience as Orthotic Fitter

Years of Experience 10.4

TABLE 2 Years of Experience in Ranges

1 to 2 11.2% 3 to 5 24.9% 6 to 10 26.8% 11 to 15 16.6% 16 or more 20.5%


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As shown in Table 3, half the respondents work at an orthotic and prosthetic facility (50%) and more than one-fourth (28%) work in a DME/medical supply facility. The remainder of the respondents work at a variety of facilities, with 5% or less working at any other facility type.

TABLE 3 Type of Facility

Orthotic and prosthetic facility 50.0% DME/medical supply 28.2% Pharmacy 3.8% Manufacturer 1.3% Hospital (in-patient) 3.4% Hospital (out-patient) 2.1% Doctor’s office 5.0% Clinic 2.9% Long-term care facility 2.1% Other 1.3%

More than half the respondents (55%) are the only orthotic fitter at their work location; nearly 40% work at facilities where there were two to four fitters.

TABLE 4 Number of Orthotic Fitters at Work Location

I am the only orthotic fitter 54.6% 2-4 39.5% 5-7 3.4% 8-10 .8% 11 or more 1.7%


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Fitters are supervised by a variety of professionals. Respondents were able to identify each type of supervisor they have and were permitted to select more than one answer. As shown in Table 5, the majority of fitters are supervised by an Orthotist (53%) and 30% are supervised by a Prosthetist. A significant number (35%) work independently, and 15% are supervised by a pharmacist.

TABLE 5 Supervisor

Orthotist 52.7% Prosthetist 30.0% Pharmacist 15.2% Physician’s Assistant 7.6% Nurse Practitioner 3.0% Physician 5.1% Physical Therapist 4.2% Occupational Therapist 3.0% Athletic Trainer 1.3% I work independently 34.6%

Total does not sum to 100%. Respondents could select all that applied.

As shown in Table 6, slightly over one-third of respondents (34%) have completed a high-school or GED level of education. Twenty-two percent hold an associate’s-level degree and 36% have a bachelor’s degree. Less than 10% have a degree beyond the bachelor’s level.

TABLE 6 Highest Level of Education Completed

High School/GED 33.9% AA/AS (O&P) 5.9% AA/AS (non-O&P) 16.1% BA/BS (non-O&P) 25.0% BS in O&P .8% BA/BS and O&P post-baccalaureate certificate 10.6% Master’s degree in O&P .0% Master’s degree (non-O&P) 6.8% Doctorate .8%


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Table 7 presents data on which ABC credentials the survey respondents hold. The most frequently held credential, after the CFo, is the Certified Fitter-orthotics/mastectomy (CFom) with nearly 19% of respondents, followed by the Certified Pedorthist (C.Ped) with 16%. Almost 7% hold the Certified Fitter-mastectomy (CFm) credential.

TABLE 7 ABC Credentials Held

Certified Fitter-orthotics (CFo) 99.2% Certified Fitter-mastectomy (CFm) 6.7% Certified Fitter-orthotics/mastectomy (CFom) 18.8% Certified Fitter-Therapeutic Shoes (CFts) 7.1% Certified Pedorthist (C.Ped.) 15.5% Certified Technician-orthotics (CTO) 1.7% Certified Technician-prosthetics (CTP) .0% Certified Technician-prosthetics/orthotics (CTPO) .8% Certified Orthotic Assistant (COA) .8% Certified Prosthetic Assistant (CPA) .4% Certified Prosthetic Orthotic Assistant (CPOA) .4% Certified Prosthetist (CP) 5.0% Certified Orthotist (CO) 1.3% Certified Prosthetist Orthotist (CPO) 1.3%

Total does not sum to 100%. Respondents could select all that applied.

Reflecting the fact that the CFo credential is relatively new, almost 90% of CFo’s earned their credential within the past 10 years, and 56% earned their CFo credential since 2005.

TABLE 8 Year CFo Credential Earned

Up to 2000 11.4% 2001 to 2004 33.2% 2005 to 2007 22.7% 2008 to 2010 32.8%


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A small number of respondents hold Board of Certification/Accreditation, International (BOC) credentials in addition to their ABC credentials, as shown in Table 9.

