The following true story illustrates how professional complacency, combined with political apathy can result in a near-loss of a practice niche and a private practice.
In recent years, industrial rehabilitation has become a specialty area for OTs, and they practice mostly in clinics that provide work conditioning, work hardening and functional capacity evaluations or in corporations, where they may hold positions such as occupational safety coordinator.
The therapists in either type of setting frequently have contact with rehabilitation or vocational rehabilitation counselors who are responsible for coordinating services and return-to-work plans for clients receiving workers' compensation benefits. Most of these counselors have educations in either nursing or vocational rehab. They have a professional association analogous to AOTA .
Within the association are commissions designed to certify people from differing but relevant backgrounds, such as the Commission for Rehabilitation Counselor Certification (CRCC) and the Commission for Certified Disability Management Specialists (CDMSC). Until 1996, this credential was known as "certified Insurance rehabilitation specialist"- CIRS. The name was changed to provide a more accurate reflection of the skills of certificants, as well as the nature of their relationship with the insurance industry.
Each commission has a certification examination, with specific criteria of education and work experience to determine eligibility to take the exam. Analogous processes exist for a related credential, the certified registered rehabilitation nurse (CRRN), which is granted by the Association of Rehabilitation Nursing (ARN).
Although analysis of the educational and experience requirements suggest otherwise, it can be difficult, if not impossible, for an OT to be considered eligible by CRCC or CDMSC for either the CRC or CDMS examination.
A small group of OTs in Minnesota discovered this dilemma when the Minnesota Department of Labor and Industry (MNDOLI) revised the workers' compensation rules about credentials necessary to be certified in Minnesota as qualified rehabilitation consultants (QRCs). QRCs are the professionals designated in the Minnesota, workers' compensation statutes to provide vocational rehabilitation services to injured workers meeting certain criteria.
When QRCs were "created" by MNDOLI in 1979 as part of workers' compensation reform, the criteria to obtain certification as a QRC specifically included occupational therapy as a relevant educational background. In 1986, however, MNDOLI decided to transfer a major portion of its certification responsibility.
Effective in 1987, all current QRCs in Minnesota had to obtain CRC, CIRS or CRRN by the end of 1992 in order to be able to continue to practice as a QRC; and all applicants for QRC Intern (analogous to level-II fieldwork for occupational therapy) had to show proof that they were eligible to sit for one of the exams within two years of receiving QRC-intern status. MNDOLI did not realize that this new credentialing process would eliminate a profession from the ranks of QRCs.
I became a QRC-intern in 1984 and became a self-employed QRC in 1987. I determined by reviewing the CRCC and CIRSC guidelines that CRC appeared to be the certification most relevant to my actual responsibilities as a QRC. At the time of the MNDOLI rule change, a person could sit for the CRC exam if s/he had a bachelor's degree in a relevant field, with seven years' work experience in a relevant field. Access for bachelor's level applicants would be eliminated in 1992.
My QRC license period was such that I had to apply for the "last chance" CRC exam just 4 months short of reaching my seven years of experience. To round out those four months, I had to quote my last pre-QRC job experience, in which I had provided occupational therapy services in a program designed to increase the employability of developmentally delayed adults. This occupational therapy position involved many of the same responsibilities and tasks as my job as a QRC. This job had been so non-traditional that my contract agency had not known how to supervise me, much less bill for my services.
Much to my dismay, CRCC rejected my application, stating "supportive documentation indicates that the activities performed reflect OT activities, not rehabilitation counselor activities as defined by CRCC." I appealed, describing how, in fact, my services to the DD program fit CRCC's definitions, but I received an exact replica of the original rejection letter in response.
Luckily, I did have enough years as a QRC to qualify for the CIRS exam without needing to cite any occupational therapy work experience. However, several other OTs had entered the QRC niche after me, and were told by CIRSC when their applications were rejected that "OTs don't know anything about rehabilitation" and "OTs don't deal with insurance." One of my OT/QRC friends reported to me that when she phoned CIRSC in an attempt to clarify the relevance of her OT experience, she was told that if the application reviewers see "occupational therapy" anywhere on the application materials, the application is automatically rejected without detailed review.
This was especially shocking news in light of the fact that "OT" was one of the educational choices on the application form.
I obtained my CIRS and so was safe under the new QRC rules, but I was incensed at the close call, not to mention the fact that my friends would lose their QRC jobs, and no OT could become a QRC in the future. This complacent, apolitical, apathetic OT was now "loaded for bear." I decided to mount a campaign to change the MNDOLI rules so that occupational Therapy could be made exempt from the CIRSC certification path to QRC.
* OTs were the original rehabilitation counselors;
* OTs have their own rigorous training and credentialing process; and
* OTs have more training and experience relevant to controlling workers' compensation costs and developing effective return-to-work plans than any other profession. I proposed two possible revisions to the MNDOLI rules. I also asked for a meeting to discuss the issues in more detail.
