Bellwether 2019: The Nate Waters Physical Therapy Clinic

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If you build it, they will come.

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TCC NATE WATERS PHYSICAL THERAPY CLINIC

ABOUT TCC

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Tulsa Community College (TCC) has served Tulsa and northeastern Oklahoma since 1970. Now Oklahoma’s largest multicampus community college, TCC serves 25,000 students in college programs annually. TCC consistently ranks among the elite of the nation’s 1,150 community college associate degree producers, serves more college students in northeastern Oklahoma than any other public college or university and reports one of the largest freshman classes in Oklahoma every year.

CONTENTS PROJECT SUMMARY

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THE PROGRAM

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THE PROBLEM

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THE IDEA

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THE SOLUTION

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THE OUTCOMES

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LESSONS LEARNED

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APPENDIX

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BARRIERS

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PLAN

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LEARNING & ASSESSMENT 97 AWARDS

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PROJECT SUMMARY

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PROJECT SUMMARY Allied health workforce programs face continual challenges in recruiting quality clinical education experiences for students. Competition for clinical sites is increasing. Stringent onboarding processes to area clinical facilities are costly to the academic institution and the student. Once in a clinical facility, student learning may be negatively impacted by productivity demands on the clinical staff as health care costs increase and reimbursement dwindles. The Nate Waters Physical Therapy Clinic (NWPTC) was designed to provide onsite clinical education for students while providing pro bono physical therapy services to the community. This College subsidized setting solves these problems.

This faculty-driven concept is a clinical laboratory where students can take concepts straight from the classroom to the clinic. Which reinforces what they have learned. Patients are active contributors and termed “community instructors” as they, too, provide constructive feedback to students about their performance. The NWPTC reduced required outsourced clinical placements while providing valuable services to the community as many individuals still lack resources to recover from catastrophic events such as cerebral palsy or stroke.

Dr. Suzanne Reese began work on this clinic concept 11 years ago. In addition to dwindling outsourced clinical sites, the program had been treating patients once a week in a 2400 square foot lab and saw how powerful this type of learning could be. Expanding this practice was critical. Other lab window was an abandoned car dealership; the perfect location for a clinic. Dr. Reese used a sabbatical to research the feasibility and presented a business plan to Administration. The College’s Foundation was tasked with developing a campaign to achieve the estimated $2 million needed to remodel and properly furnish a PT clinic.

Over several years, the Foundation accepted donations ranging from $10 to $300,000 from supporters. The College purchased and renovated the building to an 8500 square foot facility.

This education model, recently published in the Journal of Physical Therapy Education, reduced outsourced clinical education by 18 percent. Students saved time and money related to travel, and despite the reduced clinical time, continued to achieve entry-level by the program conclusion. This self-funded and self-contained teaching clinic allowed faculty to provide a reflective learning environment aligned with the curriculum. The NWPTC reduces students’ anxiety and fear of failure.

The NWPTC exceeded all expectations and lessons learned were many: 1) The funding for NWPTC was well supported from community partners who appreciated a place to refer patients without health insurance; 2) Complicated patients become less intimidating to students over time; 3) Area clinical instructors are delighted with the increased preparation of students because of the NWPTC; 4) Adequate faculty resources are needed to meet Clinic and Program needs; 5) Faculty maintain contemporary clinical expertise important to accreditation 6) Many creative learning experiences, including interprofessional education are possible with this innovative model. The combined impact of student learning and community benefit makes the NWPTC a unique accomplishment with handprints on the quality of many lives.

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The Nate Waters Physical Therapy Clinic is a place that cannot be replaced. It’s a place that has to be there. There should be a thousand of them.”

-Alan Taylor, Community Instructor

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THE PROGRAM

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PROGRAM

THE PROGRAM The Physical Therapist Assistant Program at TCC was initially founded in the late 1970s and was almost immediately closed due to lack of support from the physical therapy community.

The Program was resurrected in 1982 and has enjoyed robust development ever since. Over the past three decades, the number of students accepted each year and the number of faculty has doubled.

Following a competitive application selection process, 35 students are admitted into the PTA Program each academic year. The Program is five semesters and 68 total credit hours.

Students graduating from the TCC PTA Program earn an Associate of Applied

Science and are eligible to sit for the national licensing examination.

Clinical education in physical therapist assistant programs utilize community healthcare facilities as guest hosts to students. Students shadow and practice patient care skills alongside a licensed therapist or therapist assistant. These guest facilities have always hosted students without financial incentive or reward because physical therapy personnel view it as a professional responsibility and obligation. This clinical model is different than dental hygiene, nursing, and other workforce development programs as it is not subsidized by the academic institution

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in anyway. Modern healthcare imposes complicated demands on hospitals and rehab settings that challenge the traditional model of clinical education of the physical therapist assistant.

Productivity targets, stringent risk management processes, and everchanging third-party payor regulations significantly impact quality student learning. The Nate Waters Physical Therapy Clinic (NWPTC) was born from the increasing difficulties experienced with traditional outsourced clinical education. The mission of the NWPTC is to provide on-site clinical education for students while providing pro bono physical therapy services to the community.

This faculty-driven concept is a community laboratory where students, with guidance from faculty, take concepts taught in the classroom for immediate application and reinforcement in a clinic setting. Patients are active contributors and termed “community instructors� as they too, provide constructive feedback to students about their performance.

The NWPTC reduced required outsourced clinical placements by one while providing valuable services to the community as many individuals still lack resources to recover from catastrophic events such as cerebral palsy or stroke.

The Clinic provides approximately 2025 patient visits per week to restore mobility, function, and life roles to those

THE PROGRAM

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affected by disease, disability, and pain.

We believe our work is having a huge impact on student learning and our community. The NWPTC has allowed our program to reduce the total outsourced clinical education hours by 4,200 annually (18%) while increasing student clinical performance. Additionally, the underprivileged of our community have been served with close to $500,000 of pro bono physical therapy services since its inception. Bringing the NWPTC into reality required significant investment from the community and the College.

We hope the information provided in our binder gives readers an overview of our journey and the lessons we learned along the way. Alan Taylor, a patient from NWPTC, puts it best when he says “The Nate Waters Physical Therapy Clinic is a place that can’t be replaced.

It’s a place that has to be there. There should be a thousand of them.” Our hope is to guide others to develop their own Nate Waters PT Clinic.

The Nate Waters Physical Therapy Clinic provides approximately 20-25 patient visits per week to restore mobility, function, and life roles that to those affected by disease, disability, and pain.

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The Center and the students it will train are needed by our community and the program is a fitting tribute to a good man.”

-Tulsa World Editorial

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THE PROBLEM

PROBLEM

THE PROBLEM PTA Programs are required by accreditation to provide 520-720 hours of clinical education per student in natural clinic settings. Prior to the opening of the Nate Waters Physical Therapy Clinic, the clinical education model for the Tulsa Community College Physical Therapist Assistant Program required each of the 35 admitted students to participate in 680 outsourced clinical education hours with five separate clinical placements.

The faculty recruited 23,800 outsourced clinical education hours each year.

Community healthcare facilities host PTA students for clinical internships using their own therapists as clinical instructors at no charge to the academic institution. Prior to the students’ first day, the Program

Risk Management

High Staff Productivity Demands Costs related to student travel, onboarding, fees, etc.

Managing, scheduling, and negotiating 175 out-of-house clinical experiences per cohort was very labor intensive on PTA faculty.

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generates a clinical affiliation agreement with each facility outlining the roles and responsibilities of the clinical facility, the academic institution and the student.

and OSHA training, background checks and drug screens. Onboarding new clinical instructor faculty at the host sites required ongoing program faculty support.

Managing, scheduling, and negotiating 175 out-ofhouse clinical experiences per cohort was very labor intensive on PTA faculty.

Over the past decade, clinical contracts have required more stringent risk management requirements including a variety of immunizations, CPR certification, HIPAA

Despite all faculty efforts, host clinical facilities began struggling to offer student placements and provide quality learning experiences for the students. Facilities were reluctant to host students early in their PTA education as they did not have a full complement of clinical skills ready for application.

Healthcare administrators voiced increasing concerns with their clinical staff meeting required productivity standards, when they hosted a student.

Some facilities even began charging the academic institution or the student a hefty fee for their clinical experience to offset the loss in productivity.