TABLE 9 Other Credential(s) Held

BOC Certified Orthotic Fitter (COF) 12.2% BOC Certified Mastectomy Fitter (CMF) .8% Both BOC COF and BOC CMF 3.7%

Slightly more than half the respondents are male (54%). Their mean age is 45 years old, and the vast majority (82%) are Caucasian/White.

TABLE 10 Gender

Male 53.8% Female 46.2%

TABLE 11 Age of Respondents

20 to 29 10.2% 30 to 39 22.0% 40 to 49 30.5% 50 to 59 26.7% 60 and older 10.6%

TABLE 12 Racial/Ethnic Background of Respondents

American Indian/Eskimo/Aleut 1.3% Asian or Pacific Islander 2.2% African American/Black 3.0% Caucasian/White (non-Hispanic) 81.8% Hispanic/Latino/Latina 9.1% Multiracial 1.3% Other 1.3%


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SECTION TWO

Domains, Tasks, Knowledge, and Skill Statements

Domains are global areas of responsibility performed by credentialed professionals, in the current

Implementation of the Treatment Plan, Follow-up Treatment Plan, Practice Management, and Promotion of the Competency and Enhancement of Professional Practice.

Tasks are the activities performed within a domain of practice.

Knowledge and skill statements describe the organized body of information and the physical or mental manipulation of information or things required to perform the tasks associated with each domain.

domain are contained in Table 13.

TABLE 13 Domains and Tasks

Domain Number of Tasks

Domain 1 – Patient Assessment 6 Perform an assessment of the patient to obtain an understanding of patient’s prescribed needsDomain 2 – Formulation of Treatment Plan 6

and goals of the patientDomain 3 – Implementation of Treatment Plan 9 Perform the necessary procedures to deliver the appropriate orthotic services, including adjustments and alterationsDomain 4 – Follow-up Treatment Plan 6 Provide continuing patient care and periodic evaluation

Domain 5 – Practice Management 3

organizational managementDomain 6 – Promotion of Competency and 2Enhancement of Professional Practice Participate in personal and professional development through continuing education


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DomainsResults and Discussion related to the Domains

This section presents the results of the ratings related to the six domains delineated in the survey.Respondents rated each of the domains on two ratings scales: • Percentage of Time: Overall, what percentage of your work time do you spend performing the tasks related to each domain during the past year? • Criticality: How critical is this domain to optimizing outcomes for patients and/or caregivers?

Table 14 presents the results of the Percentage of Time and Criticality rating scales. Respondents spend the majority of their time performing tasks in the Patient Assessment Domain (25%), followed closely by Implementation of the Treatment Plan (24%). Formulation of the Treatment Plan takes about 15% of their time, and the remaining three domains require between 10% and 13% of their time.

The mean Criticality ratings were highest for Patient Assessment and Implementation of the Treatment Plan, indicating close to highly critical. All other domains received mean Criticality ratings indicating that respondents felt the tasks in these domains were between moderately to highly critical. Accordingly, all six domains appropriately focus on activities that are critical to optimizing outcomes for patients and/or caregivers.

TABLE 14 Time and Criticality in Each Domain

% of Time Criticality Domain 1 – Patient Assessment 25.3% 3.8 Domain 2 – Formulation of the Treatment Plan 15.1% 3.5 Domain 3 – Implementation of the Treatment Plan 23.6% 3.7 Domain 4 – Follow-up Treatment Plan 11.9% 3.4 Domain 5 – Practice Management 12.7% 3.2 Domain 6 – Promotion of Competency and Enhancement of Professional Practice 10.1% 3.2 Other 1.4% N/A

Numeric values of criticality scale: 1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical


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TasksResults and Discussion Related to the Tasks

This section presents the results of the ratings related to the 32 tasks delineated in the survey.All survey respondents rated the tasks using two scales: • Frequency: How frequently did you perform the task during the past year? 1=Never or rarely, 2=Occasionally, 3=Frequently, 4= Very frequently • Criticality: How critical is this task to optimizing outcomes for patients and/or caregivers? 1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical

Table 15 shows the mean Frequency and Criticality ratings of tasks for respondents. The two highest rated tasks are found in the Implementation of the Treatment Plan domain: Ensure that device and components are fit and delivered as prescribed and Educate patient and/or caregiver about the use of/maintenance of the orthosis (e.g., wearing schedules, donning/doffing, other instructions). Both of these tasks received a mean Frequency rating of 3.8. Only one task received a mean Frequency rating below 2.5 – Participate in/with consumer organizations and nongovernmental organizations to promote competency and enhancement of orthotic profession.