I sent a copy of this letter to AOTA's practice division and received a large pile of information intended to support our position. I say "intended" because I was struck by the fact that all of the materials focused on OT as a clinical, direct-treatment service, with no mention of OT as a consultant or case manager. This rigidity was a major contributor to our predicament in the first place: MNDOLI knows OTs in only one context. I wrote back to AOTA expressing this concern, and received the document "OT as Case Manager."
Unfortunately for our campaign, this document perpetuated the myth that OTs function only within institutions, not as independent, "external" case managers.
Meanwhile, I went into my network to create a task force, and when the meeting date was set, for January 1992, the MNDOLI group would face:
* three OTR/QRCs who had been rejected by CIRS and CRC, and who had been COTAs before acquiring the additional training for OTR;
* one OTR who had abandoned her QRC internship when she found out CRC and CIRS would not accept her OT experience and she would not have time to acquire enough QRC experience before the 1992 deadline;
* one OTR who had been an instructor at a local OT school and neared completion of a master's in rehabilitation counseling;
* one OTR who had acquired CRC by being a QRC for seven years, and who was a manager at a QRC firm. She was concerned that her firm could no longer recruit OTRs to be QRCs due to the unexpected constraints.
At a follow-up meeting in April 1992, the task force made two statements that MNDOLI characterized as "bombs in our lap":
* that OTRs are better-equipped to effect return to work with the same employer, and
* that to prevent OTRs from becoming QRCs would deprive employers and injured workers of access to the professionals most likely to provide them with comprehensive services in the areas of injury prevention and ergonomics, adjustment to disability, restoration of function, and accommodation and compliance with ADA.
These statements were supported by the results of MNDOLI's own survey of QRCs, where the majority of respondents had identified "job analysis" and "job modification" as the areas in which they needed the most extra training.
MNDOLI acknowledged that workers' compensation is supposed to be a service that benefits both injured workers and employers, not the providers within the system. Therefore, OTR/QRCs as providers of services that highly benefit both employers and injured workers is a concept MNDOLI could not afford to ignore.
The task force's efforts resulted in a compromise: MNDOLI agreed to re-write the rules to state that OTRs meeting AOTA's standards for Case Manager (five years' experience as an OTR) could become QRCs without having to obtain either CRC or CIRS. But OTRs were now required to have more experience in order to become QRCs than members of other professions with less relevant or extensive training do.
Language incorporating this compromise appeared in the new rules written in the summer of 1992.
Former QRCs who couldn't take or pass the exams could re-enter the arena;
Anyone with good marketing skills, claiming to be "injury prevention specialist," "ergonomics expert" or "disability management expert" could deliver services only so recently highly regulated.
The law changes created a historic event in Minnesota: rival factions of rehab providers joined together as an ad hoc special interest group called United Rehab Associates of Minnesota (URAM). They hired a lawyer to challenge the new laws and rules as depriving injured workers of rights to appropriate and timely rehab services. I had to renew the battle for OT inclusion when, in combing through the new rules during strategy meetings, several QRCs questioned the addition of OTRs to the list of professions eligible to become QRCs.
When I approached these dissenters to dispel the mythology providing the context for their objections, I was informed that the subject would be dropped. URAM members knew me as a competent QRC who happened to be an OTR. My "colleagues" still believed that OTRs did not belong in this niche.
* We found out about the problem during a rule-change period; therefore MNDOLI was in a position to take us seriously.
* MNDOLI officials were well acquainted with several of the task force members through their activities in the QRC community. For example, I had been active on several MNDOLI/Rehab and Medical Affairs-sponsored committees. MNDOLI had thus developed positive, personal relationships with us.
* The MNDOLI/RMA director had, in his early career, worked in the vocational rehab department of a rehab facility, and therefore had gained first-hand knowledge of the relevance of OT to return-to-work.
* As a member of the Minnesota Association of Rehab Providers (MARP) and one of the founding members of the MARP Peer Review Committee, I had became well-known as a competent colleague to rehab counselors and nurses who would otherwise have dismissed my OT training.
* QRCs had been a mandated service in Minnesota for 12 years; therefore, there were plenty of statistics on which to build our case.
To protect individual career choices, as well as the potential for us to change the way we use our OT training, every OT needs to be able to articulate his/her "transferable skills." We analyze our clients' transferable skills all the time when developing goals and intervention plans, and we need to do the same for ourselves. Each of us needs to devote some time and attention to the ways in which other professions are entering our practice niches.
We each need to become members, whenever possible, of professional organizations that support services compatible with (and possibly challenging of) our training and expertise.
Having a foot in the rehab counselors' door literally saved my business.
No matter how high or low a profile and individual's personality style allows, each of us needs to find a way to speak up for the value of occupational therapy in human lives.
Not all activism on behalf of OT occurs at the national or organizational level, and each of us needs to be alert for opportunities in our own small spheres of influence. Don't wait for a "near-miss" to light your activist fire. Timing could be everything.
© Copyright 1998 Allie Hafez /Vital Link Consulting
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