Additionally, Medicare and Medicaid (CMS) outlined new regulations limiting reimbursement for patient care performed by a student.

THE PROBLEM

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After a request was made for clinical sites in December 2018, the PTA Program received this email from a hospital-based physical therapist, I am concerned about how much we can educate students in this setting with the new rules of “Use of students in an IRF/ARU/Part A setting” rules that CMS rolled out... I don’t know how they expect students to gain skills and confidence without hands on. In my letter, I asked if any of them would like a therapist or any medical professional to work on them or their loved one without “hands on experience” because that is basically what they are asking us to hire in the hospitals with these new rules. Grrr. Every therapist I know struggles with documentation being a weak point as a new grad.

The new ruling doesn’t allow the student to chart. It is so ridiculous. I see now why you are having such a hard time finding acute care placements.

Tulsa Community College has clinical contracts with facilities in these highlighted counties. In addition, the PTA Program uses five bordering states, Colorado, Kansas, Missouri, Arkansas and Texas.

All of these issues not only impacted clinical site availability, but also student learning.

Students voiced concerns over limited time for reflection and feedback with clinical instructors due to productivity expectations. There was no time to discuss the completed treatment session before a new patient was to be seen. Students additionally voiced concerns about the travel costs incurred in addition to course tuition and fees. Competition for clinical sites with other area PTA Programs requires students to drive up to 100 miles for a clinical placement. If the goal of clinical education was to ready the PTA student for the workforce through real life patient care, was there another path that worked around the mounting barriers?

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The community will create the classroom” -Suzanne Reese,

Tulsa Community College

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THE IDEA

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IDEA

THE IDEA In the spring of 2008, Associate Professor Suzanne Reese was the Program Director of the Physical Therapist Assistant Program.

She was granted a sabbatical by Tulsa Community College and her sabbatical would focus on the development of a free physical therapy clinic close to the Metro Campus that would house the Physical Therapist Assistant Program.

This idea was generated by her fellow professor Jeff Hammontree, PT who was treating patients on Friday afternoons in the existing program laboratory space on the 5th floor of the Metro Campus Philips Building. This idea would also directly address the concerning trend of dwindling clinical sites available to the program.

The existing laboratory space only allowed patient-use of the facility on Friday afternoons due to class scheduling throughout the week. Plus, if the elevator was temporarily out of service or in the event of a random fire alarm, patients had to be evacuated from the 5th floor down the stairwell. A new clinic setting had to be on the ground floor. The proposed clinic would not be able to replicate a hospital or skilled nursing facility, but it would create a learning space for students to work with local residents who did not have insurance or whose insurance would no longer cover the need for continued physical therapy.

Although open to many proposed locations of this clinic, Professor Reese had her sights on the vacant car dealership across the street

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which she saw everyday outside her office window.

At the conclusion of the sabbatical, Reese provided a PowerPoint presentation to then President of TCC, Tom McKeon and the Board of Regents titled, A Business Plan for the Development of a Downtown Pro-Bono Physical Therapy Clinical Laboratory. Some of the key takeaways from the business plan were: • Student learning is the focus of the clinic • Working with real patients would create powerful experiential learning opportunities • Faculty would stay current in clinical practice by working with patients in the clinic • The clinic would provide an excellent venue for student remediation if warranted • The clinic could reduce

our clinical footprint in the community by 17% • Other allied health programs could also use the clinic for interprofessional education • The College would incur the financial burden of the clinic space and operations • There would be plenty of people wanting to be a patient in the clinic The result of the business plan, the support of Tulsa Community College administration, the Tulsa Community College Foundation and the Tulsa community, was the Nate Waters Physical Therapy Clinic. The NWPTC is a unique learning laboratory designed to serve the community with pro bono physical therapy services while facilitating optimal clinical education opportunities for TCC PTA students.

Every key takeaway from the decade old business plan was actualized during the plan’s implementation.

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N AT E W AT E R S The clinic is named after Nate Waters, a young man who overcame challenges to reach extraordinary goals and inspired the Tulsa community with his determination, passion and service to others before his death in 2013. At the age of 19, a catastrophic injury severed Waters’ spinal cord and left him as a quadriplegic. Despite his paralysis, he got his GED and his associate’s degree from TCC and eventually his bachelor’s degree from OSU.

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This clinic is a legacy for a hometown hero.”

- Thomas K. McKeon President Emeritus, Tulsa Community College

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THE SOLUTION

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SOLUTION

THE SOLUTION “A place like Nate Waters Physical Therapy Clinic puts the word ‘community’ in a community college. We always think about educating new students who will contribute to their community by becoming a knowledgeable, working professional, but another valuable aspect of service that a community college can provide is through experiential learning with community members in need.

Many of the patients of Nate Waters Clinic are lifelong Tulsans who have contributed to this community their entire lives and are now receiving much-needed assistance from the College, faculty, and students. Because of Nate Waters, community members are returning to work and other life roles they might not be able to otherwise. The Nate Waters Physical Therapy Clinic is a perfect example of the mutually beneficial partnerships that are critical to the success of the mission of the community college.”

- Dr. Leigh B. Goodson, President & CEO of Tulsa Community College

SOLUTION STEP 1: BUY IN Professor Reese first proposed the idea of a clinic to then President McKeon in 2007 as they were meeting to discuss the pending program accreditation visit.

Dr. McKeon liked the idea immediately, which laid the groundwork for the fall

2008 sabbatical and ultimate purchase of the vacant car dealership across the street. Ironically, the car dealership was purchased in October 2008 a few months prior to completion of the business plan for $762,000. At that point the project was considered one of the top three capital priorities of the College and the additional $1.2 million renovation and equipment costs would be raised

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by private donations. The fundraising efforts for the clinic moved much slower than predicted. Initial attempts to sell the naming rights of the clinic to potential donors failed. By early 2012, the College had only raised $400,000.

At that point, the Foundation reinvigorated the capitol campaign by budgeting $30,000 and hiring Hampton Creative to market and brand the fund-raising campaign.

Promotional materials and videos were developed to use as Foundation personnel approached potential donors.

Another significant boost to the fundraising campaign was a $500,000 gift to the College by the Board of Saint Francis Hospital ($300,000 allotted to the clinic) and $138,000 from the Founders of Doctor’s Hospital. With these gifts, the Foundation was ready to launch the public phase of the campaign and it coincided with the 30th Anniversary of the PTA Program. The Founders of Doctor’s Hospital gift was directly tied to Hampton Creative ideas.

They produced a very emotional video of a young mother and her daughter.

The mother was filmed explaining her gratitude to TCC for the care her daughter received by Jeff Hammontree PT and his students. She became emotional in the video and it touched the heartstrings of all who watched it. The two Foundation

members, both grandmothers, reacted favorably to the video and awarded a restricted grant to be used for any and all equipment. By the end of 2012, the College was just over $300,000 of its fundraising goal. In early 2013 a bittersweet event brought the capital campaign to a successful end - the sudden death of Nate Waters at the age of 35. Waters, a graduate of TCC and Oklahoma State University became a quadriplegic at age 19 as a result of a domestic abuse tragedy.

Upon his graduation from Oklahoma State, he worked for Williams Companies and was an active volunteer for local non-profit agencies. He was a strong advocate for the disabled and was known by thousands of people. Soon after his death, a $157,500 challenge grant issued by an anonymous donor was announced and the new physical therapy clinic would be named after Nate. The matching award money was raised in less than a month and an additional large award was gifted to the College. The Foundation had exceeded their capital campaign by $300,000 and the groundbreaking for the Nate Waters Physical Therapy Clinic at Tulsa Community College was scheduled for fall 2013.

In all, 86 individuals, foundations and organizations from the Tulsa community donated gifts from $10 to $500,000.

It was fitting that Nate Waters became the namesake of the physical therapy clinic.

While seeking his Associate’s Degree at Tulsa Community College, he was one of the program’s early patients, long before the idea of the free-standing clinic. Students would transfer him from his wheelchair to a treatment mat for range of motion exercises and stretching of tight muscles. They also helped him slowly develop enough dexterity in his hand to manipulate a computer keyboard and eventually write again. He loved being

around the students because he spent his early adult years living in a nursing home.

