Framework occupational therapy services guidelines

The provision of framework occupational therapy services

These guidelines are in line with the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act) and the Accident Compensation Act 1985.

WorkSafe will have regard to these guidelines when making decisions for the provision of framework occupational therapy services to people who have an accepted claim under the Victorian Workers Compensation Scheme.

These guidelines also apply when a person is entitled to provisional payments on a claim that includes a mental injury.

Throughout these guidelines, any reference to WorkSafe also includes WorkSafe’s agents and self-insurers.

Framework occupational therapy services

WorkSafe can fund the reasonable costs of services delivered under framework occupational therapy to assist people to effectively recover from workplace injuries and safely return to work and life following the provision of a written request from a medical practitioner.

Framework occupational therapy is a service model that recognises the importance of a worker's participation and independence in the everyday activities at home, at work, at school or within the community. Framework occupational therapy providers have specific experience in treating workers who have received an acquired brain injury, spinal cord injury or limb amputation as a result of a work-related injury or illness.

WorkSafe has developed the Clinical Framework for the Delivery of Health Services which is a set of guiding principles intended to support healthcare professionals in their treatment of an injury through the following.

• Measurement and demonstration of the effectiveness of treatment.
• Adoption of a biopsychosocial approach.
• Empower the injured person to manage their injury.
• Implementing goals focused on optimising function, participation and return to work.
• Base treatments on best available research evidence.

WorkSafe expects that all health professionals providing services to workers will integrate the principles of the Clinical Framework into their daily practice.

This policy must be read in conjunction with the following:

What we can pay for

WorkSafe can pay the reasonable costs of framework occupational therapy services a person needs as a result of a work-related injury or illness under Victorian workers compensation legislation.

The treatment or service must meet the following criteria.

• Be clinically justified, safe and effective.
• Be likely to achieve measurable improvement in a person’s functioning.
• Promote progress toward a person’s functional independence, participation and self-management.
• Be for rehabilitation purposes for a work-related injury only.
• Be delivered in line with the Clinical Framework.
• Is required as a result of a work-related injury or illness.
• Is reasonable, necessary or appropriate in the circumstances.
• Aligns with WorkSafe's guidelines.
• Has prior approval by WorkSafe.

All services must be billed in accordance with the WorkSafe Framework occupational therapy fee schedule.

Services

A framework occupational therapy service is an individual one-on-one service that may be no shorter than 15 minutes and no greater than the maximum agent-approved amount as determined to be appropriate by the treater, worker and the agent.

Prior written approval is required for all framework occupational therapy services. Services can be billed only as a single service on any one day.

Travel

The agent can pay the reasonable cost of travel on a pro-rata basis for framework occupational therapy providers conducting services outside their clinic.

Travel is defined as the provider driving a registered motor vehicle from their clinic address to an approved consultation in the community.

The agent expects the worker to seek treatment from a provider within their local area. Travel can be paid only where travel to the worker is clinically justified. Travel is payable only with prior written approval from the agent. For more information, refer to the Framework occupational therapy fee schedule.

Reports and assessments

WorkSafe may request that a framework occupational therapy provider assess and report on a person’s daily living support needs. An OT assessment provides advice to the agent about the type of services that may be required to maximise a worker's independence and participation in everyday activities and in returning to work.

Other services

Framework occupational therapy service providers can also be asked to provide advice to WorkSafe regarding a worker's need for other services. These include:

• attendant care
• post-acute support
• household help
• home modifications
• car modifications
• equipment and related services.

WorkSafe will periodically review a person’s entitlement to framework occupational therapy services to make sure treatment and services remain reasonable, clinically justified, outcome focused and payable under the legislation.

Services we will not pay for

Under the Victorian workers compensation legislation, WorkSafe cannot pay for the following framework occupational therapy services.

• Services that are not required as a result of a worker’s accepted injury or illness.
• Services for a person other than the person with an accepted claim.
• Services that are not a reasonable cost as determined in accordance with the Victorian workers compensation legislation.
• Services provided outside of Australia without prior approval from WorkSafe.

Under WorkSafe’s determination of reasonable cost, WorkSafe will not pay for costs relating to the following.

• Treatment or services provided by a health professional not registered and approved by WorkSafe.
• Fees associated with cancellation or non- attendance.
• Fees associated with clinical supervision, training, continuing professional development or upskilling.
• Treatment or services provided by telephone or other non face-to-face mediums that do not align with WorkSafe's telehealth policy.
• Separate telephone calls and telephone consultations between providers and workers, and between other providers, including hospitals.
• Treatment provided more than once on the same day to the same worker.
• Treatment, services, prostheses or equipment where there is no National Health and Medical Research Council level 1 or level 2 evidence that the treatment, service, prostheses or equipment is safe and effective. Refer to the Non- Established, New or Emerging Treatments and Services Policy.

