This matrix typifes the range of performance evaluation necessary in all the client's realms of living, which the OT can then address.
(Adapted from author A. Hafez's OT course notes.)
This article on this page was originally published in The Journal of Care Management (1998) (4)2; pp. 10-20. It is posted with permission of the copyright holder, Mason Medical Communications, Inc. For a copy of the original, contact the Executive Editor of TJCM: PO. Box 210, Greens Farms, CT 06436-0210 (USA); Phone: (203) 259-9333 Fax: (203) 259-9311.
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Occupational Therapists are typically underutilized in the healthcare arena, both as treatment providers and as case managers. This article discusses how and when occupational therapists can be used to best advantage in maximizing case management outcomes. |
At what point should a case manager request occupational therapy services for a client in order to maximize case outcomes? What unique training, skills, and perspectives of occupational therapists make them assets to a health care team as well as excellent case managers?
This article attempts to address these questions by exploring the qualifications of Occupational Therapists (OTs) and what they can offer to the case management process.
Occupational Therapists begin their training with intensive courses in physiology, kinesiology, neuroanatomy, and anatomy. Many anatomy courses include cadaver laboratory work. From these foundations, students then study a variety of medical conditions, the effects of medications on physical and mental capacity, and their overall impact on the functioning of clients. While OTs cannot prescribe or administer medication, every OT learns the importance of knowing the specific actions and side effects of each medication that their clients take.
The uniqueness and value of OTs, however, come from their intensive study of all the vital components of human functioning and how these interrelationships impact a person's well-being and quality of life. The practice of occupational therapy goes beyond the focus on the body per se - range of motion (ROM), strength, muscle tone, anatomical structure, gait - to encompass both physical and lifestyle factors and their application in the complex task of helping a client continue to live a meaningful and purposeful life. The words "meaningful" and "purposeful" can be considered icons of occupational therapy practice and will be explored more fully as our discussion continues.
More Than Return-To-Work Differences in understanding terminology can be a pervasive barrier to full communication, cooperation, and collaboration among payers, case managers, service providers, and clients. For example, the term "occupation" has been traditionally used by everyone except OTs to mean simply "work" or "vocational activity." This narrow use of the word is evident in the debates about 24-hour care eliminating the distinctions between workers' compensation and "personal" health care claims. For OTs, the word "occupation" has a many-layered meaning; a person's occupation comprises all the activities, roles, self-images, values, environment, and culture of the human individual. Each of these general areas has a number of components that are unique to every person. A change - positive or negative, voluntary or involuntary - in any one of these areas can have a wide-ranging effect on one or more of the others.|
To OTs, the word "occupation" has a many-layered meaning. |
The general content of such a performance measure is presented in Figure 1, which shows how a typical assessment of functional performance can be categorized. Figure 2, adapted from the Canadian Occupational Performance Model (COPM), provides a different and more in-depth sample evaluation and displays a matrix of Temporal Aspects (chronological, developmental, life cycle, disability status) and Environment (physical, social, and cultural). This model should be familiar to case managers: it describes the holistic approach of case management principles. More than any other health care discipline, however, it is OTs who are trained to identify a functional problem, locate the source, and assess its effects (via contact points of the ripples created by the disturbance in the matrix) and therefore help the client determine which ripples have the most important effects and on which aspects of their overall functional profile.
Job Analysis
In a letter published in the Fall 1995 issue of the CIRS newsletter, UPDATE, the writers claimed that OTs are not qualified to perform job analyses for the purposes of ADA compliance because no accredited OT degree programs require formal training in job task analysis. (2) Although it is true that OT programs do not specifically teach job task analysis, OT educational programs at all stages include instruction in and emphasis on activity and task analysis. Vocational tasks are an integral part of the continuum of all human tasks and activities. Therefore, to attempt to compare the specialized training in job task analysis that rehabilitation counselors receive to the training that OTs receive in the analysis of all human tasks and activities is meaningless. As with a camera providing two distinct features-wide angle and zoom lens-each produces different results. Analogous to the story of the blind men attempting to describe an elephant based strictly on the single body part that each man has touched, the whole is made more recognizable via the "big picture." Indeed, a wide-angle insight, as we all know, can verify or invalidate a close range viewpoint.
ADLs Defined
ADLs are another example where differences in terminology create a barrier. Through tradition, habit, or careless word choice, the term "activities of daily living (ADLs)" has come to mean only the functional activities of feeding, dressing, grooming and hygiene. How ever, as Figure 1 illustrates, these three activities are only a part of the larger whole of self-care, which is itself but one type of "activity of daily living" within an even greater context: the whole sum of an individual's life activities. Therefore, it is important that all service providers and case managers take care to clarify - especially with the client - what exactly they mean when they refer to ADLs, since goal setting and resource budgeting hinge on everyone being "on the same page" when discussing a client's functional goals and outcomes.