All tasks were quite highly rated as being critical to optimizing outcomes for patients and/or caregivers. The two tasks that were the most highly rated on the Frequency scale were also most highly rated on the Criticality scale, with mean ratings of 3.9 for each. No tasks were rated below a mean of 2.5 on the Criticality scale, and only one task received a mean criticality rating of lower than 3.0. As on the Frequency scale, that was Participate in/with consumer organizations and nongovernmental organizations to promote competency and enhancement of orthotic profession; even so, this task was rated as very close to moderately critical.

These ratings indicate that the tasks identified in the practice analysis are well targeted to identify the essential activities that comprise the practice of orthotic fitters. The pattern of Frequency and Criticality ratings validates the use of these tasks in initiatives related to item writing and examination development.


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TABLE 15Task Frequency and Criticality

Task - Patient Assessment Frequency Criticality

Review patient’s prescription/referral 3.7 3.8

Take a patient history (e.g. previous device use, medical history, physical limitations, activity levels) 3.5 3.7

Perform a clinical assessment based on prescription and diagnosis 3.4 3.6

Communicate to patient and/or caregiver about the recommended treatment plan 3.6 3.7

Consult with other healthcare professionals and caregivers about patient’s condition 2.9 3.3

Refer patient, if appropriate, to other healthcare professionals (e.g., orthotist, physician) for intervention beyond orthotic fitter scope of practice 2.5 3.4

Task - Formulation of the Treatment Plan Frequency Criticality

Determine the appropriate device recommendation based on the prescription 3.5 3.8

Formulate treatment goals and expected outcomes (e.g. reduce pain, provide support, increase function, prevent deformity) 3.2 3.5

Consult with physician/referral source to modify, if necessary, the original prescription and/or treatment plan 2.6 3.5

Identify material and device design to support anticipated outcome 3.2 3.4

Develop a plan for patient needs, including patient education and follow-up (e.g. precautions, appropriate use, device hygiene) 3.4 3.6

Inform patient or responsible parties of their financial responsibilities as they pertain to proposed treatment plan 3.2 3.4

Task - Implementation of the Treatment Plan Frequency Criticality

Inform patient, family and/or caregivers regarding orthotic treatment plan, including procedure, time involved, and possible risks 3.3 3.6Select appropriate device required to implement treatment plan 3.5 3.7Take appropriate measurements and cross reference measurements to manufacturer’s guidelines 3.7 3.7Consult manufacturer’s device guidelines (e.g. recommended use, limitations, care, structural safety) 3.3 3.5Assess fit and function of device in sagittal, transverse, and coronal planes 3.4 3.6Ensure that device and components are fit and delivered as prescribed 3.8 3.9

Frequency: 1=Never or rarely, 2=Occasionally, 3=Frequently, 4=Very frequentlyCriticality: 1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical


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TABLE 15 cont.Task Frequency and Criticality

Task - Implementation of the Treatment Plan Frequency Criticality

Instruct patient on manufacturer’s warranty 3.2 3.2Educate patient and/or caregiver about the use of/maintenance of the orthosis (e.g., wearing schedules, donning/doffing, other instructions) 3.8 3.9Document treatment to verify delivery, use, care, and precautions 3.7 3.8

Task - Follow-up Treatment Plan Frequency Criticality

Determine patient’s compliance (e.g., wearing schedule, proper usage and function, patient satisfaction) 3.0 3.4

Reassess patient’s functional level, skin condition, general health 2.9 3.4

Determine need for changes to device by assessing fit 2.9 3.4

Adjust device based on assessment and inform patient and/or caregiver of changes 2.9 3.5

Evaluate results of modifications 3.0 3.5

Inspect device for signs of material fatigue or excessive wear that may lead to product failure 2.9 3.4

Task - Practice Management Frequency Criticality

Consider requirements of federal compliance regulations for the delivery of device within the Orthotic Fitter Scope of Practice (e.g. Medicare, HIPPA, L-codes, documentation requirements) 3.6 3.7Consider requirements of state compliance regulations for the delivery of device within the Orthotic Fitter Scope of Practice (e.g. Medicaid, licensure) 3.5 3.7Utilize procedures for universal precautions and disposal of bio-hazardous materials 3.2 3.7