How much we can pay

WorkSafe will pay for framework occupational therapy services in line with our fee schedules.

Sometimes there is a difference between what a provider charges and what WorkSafe will pay as the reasonable cost. If the provider charges more than what WorkSafe will pay, workers will need to pay the difference. In this instance, WorkSafe recommend the provider advise the worker prior to providing any services.

Fees and invoicing information

WorkSafe provides guidance on invoicing for framework occupational therapy services.

Who can provide these services

WorkSafe will only fund framework occupational therapy services delivered by providers that meet the following conditions.

• Are registered with the Occupational Therapy Board of Australia.
• Are registered with WorkSafe as an occupational therapy provider.
• Have met the WorkSafe eligibility requirements outlined in the Framework occupational therapy application form.
• Have signed a declaration committing to provide services in line with the Clinical Framework and the Framework occupational therapy model.
• Have received confirmation of registration and approval to deliver framework occupational therapy services from WorkSafe.
• Hold the requisite insurance coverage to deliver framework occupational therapy services.

Eligibility to provide framework occupational therapy

To be eligible to become a framework occupational therapist, applicants are required to meet the criteria of one of the following categories.

• Three years' experience as an OT, including 2 years' experience providing services to people with an Acquired Brain Injury (ABI), Spinal Cord Injury (SCI) and/or limb amputations. If applicants in this category cannot demonstrate they have provided services to these cohorts in the previous 5 years, then they are eligible for application under the third category of criteria for eligibility and subject to the same conditions as that category.
• Three years' experience as an OT without experience providing services to people with an ABI, SCI and/or limb amputations. To be eligible for this category the applicant is required to declare that they will complete 50% of the required OT Continuing Professional Development (CPD) over the next 2 years on providing services to people with ABI/SCI/limb amputations. Each CPD must include clinical supervision specific to this cohort.
• Two years' experience as an OT including experience providing services to people with an ABI, SCI and/or limb amputations. In this case the applicant will be required to declare that they have arrangements in place for clinical supervision specific to this injured worker group for the first year of practice as a Framework OT, and the applicant will be required to declare that they will complete 50% of the required CPD over the next two years on providing services to people with an ABI/SCI/limb amputations.

Occupational therapists are required to provide details of their experience in treating people with an ABI, SCI and/or limp amputations with their application. This must include where they gained experience in the treatment of workers with ABIs, SCIs and/or limb amputations.

WorkSafe will not pay the cost of CPD, clinical supervision, training or fees associated with upskilling in order for an occupational therapist to meet the threshold of WorkSafe requirements necessary to provide services under the Framework OT Model.

WorkSafe will audit CPD undertaken by providers to make sure they continue to meet the requirements to provide framework occupational therapy services.

Service delivery expectations

WorkSafe expects that all providers delivering services as part of the Victorian workers compensation scheme follow the below principles.

• Provide culturally safe and respectful services.
• Protect the person’s human rights and report any concerns of abuse, neglect or discrimination to an appropriate regulatory or complaints body.
• Support the person to maximise their independence, promote recovery and self-advocacy.

WorkSafe also expects that any treatment provided is reasonable, clinically justified, outcome focused, and in line with the Clinical framework.

WorkSafe has reporting and engagement expectations for all providers delivering services to workers. WorkSafe expects providers to communicate, collaborate and provide information to WorkSafe and other relevant parties as required.

For example:

• Providers should work with treating health practitioners or other providers, such as medical practitioners to enable the most appropriate treatment.
• Providers should work with occupational rehabilitation providers, treating health practitioners and employers in relation to return to work.

Providers are required to comply with the requirements set out in these guidelines, in the Application for registration to provide services to workers, and in the Framework occupational therapy application form.

If a provider does not meet these requirements or WorkSafe has concerns about the provider’s conduct or services delivered, WorkSafe may take appropriate action in accordance with the legislation.

Information the agent requires

To consider paying the reasonable cost of framework occupational therapy, the agent requires a request from a medical practitioner, which states that the worker requires the service for the rehabilitation of their work-related injury or illness. The agent may contact the medical practitioner for further information regarding the request.

Agent response to a request

Within 10 working days of receiving the framework occupational therapy request, the agent will advise whether:

• the request has been approved
• the request has been denied
• further information is required to make a decision.

Where further information is required, the agent will advise if the request has been approved or denied within 10 working days of receiving the additional information.

To help the agent make a decision, a request may be reviewed by the WorkSafe Medical Advisor. The Medical Advisor may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment prior to making a recommendation to the agent regarding the request.

The agent will respond to the request when they have received the Medical Advisor's recommendation.

Further information

Contact the referring agent or email [email protected].