Nate Waters would eventually move into his own home and received numerous community honors and awards. Upon his passing, Tulsa World Community Advisory Board member, Susan Neal said, “Nate Waters was widely respected for his generous spirit and love of community.�

Even five years after his death, friends and colleagues of Nate drop by the clinic to bring a keepsake or to share a memory of time spent with Nate.

SOLUTION STEP 2: BUILD Tulsa Community College hired Selser Schaefer Architects to plan and implement the renovation of the car dealership into a beautiful building on the northeast corner of the Metro Campus.

The Physical Therapist Assistant Program faculty were involved in the design process its completion.

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the clinic was equally impressive with traditional entry steps, two wheelchair accessible ramps and a Gait Garden.

The Gait Garden includes a variety of challenging walking surfaces that allow patients to practice their balance and gait training. The original, warehouse feel was maintained in the renovation and the architect firm was awarded the 2014 AIA Eastern Oklahoma Small Commercial Architecture Citation Award for its design of the clinic building.

Existing program equipment furnished the clinic space with some additional grant funded purchases including a gait trainer/unweighing system, and a 50-foot supported ambulation system. Waiting room furnishings and furnishings related to faculty offices and the conference room were also purchased.

The original plan of 5,500 square feet was expanded to 8,500 square feet. The building houses the Physical Therapist Assistant Program, including two instructional areas (one designed as a traditional skills laboratory and one as a natural physical therapy clinic space); faculty offices, patient waiting room, secured medical records room, storage, kitchen, laundry room, student locker room, patient loaner equipment locker, two private exam rooms and a small conference room. The outside of

Another expense related to the clinic was the development of an in-house electronic medical record.

This was custom designed in the Filemaker Pro development platform.

Students can use iPad or iPhone to take videos and pictures of patients to upload into the health record. This sensitive patient information is totally secure as a geo-fencing component was also programmed into the devices that use the TCC Filemaker Pro platform. This keeps faculty and students from being able to access patient data outside the confines of the clinic building.

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The clinic is open for patient care approximately 10-12 hours per week when the campus is in session, allowing 20-25 patient slots per week. The clinic is staffed by the program faculty with the assistance of a part-time PTA who helps schedule patients and supervise students in the clinic. One faculty member is considered the lead clinic therapist and serves in the role of Clinic Coordinator, but other faculty supervise students and patients during course related clinical education activities. As the clinic is located in an urban area, the building has electronic badge access to students and faculty. There were early concerns about misconceptions that the clinic was a medical clinic and dispensed medications. To prevent walk-in traffic, the clinic doors are only opened to the public during patient treatment times.

The planned location of the clinic at the downtown campus was strategic for two reasons. One, lower socioeconomic areas of Tulsa sit immediately north of the downtown area. Potential patients without insurance benefits were more likely to live in close proximity of the clinic location. Two, downtown is the heart of the public transportation service area, including the Tulsa Transit

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Lift Program. The Lift Program is administered by ADARide, a national paratransit services company that provides door-todoor service using lift-equipped vans. Several clinic patients and their families ride the lift to the Nate Waters Physical Therapy Clinic.

SOLUTION STEP 3: EXECUTE Despite years of preparation for the clinic, there was a distinct learning curve for the faculty during the first year of operation. When the clinic doors opened, a Policies and Procedures Manual was still in draft form and there were no significant clinic-related assignments included in any of the PTA courses syllabi. The decision was made by the Clinic Coordinator to just “play� and let students and faculty explore the benefits of the community laboratory.

Individuals were referred from multiple medical and community sources and those with musculoskeletal and neurological diagnoses were the most commonly seen in the clinic, especially those with chronic neurological impairments such as traumatic brain injury and stroke. Patients scheduled to be treated by the faculty and students were allowed to help in the clinic at any time. Some did, some did

not. After the conclusion of the first year, a focus group was conducted with students who had spent many volunteer hours in the clinic. Their insights on time spent in the clinic and subsequent clinical performance out in the community demonstrated to the faculty, that students should be required to be in the clinic. Time in the clinic was embedded in every laboratory class for the following academic year. Faculty found successful learning occurred when utilizing the first two hours of lab time for the teaching of new clinical skills and the last hour with direct application of skills utilizing patients. Faculty provided direct supervision for all students during patient care times and the debrief following the session. The debriefing time was a rich dissection filled with suggestions such as improving therapistpatient rapport, nuances of documentation, treatment effectiveness, community resources, and eventual discharge planning.

Unlike traditional clinical education, faculty and community instructor feedback is provided to

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students and is not graded.

We kept an informal learning environment for students and unbeknownst to us, we had created a learning space. According to educational theorist, David Kolb, learning spaces are areas which allow for conversational learning, development of expertise, acting, reflecting, feeling and thinking. The learning space in the NWPTC allowed students to benefit from the interactions and coaching from faculty, volunteer professionals, community instructors and peers. The learning space provided by the clinic is free from time restraints, high productivity requirements, and reimbursement restrictions found in actual clinical settings. Students gain confidence working

with patients in a supportive learning environment. As a result, we have even been able to successfully remediate students who have struggled during formal clinical assignments in the community. Before the clinic opened, the faculty had to find another facility willing to work with an underperforming student. This was often a very delicate negotiation and always felt like a significant burden to place an underperforming student with volunteer clinical instructors. Now with the clinic, program faculty can assume the responsibility to remediate without calling in a favor.

Student experiences as an extension of each laboratory course and a

variety of clinic-based assignments in the NWPTC are aligned to learning in the classroom.

During a student’s first year, the NWPTC learning space resource is used for course assignments such as chart reviews, create documentation by observing treatment sessions, observation of verbal and nonverbal patient-therapist communications, and conducting interviews with patients. First year students also practice how to monitor vital signs of compromised pulmonary patients along with respiratory care personnel and assist with other data collections methods related to kinesiology.

During the second year, students practice and

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refine skills which have been taught in class, especially in therapeutic exercises courses.

Two students are assigned to each patient and they perform the treatment and appropriate documentation in the electronic medical record each week.

As therapeutic relationships with community instructors have grown over the years, they are prepared to come back and work with students for specific content modules. For instance, patients with chronic obstructive pulmonary disease come for four weeks of pulmonary rehabilitation each April, and patients with stroke come for rehabilitation in March and April.

Patients are discharged at the end of each academic semester, but many are asked to return the following semesters if they prove to be especially good at guiding and coaching students.

Over time the clinic afforded the faculty more creative uses of the clinic space.

Collaborative interprofessional learning experiences were developed. The PTA students now interface with other TCC programs such as occupational therapy assistant students and respiratory care students in patient care activities.

The clinic has also hosted community events such as fall prevention clinics, a caregiver support group, wheelchair maintenance/clean up fair, an amputee golf clinic and numerous continuing education courses.

Prior to the clinic opening, students were assigned to five outsourced clinical education experiences totaling 680 hours. Over the past four years of clinic operation, the faculty has been able to eliminate a one week clinical placement and reduced the final clinical placements by two weeks. This has subtracted 120 hours (18%) from the original curriculum design. The impact of the reduction in hours showed no negative consequences on student performance. Based on these results, the PTA program plans to eliminate one additional clinical placement starting with the 2019 cohort of students. Once implemented, this will be a 24 percent reduction of outsourced clinical education.

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R E D U C T I O N O F O U T S O U R C E D C L I N I C A L E D U C AT I O N HOURS PER STUDENT

800 700 600 500 400 300 200 100 0

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Integrated in the Curriculum

SOLUTION STEP 4: E V A L U AT E After the first year of clinic operations, we conducted a focus group of students and the response was overwhelmingly positive.

Five themes were identified: teaching in context, confidence, communication, absence of fear of failure, and PT/ PTA team interaction. Learning in context was voiced by several students. In particular, the fact that they all experienced common patients at the clinic opposed to 35 different clinic locations lead to richer classroom discussions. They also related that they were more confident and less intimidated by complicated patients. They liked getting feedback from patients, families, and faculty early in their training without the pressure of being graded.

The non-graded

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2018

At Conclusion of Didactic Curriculum

2019 Total Hours

environment of the NWPTC and the learning space approach facilitated questions of oneself, peers, and faculty.

One student stated, “We concentrate on learning opposed to fear of making mistakes; we are not making mistakes in front of our clinical instructors and potential employers; patients forgive our mistakes”.