Most health care providers and case managers are well acquainted with the frustration and miscommunication that can arise out of documentation and reporting that focus on "abilities" such as range of motion (ROM), muscle strength/tone, gait patterns, ambulation distances, and the like. The case manager or utilization reviewer will often ask, "But what does this mean in terms of what our client can do?"
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OTs can clarify the position that each activity occupies on the functional continuum in the client's life scheme. |
Similar difficulties can arise from reports that make generic statements such as "patient needs moderate assist with ADLs." In the greater scheme of the client's roles, responsibilities, ambitions, and desires, such a statement often generates a response of "So - what now?" OTs can clarify the position that each activity occupies on the functional continuum in the client's life scheme. OTs facilitate a macro-approach to health care provision through their wide-angle approach to assessment.
For example, an attorney who had become a quadriplegic emphasized to his case manager that he wanted to concentrate on treatment and rehab activities that would enable him to continue to work as an attorney. He stated that independence in "ADL" (in its most common, narrow meaning) was not a priority for him because if he could resume working as an attorney, he could afford to pay people to help him accomplish his "ADL." Such issues of goal setting, compliance with intervention plans, and goal accomplishment are, as health care professionals know all too well, complicated when clients' personal agendas (especially unconscious ones) are not compatible with the health care system's demands and needs. An OT's comprehensive training in analyzing the subtle details of function can be extremely valuable in helping clients both to identify priorities that are compatible with those of the health care "system" and to educate clients on the consequences that incompatible choices or poor prioritization can have on their access to resources within and external to the "system."
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OT educational programs include instruction in and emphasis on activity and task analysis. |
"Meaningful and Purposeful"
Occupational Therapy's focus on therapeutic activities that are "meaningful and purposeful" is a primary factor that distinguishes it from Physical Therapy. The OT's review of meaningful activities helps the client focus on what she or he can do rather than on functional losses or discomfort. OTs ask: What is required that will allow the client to continue or resume his or her most meaningful and purposeful daily activities while providing therapeutic benefit? One significant aspect is adaptation - of tasks, approaches, tools/equipment, and environment - to remove or compensate for barriers to function. Identifying the area of need and devising adaptations require extensive training in understanding the components of tasks, so that all problem-solving efforts can be focused on the key issues and the most efficient adaptations.
This focus is not as easy as it sounds. Without OT input, a lack of insight into the functional components of living contributes to the high rate of nonuse of adaptive equipment; some of which is extremely expensive. For example, there are a variety of retail stores and catalogs from which people can purchase "adaptive equipment." A case manager might direct a client with a broken wrist in a cast to such resources in order to purchase an item that would compensate for difficulty with writing, another item to assist with hygiene and grooming, and yet another item to assist with grasping a steering wheel. An OT would help accomplish the same adaptations by instructing the client in the uses of one simple, inexpensive item: a universal cuff. Case management can only gain from such cost-effective adaptations. Often, a full-blown referral for OT services is unnecessary to accomplish a successful case outcome when an OT consultation can remove the barriers.
Understanding the full power of meaningfulness and purposefulness in an occupational therapy plan can help case managers think "outside the box" when considering using OTs. The "box" includes the traditional distinctions between therapy services provided in a client's home and those provided in a clinical setting. Research indicates that recovering a functional ability is significantly dependent on the client's context of activities; often a clinical setting is less desirable than the home or worksite for achieving functional remediation. (3)
Once again, careful choice of words is important when communicating with team members about service options. Occupational therapy services provided at home should always be considered because of the importance of a client's full "context of activities." With its own special concomitant meaning and purpose, a home care setting augments functionally focused therapeutic activities for the client.
Traditional thinking (influenced by reimbursement structures) tends to discourage the use of home-based occupational therapy for people who typically would be expected to attend a clinic. The meaning and purpose that a client derives from therapeutic activities in a familiar environment, however, can have a profound influence on compliance and recovery. The traditional logic governing home- versus clinic-based treatment is similar to equating "occupational" with "vocational;" it thereby undermines the interdependence of all functional abilities within the matrix of full human activity.
Timely and Effective Utilization of Occupational Therapists
Certainly, many situations do not require an occupational therapist either as the case manager or as the direct treatment provider. For example, many acute medical treatment/management protocols, such as home infusion, do not include functional issues. It is very important, however, that an OT is not utilized as a last resort when attempts to "fix" the cause of functional problems have not panned out and now adaptation or compensatory techniques are all that are left. An OT consultation early in the service plan can provide solutions that will allow the client to allocate and focus physical and emotional energy in dealing with acute issues, including the psychosocial effects of sudden, unwelcome, and confusing change brought on by the medical condition.
