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IntroductionAs OTs throughout the U.S. worry about the future of the profession of OT in the face of managed care and the Balanced Budget Amendments, there have been lively discussions on the international listserves for OTs on how to improve/increase the recognition of OT as a unique and vital service within healthcare and wellness services. As a Disability Case Manager (DCM), I see and hear a variety of OT documentation formats and communication styles; and I am concerned about how few OTs use vocabulary - written or spoken - that identifies the occupations and occupational goals of the people whom they serve. I offered my perspective and expressed my concerns by commenting on a posting made to the listserve. The following article is a summary of my position on this subject.
It has been argued that our skill as OTs is always seeing the function as the bottom line. However, I consider "function" to be a level below "occupation" in the "hierarchy" of human existence, and as such, a type of "component of occupation." That is, a person can have difficulties with any combination of functional (performance) areas, and it's these functional difficulties that might affect the ability to engage in occupation. As OTs well know, functional limitations don't necessarily interfere with occupation (and, from my perspective, it's the intrinsic purpose of OT to minimize, if not eliminate, the effects on occupation of functional limitations): thus the difference between "disability" and "handicap." I have many functional limitations, but they don't really affect my occupations, as I have adjusted my occupational priorities and options to accommodate my functional limitations. Thus, from a case management perspective, I might be considered a candidate for medication and/or passive modalities to manage my symptoms, but not for OT.
The listserve had a discussion along these lines when the thread-subject was the relevance of Functional Capacities Evaluations (FCEs) to determining what people can actually do occupationally. I don't believe OTs have done a good job of distinguishing between "function" and "occupation" - either among ourselves, or to "outsiders," and that this lack of distinction has contributed to the mass hysteria about PTs' "stealing OT thunder."
Once a distinction has been made between "function" and "occupation," OTs should strive to provide occupationally relevant documentation. By talking about "functional" goals without providing the occupational application/context of goal achievement, OTs do not look/sound any different than PTs or any other discipline (including Case Managers - CMs) for whom "function" or "functional" is a buzzword.
Consider a goal such as: "Mrs. X will learn 10 strategies for managing her anxiety/stress over the next 2 months. She will choose and implement one strategy independently at home." Without saying what occupational performance(s) will be enhanced by successful implementation of any of the strategies, how can Mrs. X's "learning" be measured or observed? For example, some time ago, Jane Sorensen posted how she obtained a physician's prescription to treat a person suffering from writer's block by letting the MD know what components (depression, anxiety) she would be addressing; but she and the person seeking her help used the diminishing of the writer's block (increased production of written material) as the occupational "measurement/observation" of his having learned - and applied - the strategies presented to him by Jane. Thus, reduction of the effects of (or elimination of) the problems with psycho-social and/or emotional functioning was measurable and/or observable via the active resumption of the occupation of "writer."
Or consider another example: "Ms. X. will develop and implement a daily, morning routine including bathing, dressing, eating breakfast by the end of one month." What will Ms. X. be able to accomplish occupationally now that she can complete the morning self-care routine? Will she now be able to get to work on time because she isn't using up non-functional amounts of time just getting through the getting-ready part? Will she now be able to engage in other occupations as a result of not getting "bogged down" by not being dressed or fed, or by having to wait for someone to do it for her? In other words, how do self-care ADLs fit into the occupational whole of a person's life?
I don't have a problem with the nature of the goals given as examples above; just with the lack of occupational relevance attached to the documentation of the goals. Take it from me and other CMs with whom I communicate, we see piles of PT and OT documentation regularly, and unless we look at the therapists' signatures, we can't tell if it's OT or PT providing the service. Also, OTs who deliver physical agent modalities, exercise programs, splinting or other "do to" services aren't doing OT, they're engaging in a specific therapeutic approach that isn't unique to one discipline. That doesn't mean OTs shouldn't be engaged in such approaches; they just shouldn't call those approaches OT! Call them "ultrasound", "splinting" or "designing a home exercise program to improve [specified performance components]" - that is, name the therapeutic approach, rather than your professional discipline when describing such trans-disciplinary methods.
In my opinion as a loyal OT, these sorts of vocabulary/terminology issues are the crux of the "professional recognition" problem, not that PTs are trying to "do OT" now, or even that OTs shouldn't be claiming "PT turf" in the form of passive therapies.
As I follow the discussions on the listserve, I can usually read between the lines to find the occupational themes people are talking about; but if the example is lifted from a specific case, I can't extrapolate what occupations are most meaningful to the person whose case is being described, and therefore can't figure out if the goals the OT is describing have any relevance to the person's life post-discharge. Non-OTs can't even begin to find the clues to "real-life outcomes" in such "functional" information. Bring the occupation-specific information to the surface in your written and verbal communication, and do so using what I call "bridge language" - e.g., following an OT-specific phrase such as "Ms. X's occupations of..." with everyday language about people's activities within the context of their roles, responsibilities, and ambitions, so that non-OT readers/listeners get repeated, specific examples of what we mean by "occupation!"
If I didn't have continuous verbal and occasional in-person contact with the people whose cases I manage, I wouldn't be able to figure out what occupations are being enabled by the OTs they're seeing. Many case managers never meet the people on their caseloads, and many also never speak to them by phone either; so unless the OT tells them - by phone or on paper - what occupations are being enabled by the OT services, the case managers won't be able even to guess and then verify/clarify their guesses like OTCMs can. Further, since I see the people with whom I work in their real-world environments (home, work, community), I'm in a position, within my DCM responsibilities, to assess the effects therapies have on their occupations. I shouldn't have to do it myself, however - it borders on duplication of services - but a serious issue for the people receiving services is that since few case managers are OTs, most of the time the occupational information can't be "teased out" of the mountains of paper and "functional information," thus potentially depriving the people receiving services of continued and/or future access to services.
With OT having such a diversity of application to human "functioning," it is unlikely we will ever develop a concise, descriptive statement of the profession that fits everyone's practice. By making a point of describing how our intervention approaches/methods can increase a person's ability to engage in activities recognizable to anyone as "everyday life", each of us can help anyone with whom we interact - one at a time, conversation by conversation - to understand what we mean by "occupation," why the ability to engage in occupations is vital to every person's quality of life, and how OTs are uniquely trained to enable occupation.
Copyright © 1999 Allie Hafez /Vital Link Consulting
This article also appeared, with the author's permission, at:
Occupational Therapy: Movers & Shakers in Mental Health (Project for the Texas Occupational Therapy Association's Trinity North District Mental Health S.I.S.)