The faculty were also impressed with the comments from area clinical instructors about the performance of the students after they had spent time in the TCC clinic. This input gave early indications that the clinic had helped students’ performance on their final clinical placement. Soon after, a more formal look at the impact of the clinical was done.

While completing her DPT from the University of New England, Professor Reese wrote a manuscript for her capstone course that was eventually published in the Journal of Physical

THE SOLUTION

Therapy Education. The Impact of a Self-contained Clinical Learning Space on a Physical Therapist Assistant Education Program was published in the September 2018 issue. This was a mixed-method program assessment of the first two years performance of the Nate Waters Physical Therapy Clinic.

Assessment methods for the manuscript included analysis of midterm student clinical performance, individual interviews of clinical faculty, group interview of students, and the impact on the community.

To measure the impact of time spent in the NWPTC on the PTA students and assess the impact of the reduced clinical hours on subsequent performance, midterm scores from the final outsourced clinical experiences for the 2015 and 2016 cohorts were compared with two preclinic cohorts (2013 and 2014). This was measured on the APTA Clinical Performance Instrument (CPI) which is a widely accepted tool used by other PTA Programs. The 2013 and 2014 cohorts had only experienced

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clinical education in community settings and had received an additional 120 clock hours of clinical education.

The midterm PTA CPI performance evaluation during the final outsourced rotation was chosen as the outcome measure. Clinical instructors score students on 20 criteria by marking a 100-mm horizontal line VAS. Students are expected to be at entry level by the end of their final clinical.

Scores were calculated by measurement of the marked VAS for each criterion. All students from the four cohorts were included in the study. Midterm assessment of the 2013 and 2014 group occurred during week 9 of 12 and the 2015 and 2016 group assessment was during week 7 of 10. Statistical significance was not found between the midterm clinical scores of the student cohorts before and after the clinic was established which means that the ultimate clinical education performance of the TCC PTA students remained consistent despite the 18% reduction in clinical contact hours.

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This building ensures his legacy. Nate was active in the community. He led by humility and gentle grace. We are going to miss him.”

- Mary Shaw Tulsa Community College Foundation

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OUTCOMES

THE OUTCOMES The impact of the Nate Waters Physical Therapy Clinic has exceeded all expectations. In just a few short years, students, faculty, community instructors (patients), clinical instructors and the community have greatly benefited from this initiative.

STUDENTS Students are immersed in the clinic in every semester through assignments and/or providing patient care. They are applying and transferring learning 50 feet away from the classroom every day. First semester students are enrolled in a clinical orientation class and are required to have five hours of observation in the NWPTC. Here are

two excerpts from a recent Blackboard Discussion Forum:

The best learning experience I had this semester was during clinical observations. I did all of my observations with the same patients so that I could visibly watch them progress and I loved every bit of it. I also enjoyed watching the second years and learning more from them. The whole experience reminded me why I want to be a PTA and pushed me to work harder in the program.�

- Samantha, student

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I totally agree about the patients. It has been so awesome to actually be a part of the progression, although we are just observing and learning.

I already feel like I’m in the world of the physical therapy family and have grown quite fond of the patients I observed which makes the anticipation of getting started with some of our own grow even more.

- Charyl, student

Clinic time at the NWPTC is more convenient and more relaxing for students.

Clinic time is planned on days students are already on campus.

Student also appreciate that the atmosphere of the clinic allows them to practice under faculty supervision before working with outsourced clinical instructors. They relate comfort with

faculty because faculty are not viewed as future employers. One student stated that once they go into the community as a PTA student, they become more reticent, reluctant to make a mistake that might jeopardize a future job opportunity.

The NWPTC saves students time and money related to clinical travel. Clinical travel has been reduced by 15 days. For students driving up to 200 miles each day this results in less money at the gas pump.

It also reduces the need for child care. Students also continue to work part time on these days which is a good thing for many of our students with financial concerns.

Most importantly students are performing well in the clinic despite the reduced

clinic time. Per the research project performed by Dr. Reese, despite the 18 percent reduction in clinical time, there was no statistically significant differences between the mid-term clinical scores of the student cohorts before and after the clinic was established. Students continue to achieve entry level by the final clinical date and an average of 96 percent of the graduates pass the licensure examination.

F A C U LT Y Faculty expressed no concern on the curriculum changes that shortened clinical education hours and relate several positive aspects of the clinic.

They like the instructional methodology provided by the clinic especially designing contextual learning activities perfectly

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co-treatments to victims of stroke or traumatic brain injury. This allows these two disciplines to work together in a highly effective manner. As described by the OTA Program Director,

aligned with the curriculum content.

For example, in Clinical Procedures I, students learn about pulmonary assessment techniques as they work with patients who suffer from Chronic Obstructive Pulmonary Disease or in Therapeutic Exercise II, they learn about stroke rehab with victims of stroke each week. This is an improvement to having classmates simulate pathologies during skills laboratories as students struggle mimicking signs and symptoms. The NWPTC also allowed students to practice both verbal and written communication under real patient care parameters. Faculty report that when visiting students during outsourced clinical assignments, they see confident students who are very good communicators. More importantly, there have been few concerns or complaints about students since the clinic inception.

The faculty have also embraced the opportunities for planned interprofessional education afforded by the clinic. The PTA students have had very unique collaborative learning experiences with other healthcare disciplines such as dental hygiene students, respiratory care students and occupational therapy assistant students. This fall was the second year that a PTA student and occupational therapy assistant (OTA) student provided

The Nate Waters Physical Therapy Clinic has provided the ideal venue for robust learning opportunities that bridge a social justice gap of services to the underserved members of the Tulsa community and program outcomes.

Occupational therapy assistant (OTA) and physical therapy assistant (PTA) students gain knowledge from each other to plan and implement comprehensive treatment plans. The OTA and PTA faculty developed out of class learning experiences that required a team of OTA and PTA students to plan and implement co-treatments. Treatment plans and therapy documentation are passed to the next team of students throughout the semester. Each student is provided an opportunity to experience real-world client treatment planning and implementation as a pre-learning activity to fieldwork experiences.

What started off as a one course/one semester assignment has evolved into an experience woven into each semester of the OTA program.

Collaborative assignments engage the student in alignment with Bloom’s Taxonomy and the OTA curriculum Pathway. Throughout this process students develop an increased understanding of professional roles, an awareness of professional overlap, team collaboration, conflict resolution and communication skills valued by community stakeholders and fieldwork educators. The TCC OTA and PTA Nate Waters Physical Therapy Clinic student learning experience is the only one of its kind in Oklahoma. These experiences catapult our students ahead in their fieldwork experiences as well as employment opportunities.

- Penny Stack, OTD, OTR/L, CLT

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COMMUNITY INSTRUCTORS Individuals receiving treatment range in age from one month to 70+ years with chronic neurological impairments as a result of traumatic brain injury, spinal cord injury, amyotrophic lateral sclerosis, and stroke predominating.

Typically these injuries require months of rehabilitation which is hard to come by even with good health insurance.

The NWPTC affords many patients up to several years of physical therapy if they are showing good progress. The PTA Program implements a patient satisfaction survey on a regular basis, which we have included in the appendix.

Faculty and students use the survey results for continuous quality improvement (CQI) learning activities each spring.

All respondents were very satisfied with the care and outcomes achieved in the Clinic and would recommend the NWPTC to others. Here are two compelling patient stories, Al Anzaldua and Alan Taylor.

Al Anzaldua came to NWPTC in January 2018 after learning of the clinic through his friend who was a TCC PTA student. Al had sustained a brain injury while serving in Afghanistan in the United States Marine Corp.

When Al arrived

to NWPTC, he utilized a manual wheelchair as his primary means of mobility.

He was able to walk about 20 feet with a cane, but because of severe discoordination of his trunk and lower extremities, he was unable to walk further without risking a fall. Al had undergone physical therapy in various places prior to NWPTC, but had yet to maximize his mobility.

When I evaluated Al, I just knew he wasn’t done progressing.

I was super excited for our students to have the opportunity to participate in returning Al to his life roles. Al had served our country, and we had an opportunity to serve him.