OTs as Direct Service Providers
Understanding the uniqueness of an OT's services can enable a case manager to encourage the health care team and service providers to include occupational therapy in their approach. Because it is so meticulously customized for each client, occupational therapy can heighten cost-effectiveness. We recall again our discussion about the correct use of terms that is pivotal in understanding an OT's concept of "meaningful" and "purposeful." When a case manager is considering whether to engage occupational therapy services for a client, these two concepts come into play in identifying what factors drive the referral. Some considerations include:
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Traditional thinking (influenced by reimbursement structures) tends to discourage the use of home-based occupational therapy. |
OTs as Case Managers
A case manager who is an OT (OTCM) can very easily and specifically communicate with the client's occupational therapy provider. For example, an industrial rehab clinic was contacted to provide work-conditioning services to a client at the worksite, but the intake coordinator tried to schedule the initial evaluation to take place in the clinic. After a brief discussion, the OTCM convinced the intake coordinator that an evaluation could be performed at the worksite and that the results would not only be valid but more informative regarding the client's true initial work abilities. Since the primary purpose of the onsite services was to avoid more lost time from work (a goal that the client had emphasized even more strongly than the case management team), the case manager's knowledge of OT was crucial for "breaking tradition."
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The OTCM can identify exact individual functional components of goal-centered activities that can render additional therapeutic services unnecessary. |
Often, with an OTCM, the client's initial discussion of the "true" functional goals can result in an approach that the client can try without direct OT services being required. Thus, the case manager has utilized OT skills on a consultative basis, which in many cases is all the OT expertise that a client really needs.
A case manager who is an OT can also use his/her unique knowledge of the components of function to assist doctors in determining OT interventions that will allow continuing recovery without removing the challenges necessary to effect progress. For example, the OTCM can identify for the doctor the exact individual functional components of goal-centered activities that can render some additional therapeutic services unnecessary. They can together select the most applicable therapy. This focus on goal-centered activities, which are often less demanding than proposed therapy, can often accelerate the care plan, speed a return to broader activities that might otherwise have been delayed indefinitely, and ensure that no longer relevant services are not continued.
Summary
OTs have much to offer the case management process both as case managers and as treatment providers. Since "function" is dependent on many subtle components, OTs can make significant contributions to the delivery of cost-effective and relevant services. Jeanne Boling, Executive Director of CMSA, considers OTs "a tremendous untapped talent" for case management because of their ability to see "the whole picture" and their knowledge of function and long term goals. (4) The tasks and activities that comprise a human life rely on uniquely interdependent physical and mental systems, each of which has several components. When this is not understood and addressed proactively as a vital part of a health problem, a detrimental ripple effect is created. Wasted human and financial resources and delayed treatment outcomes usually result from missing this crucial point.
OTs can help clients and their health care teams identify component problems before the ripples spread and create otherwise avoidable problems. As case managers, OTs ensure that all involved services are doing their respective parts both to address the component problems and/or their effects, as well as to provide complementary interventions. As direct service providers, OTs implement interventions that preserve people's abilities to pursue and enjoy meaningful and purposeful activities, thereby preventing "disabilities" from achieving power over their lives.
The American OT model of practice, "Uniform Terminology of Occupational Therapy," provides a breakdown of the components of task/activity performance with a corresponding list of applications to human function. The Canadian Occupational Performance Measure, (COPM), emphasizes the client's personal priorities in determining "dysfunction" and "function" for the purposes of satisfactory intervention. Each model illustrates in its own way how Occupational Therapy is committed to the same principles that are the foundation of mainstream case management. Not a luxury or a fringe intervention or a last resort, OT is instead an essential asset in preventive care as we go about enabling clients to resume the occupation of fully - with both meaning and purpose - living their lives.
References
1. Terminology Task Force, "Uniform Terminology in Occupational Therapy." AJOT. 1994;48(11):1047-1059.
2. Oakes M, Oakes B. "RCI Tips: ADA implementation/problem intervention." CIRS Update. 1995 (Spring):6.
3. Park S., Fisher A.G., Velozo, C.A. "Using the assessment of motor and process skills to compare occupational performance between clinic and home settings." AJOT 8(8):697-709.
4. Hettinger J. "Case management: do OTs have what it takes? YES!" OT Week August 1, 1996;12-13.
(author's note: The OT Week reference is correct here; not so in the original. Although the error was noted and corrected in the editing process, the correction did not make it to printing.)
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This matrix typifes the range of performance evaluation necessary in all the client's realms of living, which the OT can then address.
(Adapted from author A. Hafez's OT course notes.) |
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This structure provides an important reminder that as clients adjust to the changes forced on them by health problems, task/activity performance issues change as well. Therefore, the case management-care provider team must give clients opportunities to reconfirm and update their lists of functional problems and priorities.
Adapted from the Canadian Occupational Performance Measure (COPM), 1994 Canadian Association of Occupational Therapy, Ottawa, Ontario, Canada |
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| Ms. Hafez is President of Vital Link Consulting, a Disability Case Management company in Minneapolis, MN. |
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Ms. Brockman is a Rehabilitation Specialist at the Minneapolis office of Fortis Benefits Insurance Company. |
The Journal of Care Management is the official journal of the Case Management Society of America (CMSA)
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