Task - Promotion of Competency and Enhancement of Professional Practice Frequency Criticality

Participate in continuing education and/or provide such education for other orthotic or healthcare professionals 2.8 3.5Participate in/with consumer organizations and nongovernmental organizations to promote competency and enhancement of orthotic profession 2.1 2.9

Frequency: 1=Never or rarely, 2=Occasionally, 3=Frequently, 4=Very frequentlyCriticality: 1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical


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Knowledge and Skills StatementsResults and Discussion Related to the Knowledge and Skills Statements

This section presents the results of the ratings related to the knowledge and skills statements delineated in the survey.All survey respondents rated the knowledge and skills statements on two rating scales: • Criticality: How critical is the knowledge or skill to optimizing outcomes for patients and/or caregivers? All knowledge and skill statements received a mean rating of at least 3.0 on the Criticality scale— that is, all statements were considered to be at least moderately critical. • Point of Acquisition: At what point should this knowledge or skill be acquired by a credentialed orthotic fitter?

A majority of respondents supported the premise that orthotic fitters should acquire 50 of the 54 knowledge and skills before attaining the CFo credential.

TABLE 16Knowledge and Skills Statements

ANATOMY/PHYSIOLOGY –– Knowledge of:

General musculoskeletal anatomy, including upper limb, lower limb, spinal

Bony landmarks relating to gross musculoskeletal anatomy of upper limb, lower limb, and spine

Gross neuroanatomy (for example, major peripheral nerves of the upper and lower extremity)

The circulatory system as it relates to prefabricated orthotic care

Anatomical planes, planes of motion, and normal range of motion (ROM)

Human development and aging, including pediatric, adult, and geriatric, as they relate to prefabricated orthotic care

Medical terminology as it relates to prefabricated orthotic care

PATHOLOGIES –– Knowledge of:

Pathologies including cause and progression (for example, vascular neurologic, orthopedic)

Tissue characteristics (for example, ulcers, pressure sores)

Volumetric changes (for example, edema, weight gain/loss)


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TABLE 16 (cont.)Knowledge and Skills Statements

BIOMECHANICS –– Knowledge of:

Normal human locomotion

Gait deviations

Biomechanics (for example, actions of lever arms, application of force systems)

PATIENT ASSESSMENT –– Knowledge of:

Assessment techniques, including gait observation, weight bearing status, skin/tissue assessment, manual muscle testing (MMT), pain evaluation, and volumetric assessment

Measurement tools and techniques (for example, tape measurers, ML gauges, goniometers, Brannock device)

The psychology of the disabled

Orthotic forms (for example, assessment, measurement)

When to refer the patient to other healthcare providers (e.g., when patient needs are beyond fitters’ scope of practice, when patient’s health condition(s) require attention by other health care professionals)

PATIENT ASSESSMENT –– Skill in:

Interpreting referral documents (prescriptions and authorization for service)

Interviewing patients

Communicating with referral sources

Taking patient history and performing physical assessment

Patient assessment techniques (for example, measuring range of motion (ROM), determining muscle strength, body segment alignment)

Interpretation of physical findings (for example, recognizing skin pressures, dermatological conditions, skeletal deformities)

TREATMENT PLAN –– Knowledge of:

Prefabricated orthotic design and fitting criteria of orthoses and compression garments (for example, anatomical/device relationships, device trimlines)

Care and maintenance of prefabricated orthoses and compression garments

Device warranties

Available educational and resource materials (for example, fitting instructions, manufacturer’s guidelines)

Table 16 continues on the next page.