- Melanie Heffington,

PT, TCC PTA faculty Over the next several months, Al participated in physical therapy treatment designed to improve his coordination and enable him to walk further distances. He worked twice a week with PTA faculty and students, giving exhausting effort. By May 2018, Al was able to discontinue use of his manual wheelchair and walk with a walking stick. In August of 2018, Al stopped by the Clinic, walking unassisted by any person or device. He had returned to driving and had enrolled at TCC as a student to work

towards a history degree.

The impact of NWPTC on Al’s life is unquestionable.

I have my driver’s license again. I have a vehicle again.

I would really like to thank the therapy staff at Nate Waters and everyone who is a part of that program and who helped that program become what it is. I absolutely want to thank the students and Tulsa Community College. I mean I have my freedom again.

- Al Anzaldua,

Community Instructor Reverend Alan Taylor suffered a stroke in January 2015 while on route to serve as a minister in Brazil. The stroke left Alan with minimal use of his left side of his body. Alan had no insurance to cover the intensive rehabilitation required to maximize his function after his stroke.

I had the stroke on a Thursday and by Saturday they were talking about releasing me from the hospital on Sunday.

I had lost my income… my ability to be a dad, to be a good

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husband, to provide. We were just trying to figure out how to survive. My wife called around and found a place called Nate Waters.

I found a safe place. I’ve never met the man Nate Waters, but you can feel the heart of Nate Waters at the place. The therapist sat down with me and talked with me for over an hour. You’d be surprised that was the first time anyone had done that in three months. It was the first time anyone had given me any hope.

- Alan Taylor, Community Instructor Alan came to NWPTC in Spring of 2015.

Initially, he used a manual wheelchair as his primary means of locomotion, but was able to progress to walking community distances with a cane.

Alan has returned to preaching and even his role as an international traveling minister.

He continues to receive treatment at NWPTC for fine tuning his gait pattern and increasing his left upper extremity use. The relationship he builds with each student who participates in his care plan is invaluable. Alan is quick to encourage students and also quick to guide students with constructive feedback about their clinical skills.

As far as being in a facility with students, what I’ve received from them, the curiosity and the questions, it is what I love. Their excitement to be able to help someone. I let them know how much I appreciate them and it lets them know how great of a profession they have chosen.

- Alan Taylor,

Community Instructor

CLINICAL INSTRUCTORS In addition to positive comments on the Clinical Performance Instrument (CPI), the clinical instructors who work with TCC students frequently commend the students regarding their clinical confidence and initiative with patients. The PTA students have had so much patient contact in the NWPTC that they show no reticence with patients in area clinical facilities. As described in Dr. Reese’s manuscript, the NWPTC eliminates much of the time needed for students to feel comfortable with a new clinical setting. This allows the students to maximize their time in area clinics during subsequent off-campus clinicals.

I have had the honor of being a Clinical Instructor for nine years. The difference that Nate Waters has made on the preparation and confidence with the students is astonishing.

The students are learning so much more in regard to hands on experiences with the clinic. The ease of transitioning the students from classroom to clinicals has significantly improved, as well as the confidence to treat patients compared to the students I worked with prior to the clinic being available

- Cindi Cathey, PTA

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Competition for clinical sites with other area PTA Programs requires students to drive up to 100 miles for a clinical placement.

C O M M U N I T Y I M PA C T As we review the community impact, we take a broad view of community, to include the Tulsa community, the local physical therapy community and the national physical therapy education community.

The local community seeks rehabilitation services at the Nate Waters Physical Therapy Clinic.

Patients may self-refer but the majority of patients are referred by area hospitals, inpatient rehabilitation centers, and area health care clinics targeting the medically underserved populations such as Good Samaritan Health Services, goodsamaritanhealth. org/about and the University of Oklahoma Bedlam Clinic, ou.edu/tulsa/community_health/ locations.

The students and faculty provide approximately $125,000 of physical therapy to the community on an annual basis.

The local physical therapy community has appreciated the NWPTC as well.

It is a perfect venue for continued education and training for licensed physical therapists and physical therapist assistants. The PTA faculty have even used the venue for training current and future clinical instructors.

The national physical therapy community has also seen the value of the clinic’s educational model.

The clinic was first showcased during a competitive awards process provided by the National Council for Workforce Education, an affiliate council of the American Association of Community Colleges. In October 2016,

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the TCC PTA Program received the 2016 Exemplary Program Award, one of the criteria being the ability to replicate the program in other community colleges. In addition, in 2018, Dr. Reese received the American Physical Therapy Association Lucy Blair Service Award and the clinic success was a key part of the nomination process.

As a result of these awards, a Journal of Physical Therapy Education publication and a presentation to a national physical therapy audience, knowledge of the clinic spread. A number of faculty and administrators from other developing and existing PTA programs have visited Tulsa Community College: Cuyahoga Community CollegeCleveland, OH; Herzing University-Brookfield, WI; Cameron University-Lawton, OK; Tyler Junior CollegeTyler, TX; and Seminole State College-Seminole, OK. All of these programs expressed a strong desire to duplicate this educational model.

The Herzing University Brookfield PTA Program graduated its first class in spring 2017. From the beginning it had been a goal to give students an opportunity to provide hands-on patient care experience throughout the curriculum. I met Suzanne through CAPTE and had spoken with her about the Nate Waters PT Clinic. She welcomed me to a visit to learn more about the clinic and the operations within the PTA program. It was an inspiring visit in March 2017. From that visit I was able to create a business plan that would fit into the Herzing PTA program.

We opened our CARE Clinic door in July 2017 and it has been a fantastic teaching resource and an avenue for community service.

The acronym stands for Caring, Academic, Restorative, Engaged.

At this time, it is open twice per week in the afternoons. We have a waiting list for patients.

Although we do not offer or bill technical physical therapy services, we keep track of time and billing from an educational standpoint. Since July 2017 we estimate $38,750 worth of physical therapy treatment completed on a pro bono basis. The willingness of Suzanne and her team to share their experiences was vital to pushing our clinic forward.

- Kim DeChant, PT, Herzing University

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“I’m very thankful. Just through my life experiences, I’ve been able to turn something negative that happened to me into something positive that benefited many more people”

- Nate Waters

LESSONS

LESSONS LEARNED

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LEARNED

LESSONS LEARNED Lessons learned from the implementation of NWPTC into the TCC PTA Program are many and we are still learning. • A community will financially back an initiative if it can feel the connection between your students and the community.

When asking for financial help, plan a presentation that clearly communicates the mission. Our video of a young child with cerebral palsy receiving therapy from our faculty clearly demonstrated how a

pro bono PT clinic could significantly impact those affected by disease and disability. Be strategic in your ask. • Prepare yourself to become a part of the community and for the community to view you as a separate entity from the College.

Align your resources accordingly.

From the day the doors opened at Nate Waters, we were inundated by applications, calls, building maintenance, and security issues. In addition, becoming a physical part of the community involves navigating

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occur quicker than in years past.

Fuller, richer learning experiences such as those in NWPTC between students, patients, and program faculty illustrate content in such an impactful way- the pace of a course may speed up.

social issues such as homelessness.

Prior to NWPTC, the Program was housed securely on the 5th floor of the College campus, isolated from the social issues just outside its doors. However, once we were housed in the NWPTC on the streets of Tulsa, we were immersed in the homeless community. They made their way to our building exterior to charge their phones and sleep in our doorways; entered to use our restroom and such as they made the daily trek to the community soup kitchen just down the street. New policies and procedures related to securing the entrances had to be implemented to ensure safety and that resources intended for students and patients were not being used by others.

• Prepare faculty for unique opportunities in the implementation of curriculum and assessment.

Mastery of learning objectives may

• Complicated patients become less intimidating to students over time. Patients receiving physical therapy have increasing numbers of comorbidities that complicate their plan of care.

Exposure to these patients over time lessens the fear of students and increases critical thinking skills needed to effectively execute physical therapy treatment plans.

• Community partners and their clinical instructors will be delighted with a more prepared student entering their facilities. A Clinic like Nate Waters strengthens community clinical partnerships because it is observable and tangible how the PTA Program works towards quality improvement no matter the constraints.

• Prepare students by outlining specifically how they will participate in the clinic. In the beginning, we had an open schedule with an expectation that students would just insert themselves. However, what we quickly learned is that students don’t do optional.

Students needed structure, assignments with objectives, and a schedule to fully integrate

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themselves into the Clinic. Many of our laboratory courses begin with faculty instruction on clinical skills and end with the transfer of those skills directly to actual patients with pathologies learned that day. The community instructors (patients) exponentially impact student learning with their feedback given directly to students. It provides for great reflection by the student.

• Hospitals may be big donors. Three of the four major Tulsa hospital foundations gave major gifts as they were seeking a place for their patients to go for extended rehab once the patients’ insurance benefits ran out.

• For-profit physical therapy departments will be concerned that the pro bono clinical will siphon off their paying customers.

Be prepared to assure them that only those patients without benefits will be seen in the clinic.

• Measure everything.

Data related to academic and clinical faculty, patient progress, non-billed treatment charges, and student learning is important information to have for your stakeholders. We captured some early student related data but could have benefited from more strategic assessment planning once the clinic doors opened. We were surprised by its impact.

In addition to lessons learned, we want to acknowledge that we are still learning.

The Clinic provides a blank canvas for many new initiatives and future planning.

Faculty can be as creative as they want providing unique learning experiences for our students. Future plans include, adding volunteer physical therapy master clinicians from the community to complement the expertise of the faculty.

Also, we are hosting two continuing education events this year, combining

students and clinicians to expand our role as a hub for education post-graduation.

Plus, based on student outcome data, we plan to reduce outsourced clinical placements and clinical hours again to the required minimum of 520 hours (24%) for the 2019 cohort.

The Mission of our clinic is to provide clinical and research experiences through a structured model of mentor relationships by faculty, community partners and community volunteers, by which students gain knowledge, skill, and confidence while fostering professional behaviors and practices.

Thus promoting the exchange of information and provision of physical therapy through the community. Our mission continues with much evidence of success. However, as a work force development program, perhaps the most valuable aspect of the Nate Waters PT Clinic is its legacy of students transitioning into skilled clinicians who touch those affected by disease and disability by lightening their burden.

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APPENDIX

THE BARRIERS

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TCC NATE WATERS PHYSICAL THERAPY CLINIC

CLINICAL ROTATION AGREEMENT Between <<<FACILITY NAME>>> And TULSA COMMUNITY COLLEGE

THIS AGREEMENT is made and entered into between TULSA COMMUNITY COLLEGE (the “College”), and <<<FACILITY NAME>>> (the “Facility”) and its entities.

1. Clinical Rotations. The College shall arrange clinical rotation experience (“Clinical Rotations”) for Nursing and Allied Health students (“Health Sciences Students”) at the Facility. The College and the Facility shall mutually determine the scope of the Clinical Rotation programs, the schedule of student assignments and the number of Students who may participate in the Clinical Rotations.

2. Term. The term of this Clinical Affiliate Agreement shall be for the period of three (3) years, commencing July 1, 2018, and ending June 30, 2021, unless terminated earlier as provided in this Agreement. After the initial term, this Agreement shall continue in effect for additional periods of one year each unless one party notifies the other at least 90 days prior to the end of the initial term or any extended term of its intent to terminate this Agreement at the end of such term, in which event this Agreement shall terminate at the end of the then-current term. However, notification by a party of its intent not to renew shall not affect students currently enrolled and participating in Clinical Rotations.

3. Responsibilities of the College. a. If Clinical Instructors or Instructors do not accompany Students to the Facility for Clinical Rotations, or do not participate in the clinical rotations, then any part of this agreement referring to “Clinical Instructors” or “Instructors” shall apply to Students only. b.The College shall designate a College employee or another individual retained by the College (the “Clinical Instructor”) to serve as the coordinator for the Clinical Rotations to work directly with Facility personnel and coordinate all the activities of Students. c. The College shall designate one or more of its instructors or faculty members (“Instructors”) to instruct and supervise Students during the Clinical Rotations. d.The College shall provide a roster of the names of the Clinical Instructor, Instructors and Students (the “Roster”), along with a rotation schedule, to the Facility before the Clinical Rotations begin.

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e. For each Student and on-site Clinical Instructor who will participate in the Clinical Rotations, the College shall provide to the Facility verification of the following immunizations and tests: (i) verification that immunity requirements are met and supported by documentation for Mumps, Rubella, Rubeola, (MMR) and Varicella in accordance with CDC recommendations; (ii) Hepatitis B vaccination series (series of three or waiver); (iii) TB test within the past 12 months, and when results are positive, verification of supporting documentation for a chest x-ray and then annual medical evaluations to screen for TB symptoms, reflecting no evidence of TB disease; (iv) Tdap adult booster; and (v) annual flu shot or signed declination. f. College will have a 10 panel drug screen and comprehensive national criminal background check run on each health sciences student prior to their first clinical rotation and a 10 panel drug screen and national background check on each on-site Clinical Instructor. The comprehensive criminal background check will include the following: (i) 7 year criminal history for each county of residence; (ii) National sexual offender registry check; (iii) Social security verification; (iv) Residency history; (v) Nationwide Criminal Records Database Search; (vi) National Wants and Warrants Search; (vii) National Healthcare Fraud and Abuse Scan (FACIS III: OIG/GSA); and (viii) OFAC/FBI Terrorist List Check. The College agrees not to refer any student/instructor with a job-related adverse finding on his/her criminal background check, and will contact the facility to discuss questionable background checks, in order to ensure the student’s/instructor’s eligibility to participate in the rotation. g.The College shall require that each Student and on-site Clinical Instructor before beginning the Clinical Rotations have current American Heart Association Healthcare Provider CPR certification that meets standards acceptable to the Facility. h. The College shall provide the Clinical Instructor, Instructors and Students with training on the Facility’s policies and procedures with respect to protected health information that is necessary and appropriate for them to carry out the activities contemplated by this Agreement as required by applicable provisions of the Health Information Portability and Accountability Act of 1996 and regulations. i. The College shall ensure that the Students have been trained in applicable CDC and OSHA regulations concerning “Occupational Exposure to Blood borne Pathogens”, including training information about Blood Borne Diseases/Universal Precautions, Exposure Control Plan and Hazardous Communication Program, prior to the assignment to the Facility. j. The College shall instruct Students that they are not permitted to perform any of the following: (i) accept orders from physicians or other health care professionals in person or by telephone or to directly call a physician or physician’s office to obtain an order; (ii) double-check on medications or blood products; or (iii) begin or discontinue blood products, chemotherapy, or experimental drugs and therapies. k.The College shall require Students to have transportation to and from the Facility, to arrive and depart promptly, and to park in areas designated by the Facility.

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l. The College shall be responsible for all actions, activities and affairs of Students, the Clinical Instructor and all Instructors during the Clinical Rotations to the extent required by law. m. The College shall be responsible for planning and implementing the educational program, including administration, programming, curriculum content, books and materials, faculty appointments, eligibility and admission criteria, Student selection, matriculation, promotion, graduation, Student performance evaluation, Instructor performance evaluation, references and all academic aspects of the Clinical Rotation programs.

4. Responsibilities of the Facility. a. The Facility shall designate a Facility employee to serve as its coordinator (the “Facility Coordinator”) for the Clinical Rotations and to work directly with the Clinical Instructor and Instructors to plan and coordinate the Clinical Rotations. The Facility may also designate one or more employees to serve as Clinical Instructors. b.The Facility shall provide the Clinical Instructor with copies of the Facility’s policies, rules, regulations and procedures that are applicable to Students’ and Instructors’ participation in the Clinical Rotations. c. The Facility shall provide an orientation to the Clinical Instructor that includes a tour of the Facility, addresses any facilities or procedures of a particular Facility department pertinent to the Clinical Rotations, and may include the receipt, completion and return of the Facility’s Orientation packet. d.The Facility shall permit Students and Instructors to assist in the provision of allied health care services to Facility patients, (for which the students have been prepared academically), but the Facility may restrict their activities, including any patient care activities, at the Facility. e. The Facility shall provide parking in designated areas for Students and Instructors. f. The Facility shall permit the College and its accreditation agencies to visit, tour, and inspect the Facility’s facilities and records relating to the Clinical Rotations on reasonable notice during the Facility administration’s regular business hours, subject to requirements of patient confidentiality, legal compliance requirements of the Facility, and minimizing disruption or interference with Facility operations, including patient care activities. g. The Facility shall make its classrooms, conference rooms and library facilities available to the College for the Clinical Rotations, without charge, subject to availability and Facility policies regarding use of its facilities. h. The Facility shall make available emergency care and treatment to Students and Instructors, as necessary, which may include an Emergency Room setting in a hospital environment or a 911 notification for other facilities. The Students and Instructors will be responsible for any charges incurred for the emergency care and treatment.