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TREATMENT PLAN –– Skill in:

Managing patients relative to their diagnosis and condition as it pertains to prefabricated orthoses

Measuring for prefabricated orthoses and compression garments including upper limb, lower limb, and spinal

Fitting, modifying, and adjusting prefabricated orthoses and compression garments

Evaluating fit and function of prefabricated orthoses and compression garments

Determining outcomes as they relate to the treatment goal (for example, reduction of pain, immobilization, improved gait, improved function)

Documentation (for example, patient records, billing documentation, incident reports)

MATERIALS/EQUIPMENT/TOOLS –– Knowledge of:

Safety procedures and standards (for example, OSHA, MSDS)

Hand and power tools

Product design, composition, and materials

MATERIALS/EQUIPMENT/TOOLS –– Skill in:

Selection of and/or use of materials and components as it relates to prefabricated orthotic treatment

Use of safety equipment (for example, personal protective equipment)

Safe use of hand and power tools (for example, bending irons, heat gun, drill, grinder)

FOLLOW-UP PLAN –– Knowledge of:

When to refer the patient to other healthcare providers

When to modify the device based on reassessment of fit and function

FOLLOW-UP PLAN –– Skill in:

Restoring the optimal fit and function of prefabricated and orthoses compression garments

Maintenance and repair of prefabricated orthoses and compression garments

Solving patient’s problems related to Activities of Daily Living (ADLs) (for example, dressing, driving)


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PRACTICE MANAGEMENT –– Knowledge of:

Referral documents

Appropriate documentation procedures

Policies and procedures regarding privileged information (for example, HIPPA)

Roles and responsibilities associated with other healthcare professions

Reimbursement protocols (for example, DMERC, HCFA)

Universal precautions including sterile techniques and infection control

Scope of Practice of the orthotic fitter

Scope of Practice of other orthotic credentials

Federal and state rules, regulations, and guidelines (for example, FDA, ADA, licensure)


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SECTION THREE

Results and Discussion Related to Practice Areas, Devices, and Activities

All respondents were asked to characterize the nature of their work in regard to an extensive list of orthotic devices.

Respondents spend the greatest percentage of their time working in the Lower Extremity area (44%); Spinal and Upper Extremity each accounted for approximately 20% of work time; Fracture Orthoses* takes about 10% of work time; and Other areas account for close to 6% of work time.

TABLE 17 Percentage of Time in each Practice Area

Lower Extremity 44.2% Spinal 19.9% Upper Extremity 20.5% Fracture Orthoses 9.8% Other 5.7%

*An ABC Certified Fitter-orthotics is competent to practice orthotics within a scope of practice that is specific to fitting certain custom fitted, prefabricated, and off-the-shelf orthoses which includes prefabricated orthoses of the upper and lower extremities, except those used in the initial and/or acute treatment of long bone fractures and dislocations. The entire Certified Fitter-orthotics Scope of Practice can be found at www.abcop.org.


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A detailed breakdown of the percentage of time in each area shows the percent of time spent working with specific orthotic devices in each area.

TABLE 18 Detailed Percentage of Time in Each Area

Lower Extremity 44.2% 1.1 Orthopedic shoes 2.9% 1.2 Diabetic shoes 7.9% 1.3 Foot orthosis (FO), prefabricated 4.1% 1.4 Ankle support 4.8% 1.5 Ankle-foot orthosis (prefabricated) 4.2% 1.6 Ankle-foot orthosis (AFO-custom) 2.8% 1.7 Soft Knee orthosis (KO) 5.5% 1.8 Rigid Knee orthosis (KO), prefabricated 6.6% 1.9 Post-operative Knee orthosis (KO) 4.2% 1.10 Hip orthosis (HO) 1.2%

Spinal 19.9% 2.1 Soft Lumbosacral orthosis (LSO) 3.8% 2.2 Semi-rigid Lumbosacral orthosis (LSO) 4.7% 2.3 Rigid Lumbosacral orthosis (LSO) 2.0% 2.4 Soft Thoracolumbosacral orthosis (TLSO) 1.1% 2.5 Semi-rigid Thoracolumbosacral orthosis (TLSO) 1.8% 2.6 Rigid Thoracolumbosacral orthosis (TLSO) 1.5% 2.7 Thoracolumbar orthosis (TLO-hyperextension) 1.0% 2.8 Semi-rigid Cervicothoracic orthosis (CTO) 0.6% 2.9 Soft Cervical orthosis (CO) 1.8% 2.10 Semi-rigid Cervical orthosis (CO) 1.6%

Upper Extremity 20.5% 3.1 Hand orthosis (HO) 4.2% 3.2 Wrist Hand orthosis (WHO) 11.4% 3.3 Elbow orthosis (EO) 4.9%

Fracture Orthoses 9.8% 4.1 Rigid sole shoe 1.7% 4.2 Walking boot 5.6% 4.3 Tibial fracture brace 1.2% 4.4 Humeral cuff 0.9% 4.5 Other 0.4%



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TABLE 18 (cont.)Detailed Percentage of Time in Each Area

Other 5.7% 5.1 Compression garments 1.9% 5.2 Lymphedema sleeves 0.7% 5.3 Burn garments-custom 0.3% 5.4 Hernia supports 0.4% 5.5 Traction equipment 0.2% 5.6 Canes 0.3% 5.7 Crutches 0.7% 5.8 Walkers 0.5% Other 0.7%


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Respondents were asked which of four specific activities they perform with respect to 58 specific orthotic devices organized into four categories of devices by body area (see Table 19). On average, a slightly greater percentage of respondents Measured and Assembled and Fit devices than perform the other two activities. Overall, Measure is performed most frequently, followed by Assemble and Fit. A greater percentage of respondents perform the four activities with regard to devices in the Spinal area than with regard to devices in the other three areas.

TABLE 19Breakdown of Activities Performed Within Each Device Type

Perform Measure Assemble Perform Initial and Fit Follow-up Assessment Lower Extremity

L-1686 Post-op hip orthosis 33% 39% 37% 33%L-1800 KO, elastic with stays 64% 72% 69% 50%L-1810 Elastic hinged KO 67% 74% 72% 56%L-1815 Patellar tracking KO 62% 71% 67% 52%L-1820 Hinged KO with condylar pads 68% 74% 71% 58%L-1825 Elastic knee sleeve 62% 71% 70% 51%L-1830 Knee immoblilizer 70% 77% 78% 56%L-1831 KO with locking joints 53% 58% 56% 49%L-1832 Post-op ROM KO 64% 70% 71% 57%L-1843 KO, unloader, OA type 59% 64% 61% 56%L-1845 Prefabricated functional KO 64% 70% 66% 59%L-1902 Ankle Gauntlet, prefab 65% 71% 71% 51%L-1906 Ankle multiligamentus orthosis 54% 60% 60% 43%L-1930 Prefabricated thermoplastic AFO 48% 52% 51% 44%L-1932 AFO, rigid anterior section, carbon fiber or equal 38% 43% 42% 38%L-1951 AFO, spiral, plastic, or other material 31% 35% 33% 31%L-1971 AFO, plastic or other material with ankle joint 38% 41% 39% 36%L-4350 Ankle control orthosis, stirrup style 53% 59% 57% 42%



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TABLE 19 (cont.)Breakdown of Activities Performed Within Each Device Type

Perform Measure Assemble Perform Initial and Fit Follow-up Assessment Lower Extremity cont.

L-4360 Walking boot, pneumatic 68% 75% 76% 53%L-4386 Walking boot 73% 79% 79% 58%L-4396 Multi-podus splint 52% 58% 56% 47%L-4396 Plantar fasciitis night splint 70% 78% 78% 58%

Spinal

L-0120 Soft cervical collar 83% 95% 93% 63%L-0172 Semi-rigid collar 83% 93% 93% 70%L-0174 Semi-rigid collar with thoracic extension 82% 90% 90% 81%L-0210 Rib belt 86% 92% 91% 66%L-0450 Thoracolumbar corset 87% 94% 90% 73%L-0458 TLSO, two piece rigid shells, prefabricated 85% 91% 87% 79%L-0472 TLSO Ant. frame hyperextension 85% 89% 89% 79%L-0625 Lumbosacral corset, short 86% 94% 93% 67%L-0626 LSO warm and form 85% 94% 91% 72%L-0627 Lumbar orthosis with rigid ant/post panels 88% 91% 94% 74%L-0628 Lumbosacral corset, long 89% 93% 90% 74%L-0631 LSO, with rigid ant/post panels 88% 92% 91% 80%L-0633 LSO, with rigid frame or panel, with rigid ant/post panels 87% 92% 88% 75%

Upper Extremity

L-3651 Shoulder immobilizer elastic 55% 63% 62% 44%L-3670 Accromioclavicular splint 38% 40% 40% 30%L-3675 Canvas shoulder motion restraint orthosis 38% 42% 41% 30%L-3960 Shoulder abduction orthosis (Gunslinger, Airplane) 41% 45% 45% 33%L-3980 Humeral fracture cuff 43% 48% 48% 38%


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TABLE 19 (cont.)Breakdown of Activities Performed Within Each Device Type

Perform Measure Assemble Perform Initial and Fit Follow-up Assessment

Upper Extremity cont.