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i. The Facility shall not consider College faculty and Students employees of the Facility during scheduled clinical rotations. Students will not be monetarily or otherwise compensated in any way for their time spent in the clinical education practicum. j. Facilities that are designated as â&#x20AC;&#x153;Nursing Homeâ&#x20AC;? Facilities and/or other Long Term Care facilities regulated by the Oklahoma State Department of Health shall agree to submit a copy of their annual report to the appropriate TCC contact, evidencing satisfactory licensure by the OSDH, as a requirement for CNA student participation in clinical rotations.

5. Conflicts and Removal of Students or Instructors. If a conflict arises between an employee of the Facility, on the one hand, and an Instructor or Student, on the other, the Clinical Instructor and Facility Coordinator shall intervene in an attempt to resolve the matter. The Facility may require that the College immediately remove a Student or Instructor from a Clinical Rotation when the Facility believes that the individual exhibits inappropriate behavior, is disruptive, does not comply with Facility rules or policies, or poses a threat to the health, safety or welfare of a patient, employee or any other person. In addition, upon receipt of the Roster or at any time after a Clinical Rotation begins, the Facility may refuse to allow any Student or Instructor to participate in the Clinical Rotation if the individual has an unfavorable record with the Facility from previous employment, another clinical rotation, or any other reason.

6. Representations and Warranties of the College. The College represents and warrants to, and covenants with, the Facility as follows: a. Each Student is currently enrolled at the College. Students who are under 18 years of age have obtained written permission of a parent or guardian to participate in the Clinical Rotation; if the Student is an emancipated minor, then the Student has furnished written authorization to participate in the Clinical Rotation. b.Students are required to wear uniforms with name badges issued by the College, be well-groomed and make a neat appearance while at the Facility. c. A Student may perform duties and procedures for which he or she has been prepared academically, but not any others. The College shall continuously monitor and evaluate the competence and performance of each Student and shall remove from a Clinical Rotation any Student who is not competent or qualified to participate in the Clinical Rotation. d. The Instructors are duly licensed to practice in Oklahoma; the license of each Instructor is unrestricted; and each Instructor must keep his or her license current, in good standing and unrestricted during the entire term of this Agreement. e. The Instructors are experienced, qualified and currently competent to provide the services that are required of them for the Clinical Rotations and any services required of them under this Agreement.

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f. The College, Instructors and Students have received training on the facility’s policies and procedures with respect to protected health information that is necessary and appropriate for them to carry out the activities contemplated by this Agreement as required by applicable provisions of the Health Information Portability and Accountability Act of 1996. g. The College has not been excluded, debarred, or otherwise made ineligible to participate in any federal healthcare program as defined in 42 USC § 1320a-7b(f). h. All information that has been furnished to the Facility concerning the College, Students and Instructors is true and correct in all respects. i. All representations and warranties in this Agreement shall remain true and correct during the term of this Agreement. If any of the representations and warranties becomes inaccurate in any way, the College shall immediately notify the Facility.

7. Employees of the College. Other than any Facility employee designated as an Instructor as permitted in this Agreement, the College, and not the Facility, is the employer of the Instructors and Clinical Instructors. The College shall be responsible for (a) the compensation and benefits payable and made available to the Instructors and Clinical Instructors, and (b) withholding any applicable federal and state taxes and other payroll deductions as required by law.

8. Insurance Coverage for State-Operated Institutions. a. This provision is applicable to Colleges that are owned and operated by the State of Oklahoma. The College represents that it and its faculty are self-insured according to the Oklahoma Governmental Tort Claims Act. The College agrees to furnish verification of professional liability insurance covering the participating Students. The Facility shall maintain insurance in amounts sufficient to cover its responsibilities under this Agreement. During the term of this Agreement, the College shall require Students to maintain, and each Student shall continuously maintain professional liability insurance in the minimum amount of $1,000,000 per occurrence and $5,000,000 in the aggregate, and with such coverages as may be acceptable to the Facility. The College shall arrange for the Students to provide a certificate of insurance to the Facility evidencing such coverage and shall notify the Facility immediately if any adverse change in coverage occurs for any reason. The policies shall provide that they may not be cancelled or terminated without giving the Facility at least 30 days advance notice of cancellation or termination. b. The College affirms that its employees and agents who will be on the Facility’s property and acting in accordance with this agreement are covered by the College’s Workers Compensation Insurance as required by law and shall in no event be entitled to any such coverage from the Facility.

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9. Termination.a. Termination for Cause. The Facility may immediately terminate this Agreement for cause upon notice to the College upon the occurrence of any of the following events: (i) the failure of the College to maintain insurance coverage as required by this Agreement; or (ii) the College fails to bar a Student from participating in a Clinical Rotation after the Facility has informed the College to remove a Student for reasons permitted under this Agreement; or (iii) College fails to provide the information requested in this Agreement on Instructors and/or Students prior to the beginning of a Studentâ&#x20AC;&#x2122;s Rotation(s). b. Termination for Material Breach. If either party defaults by the failure to comply in all material respects with the terms of this Agreement, the other party may terminate this Agreement by giving at least 30 days prior written notice to the defaulting party, specifying in reasonable detail the nature of the default, unless the defaulting party remedies the default within the 30 day period. This provision shall not constitute an election of remedies by either party, and each party shall have and retain all rights and remedies that may be available at law or in equity in the event of breach or default by the other party.

10. Responsibility for Actions. Each party shall be responsible for its own acts and omissions and the acts and omissions of its employees, officers, directors and affiliates. A party shall not be liable for any claims, demands, actions, costs, expenses and liabilities, including reasonable attorneysâ&#x20AC;&#x2122; fees, which may arise in connection with the failure of the other party or its employees, officers, directors, or agents to perform any of their obligations under this Agreement. If the College is an agency or institution of the State of Oklahoma, the Collegeâ&#x20AC;&#x2122;s liability shall be governed by the Oklahoma Governmental Tort Claims Act. 11. Disclaimer of Intent to Become Partners. The Facility and the College shall not by virtue of this Agreement be deemed to be partners or joint venturers. Neither party shall incur any financial obligation on behalf of the other.

12. Notices. Any and all notices, consents or other communications by one party intended for the other shall be deemed to have been properly given if in writing and personally delivered, transmitted by electronic means, or deposited in the United States first class mails, postpaid, to the addresses or numbers set forth below the signatures of the parties.

13. Confidentiality. The College shall, and the College must require Clinical Instructors, Instructors and Students to keep confidential and not divulge to anyone else any of the proprietary, confidential information of the Facility, including patient information, unless such information (a) is or becomes generally available to the public other than as a result of disclosure by the College or any of the Students, or (b) is required to be disclosed by law or by a judicial, administrative or regulatory authority. The College, Clinical Instructors, Instructors and Students shall not use such information except as required to provide patient care services in the Clinical Rotations.

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14. HIPAA Compliance. a. The College must, and the College shall require the Clinical Instructors, Instructors and Students to, appropriately safeguard the protected health information of patients, in accordance with applicable provisions of the Health Insurance Portability and Accountability Act of 1996, as it may be amended from time to time (“HIPAA”) and applicable law. Instructors and Students may use and disclose protected health information solely for the education and treatment purposes contemplated by this Agreement. b.With respect to information obtained or received from the Facility, the College shall: (i) not use or further disclose the information other than as permitted or required by this Agreement or as required by law; (ii) use appropriate safeguards to prevent use or disclosure of the information other than as provided for by this Agreement; (iii) report to the Facility any use or disclosure of the information not provided for by this Agreement of which the College becomes aware; and (iv) require that any agents, including a subcontractor, to whom the College provides protected health information received from, or created or received by the College on behalf of, the Facility agrees to the same restrictions and conditions that apply to the Facility with respect to such information.