L-3710 Elbow orthosis with adjustable hinges 50% 54% 55% 43%L-3908 Wrist splint 75% 84% 84% 56%L-3908 Wrist splint with thumb 70% 78% 77% 53%A-3650 Figure of 8 shoulder splint 49% 53% 53% 37%L-3999 Tennis elbow strap 64% 69% 71% 45%L-3700 Elbow sleeve with stays 43% 48% 48% 34%L-3701 Elbow sleeve 52% 60% 59% 37%L-0210 L-3760 Elbow orthosis with adjustable locking joints 53% 56% 55% 45%

Other Devices

A-6533 Above knee compression hose 55% 60% 59% 43%A-6542 Custom compression hose 40% 43% 43% 34%L-3260 Post-op shoe 64% 73% 73% 48%L-3260 Unloader shoe (Darco wedge type) 55% 62% 62% 43%L-3649 DH pressure relief shoe 42% 47% 48% 34%L-3216 Ladies’ depth inlay shoe 44% 48% 48% 40%L-3221 Men’s depth inlay shoe 44% 48% 48% 40%A-5500 Diabetic shoe 57% 61% 59% 52%A-5512 Diabetic insert 58% 62% 61% 52%A-6530 Below knee compression hose 58% 63% 63% 44%


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Patient Profiles

Of the patients seen by respondents, 45% are adults (18–65 years), 41% are geriatric (66 years or older), and 14% are pediatric (up to 17 years). Slightly more than half (54%) have disease-related pathologies, 43% present with pathologies related to trauma, and 3% have other pathologies.

TABLE 20Percentage of Patients in each Age Category

Pediatric (0–17 years) 14.1% Adult (18–65 years) 45.0% Geriatric (66 years or older) 41.0%

TABLE 21Percentage of Patients with each Type of Pathology

Disease 53.8% Trauma 43.1% Other 3.2%


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Highlights of Results Related to Qualitative Responses

Each respondent was given the opportunity to respond to a series of five open-ended questions regarding the orthotic fitter profession in general and aspects of their own work life in particular. Brief synopses of the most common responses to each question are provided below.

1. In the next three years, what changes in the profession do you think will occur with regard to reimbursement? The most common responses were: • Reimbursement levels will decrease • Hopefully levels will go up • Medicare and Medicaid will have more stringent documentation requirements • There will be more stringent guidelines to obtain reimbursement from insurance companies • Fewer items will be reimbursed; codes will be eliminated • Off-the-shelf items will not be covered by reimbursement plans

2. In the next three years, what changes in the profession do you think will occur with regard to credentialing (licensure, certification)? The most common responses were: • Requirements will be stricter and more demanding • There will be more education requirements • More certification required to obtain reimbursement • Higher standards • More continuing education will be required to maintain certification • Requirements will remain the same • It is a positive thing that certification and/or licensing requirements will be more rigorous

3. In the next three years, how will your professional status change? The most common responses were: • Will attain additional credentials; working toward CO or C.Ped. • Will remain certified; no change; stay the same • Will take on more job duties without a change in title or professional status


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4. In the next three years, what changes in the profession do you think will occur with regard to expansion into diabetic/wound care? The most common responses were: • Will need more knowledge or training to do this • Diabetic patient population is increasing, so will be required to do this • There are possible problems with expanding into this area as many patients have severe problems and are impossible or difficult to treat • Do not intend to expand into this area

5. Describe your thoughts on the availability of continuing education in your profession. The most common responses were: • Answers to this question depend heavily on location - Not available locally; too much travel required - Readily available • Cost factors limit participation–too expensive to travel and courses too expensive • Need more online courses • Need more hands-on classes • Need more training in Off-the-shelf • Available training more geared to CO level; need more at the fitter level • Manufacturer sponsored training available

American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc.

330 John Carlyle Street, Suite 210 Alexandria, VA 22314–2747

703-836-7114www.abcop.org

practice analysis of abc credentialed orthotic fitters · practice analysis of abc credentialed...

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