15. Compliance. The Clinical Instructors, Instructors and Students have been screened against the United States Department of Health and Human Services/Office of Inspector General List of Excluded Individuals/Entities (available through the Internet at http://www.oig.hhs.gov), and the General Services Administration ’s List of Parties Excluded from Federal Programs (available through the Internet at http://www.epls.gov) (collectively, the “Exclusion Lists”) and neither the School nor any Clinical Instructor, Instructor or Student has been excluded, debarred, suspended or otherwise ineligible to participate in any Federal healthcare program, as defined in 42 U.S.C. § 1320a-7b(f), or has been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but has not yet been excluded, debarred, suspended, or otherwise declared ineligible (each, an “Ineligible Person”). The School represents and warrants that if at any time during the term of this Agreement the School or any Clinical Instructors, Instructors or Students becomes an Ineligible Person or is threatened with becoming an Ineligible Person, School shall immediately notify System of same.

16. Change in Control. Should any change of control of Facility or College take place, either party shall have the right to terminate this Agreement upon written notice by Facility or College to the other that such change of control has taken place, or upon receipt of either party or other definitive information reflective of any such change in control. For purposes of this Agreement, a “change in control” of facility of College shall be deemed to have occurred to the extent there is a change in ownership and/or control over ten percent (10%) or more of the aggregate membership interests in Facility or College.

17. Rights in Property. All supplies, fiscal records, patient charts, patient records, medical records, X-rays, computer-generated reports, pharmaceutical supplies, drugs, drug samples, memoranda, correspondence, instruments, equipment, furnishings, accounts and contracts of the Facility, along with all like property, shall remain the sole property of the Facility.

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18. Non-Discrimination. Except to the extent permitted by law, the Facility, the College, Instructors and Students shall not discriminate on the basis of race, color, creed, sex, age, religion, national origin, disability or veteran’s status in the performance of this Agreement. As applicable to the College, the provisions of Executive Order 11246, as amended by EO 11375 and EO 11141 and as supplemented in Department of Labor regulations (41 CFR Part 60 et. Seq.) are incorporated into this Agreement and must be included in any subcontracts awarded involving this Agreement. The College represents that, except as permitted by law, all services are provided without discrimination on the basis of, race, color, creed, sex, age, religion, national origin, disability or veteran’s status; that it does not maintain nor provide for its employees any segregated facilities, nor will the College permit its employees to perform their services at any location where segregated facilities are maintained. In addition, the College agrees to comply with Section 504 of the Rehabilitation Act and the Vietnam Era Veteran’s Assistance Act of 1974, 38 U.S.C. Section 4212.

19. Facility Policies and Procedures. The College shall, and the College must require Instructors and Students to, comply with the policies, rules, and regulations of the Facility as provided to the College by the Facility.

20. Severability. The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision.

21. No Assignment. Neither party may assign its rights or delegate its duties under this Agreement without the prior written consent of the other.

22. Binding Effect. This Agreement shall be binding upon, and shall inure to the benefit of, the parties and their respective legal representatives, successors and permitted assigns.

23. Governing Law. This Agreement shall be governed by, and construed in accordance with, the laws of the State of Oklahoma. Any action arising out of or relating to this agreement or to its breach shall be brought only in the federal or state courts sitting in Tulsa County, Oklahoma, and both parties submit to the exclusive jurisdiction of such courts. Nothing contained herein shall constitute a waiver by Tulsa Community College of sovereign immunity or of immunity or benefits afforded by the Eleventh Amendment to the constitution of the United States of America.

24. Rights Cumulative; No Waiver. No right or remedy conferred in this Agreement upon or reserved to the Facility is intended to be exclusive of any other right or remedy. Each and every right and remedy shall be cumulative and in addition to any other right or remedy provided in this Agreement. The failure by either the Facility or the College to insist upon the strict observance or performance of any of the provisions of this Agreement or to exercise any right or remedy shall not impair any such right or remedy or be construed as a waiver or relinquishment with respect to subsequent defaults.

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25. No Third-Party Beneficiaries. This Agreement is not intended to confer any right or benefit upon, or permit enforcement of any provision by, anyone other than the parties to this Agreement.

26. Entire Agreement. This Agreement constitutes the entire understanding and agreement of the parties with respect to its subject matter and cannot be changed or modified except by another agreement in writing signed by the parties.

IN WITNESS WHEREOF, the parties have executed this Agreement on the day and year first above written.

COLLEGE TULSA COMMUNITY COLLEGE By_______________________________________ ________________________ Angela Sivadon, Ph.D., RN, RCIS Date Dean, School of Nursing Address: Tulsa Community College-Metro Campus 909 South Boston Avenue, MP 458 Tulsa, Oklahoma 74119 Phone: 918-595-7075 Email: angela.sivadon@tulsacc.edu FACILITY <<<FACILITY NAME>>> List of Entities Covered: Signature: Date: Title: Print Name: Address: County: Phone: Fax: Email:

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BARRIERS: MEDICARE LETTER

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November 16, 2018 • • • • •

APTA Update on Use of Students in Hospitals APTE CSM Programming Schedule at a Glance ELC Keynote Address recording GAMER dates announced: November 14-17 FDW (July 11-14) and Mid Career Workshop (August 1-3) - Save the Dates

APTA Update Regarding the Use of Students in Hospitals On a Medicare Learning Network event entitled Inpatient Rehab Facilities (IRF) Payment and Coverage Policies: FY 2019 Final Rule hosted on Thursday, November 15 by the Centers for Medicare & Medicaid Services (CMS), a number of questions were posed to CMS officials about whether student services can count towards the three-hour rule/intensity of therapy services requirement in the IRF setting. CMS clarified that students are not qualified providers of skilled rehabilitation services; however, CMS did not offer additional details on student supervision requirements that allow students to participate in clinical education and training.

AOTA, APTA and ASHA have posted a statement in response to yesterday’s call by CMS -please see attached document.

Please note: the official transcript from yesterday’s call should be released by CMS in the near future. Once it is released, APTA will alert stakeholders and provide a copy. This written confirmation of statements made by CMS officials will validate CMS’ intent and policy interpretation. MID-CAREER FACULTY DEVELOPMENT WORKSHOP

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MAP OF AREA PROGRAMS

THE PLAN

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THE PLAN: PATIENT INTAKE FORM

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THE LEARNING & ASSESSMENT

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LEARNING & ASSESSMENT: STUDENT OUTCOMES

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LEARNING & ASSESSMENT: EXAMPLES OF LEARNING ACTIVITIES

EXAMPLES OF LEARNING ACTIVITIES

Clinical Orientation 1st Semester • Observe 5 hours of patient care • While observing patient-therapist communication, identify examples of of verbal and non-verbal methods • Using the electronic medical record, do a chart retrieval on one of the clinic patients

Therapeutic Exercise I 3rd Semester • Perform therapeutic exercises and data collection on the clinic patients following the plan of care developed by the PTA • Perform treatment documentation for each treatment session

Kinesiology for PTAs 2nd Semester • With your lab partner, perform data collection to include manual muscle testing and goniometric measurement on one of the patients in the clinic

Therapeutic Exercise I 4th Semester • Perform therapeutic exercises and data collection on the clinic patients following the plan of care developed by the PTA • Perform treatment documentation for each treatment session

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THE AWARDS

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THE AWARDS

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National Council for Workforce Education (NCWE) Award Each year, NCWE recognizes two colleges with our Exemplary Program Awards in two categories: Credit Workforce Development Program and Noncredit Workforce Development Program. Award recipients are chosen based on five application criteria: executive summary, description of partnerships and collaborations, potential economic impact, program results, and replication. The Applicantâ&#x20AC;&#x2122;s college must be a member of NCWE. American Physical Therapy Association Lucy Blair Service Award The Lucy Blair Service Award honors physical therapist members or physical therapist life members whose contributions to APTA are of exceptional quality. Qualifying contributions can pertain to association components, through work on appointed or elected positions and/or in other capacities at the association and component levels.

AIA Eastern Oklahoma Design Excellence Award AIA Easten Oklahoma Design Excellence Award honors the best work by Eastern Oklahoma architecture firms.

F.A. Davis Award for Outstanding Physical Therapist Assistant Educator The F.A. Davis Award for Outstanding Physical Therapist Assistant Educator recognizes physical therapist assistant student educators who have demonstrated and exhibited a noteworthy level of commitment to physical therapy education, physical therapist assistant students, and in advancing, promoting, and upholding standards of academic excellence.