I'm Carol Siebert. I've been an occupational therapist for more than 25 years. I LOVE being an OT.
My views of occupation and of occupational therapy have been shaped by many things. I'll share four of those here:
1) My experience as a person with a chronic condition. Dealing with a health condition (and our frustrating health care system) should never get more attention, energy or importance than having a life! Living Life to It's Fullest means that managing a health condition is just one aspect of living life. As a person, a patient and as an OT, I know that. But it's clear that too much of our healthcare system is based on the assumption that being a patient-a compliant patient-- is more important than having a life. For me, OT is about living life while managing one or more health conditions.
2)The work I was doing when I discovered OT: working in a group home with young adults with profound intellectual and physical impairments. This is where I learned the concept of Dignity of Risk. In a nutshell, that means being human is about having choices and taking chances-there's more to life than being safe. Those clients are the reason I am an OT. My boss (Jan, a social worker), is the person who taught me the meaning of "change agent."
3) The guidance of professors who were wonderful mentors and powerful OTs. They taught me that OT is as much about thinking, reasoning and advocating as it is doing--and that our profession is most powerful when it deals with the most commonplace. Yes, in many ways OT is rocket science. Thanks especially to Cathy Nielson and Marlys Mitchell.
4) An early practice encounter that forced me to learn about payment and policy. I learned-and continue to learn--that our practice does not exist in a vacuum. Just as our patients and clients live in a dynamic social, physical and cultural world, our practice exists in a dynamic social, economic and political world. Those factors and forces that influence practice fascinate me. I choose to use a term Barb Schell associated with this aspect of practice: "pragmatics" to refer to the many factors that affect our practice beyond those driven by a given patient or client's needs and priorities.
Most of my career has been in some form of home care or community practice. I've directed an adult day program, practiced in home health, consulted in home modifications, taught in an OT curriculum on practice environments, health conditions, gerontology and administration and policy. Most recently I've worked on a community health project serving low income older adults and Medicaid recipients. I am a policy geek--and thanks to the internet I can look up Medicare regulations, licensure provisions or reimbursement criteria so I am prepared to respond when someone tells me "OT can't . . . " or "OT shouldn't . . ."
OK, enough about where I'm coming from. Those who know me know that sometimes I just have to connect a bunch of ideas that are buzzing around in my brain and get them down in words. This blog is my occasional effort to do just that. Let me know what you think!
I work in a community health care management network. Some of what I do is care management. Most of what I do is occupational therapy. Our program partners with primary care practices to support health management-typically by following up with patients in the home. When I started, dealing with primary care providers (PCPs) was new to me. Occupational therapy was new to most of them--and pretty foreign. Some thought I must be a PT. Some called me the "occupational health person." I was the only OT working in one county in a statewide program. Learning about primary care was not my biggest challenge. Developing credibility with the PCPs was the real challenge.
Most of the PCP encounters are by email, occasionally by phone, and rarely face to face. Sometimes I'm face to face with both PCP and patient when I accompany a patient to a PCP encounter. Over several years, there are some PCPs who have become big fans of OT. A few weeks ago one of the most challenging PCPs called to thank me personally for doing an in-depth evaluation on a particularly challenging patient--and asking my advice on next steps. Another told her colleagues that "the info I get from the OT assessment really helps me know what's going on with the patient." At a presentation last month at one of the larger practices, a number of the PCPs clapped and cheered when I was introduced as the network occupational therapist.
But the marketing continues. There's still a provider who calls me the OT/PT. A few still don't respond to my emails. But the goal--of delivering value to the PCPs and their patients, is being achieved--one email, one call, one consult at a time. As of April we have a second OT--and another county with more primary care practices and more PCPs to whom OT is foreign, so we still have plenty of challenges (and 98 counties) to go.
The important thing is that this opportunity is not about me, or about Sharon (our newest OT), it's about occupational therapy. The opportunity--and the burden--of doing what we do is that we’re shaping these PCP’s understanding of what occupational therapy is about and why it is important not only for their patients-but also to help them provide better care for their patients. When we email a report to the PCP, they count on an assessment of the psychosocial and environmental aspects of their patient's situation, the factors affecting the patient's ability to manage at health, and reliable recommendations to optimize the patient's ability to manage in the home and to manage his or her own health. That includes recommendations we might implement, but also recommendations for other supports or services--which may also include OT in another setting.
Which brings me to the reason why I'm writing this . . . Earlier today I got a request from a PCP to assess a 92 year old woman who has sustained a significant functional decline in the past couple months--etiology unknown. This woman lives alone. Unfortunately, the woman is not in the population our program is contracted to serve. She also is not eligible for in-home aide services. I could have just sent a response to the PCP simply stating that I am not able to do the assessment. But that doesn't address the PCP's needs or the patient's needs. So I suggested an alternative--making a referral to a home health agency for PT and OT to assess the patient and to report back to the PCP on their findings and recommendations for regaining/compensating for the loss vs. the possible need for residential care. I recommended a couple of home health agencies where I know OTs are employed. I even told the PCP that she might have to be firm that she wanted PT AND OT and not to accept the agency saying that PT could do it all. Then I hit SEND. And I sighed . . .
So this is for the home health OT who gets that referral . . .
Please don’t assume that independence in ADLs is more important and has to be addressed before anything else. The PCP needs to know if it’s feasible for her to live alone and how much caregiving she’d need to stay at home. Being able to retrieve a meal, use the toilet or call for help may be more critical than independence in bathing.
Please don’t do one visit and declare the patient doesn’t need OT because she has “no potential to improve.” She’s 92 and the PCP realizes that improvement might not be possible—but it might be feasible-with OT- to either stabilize her current abilities or to adapt her methods and the environment so she can manage her activities safely.
Please don’t insist that the patient needs an upper extremity exercise program unless she’s has a new-onset muscle weakness that is causing her functional decline and is remediable. If she’s having difficulty with activities now, is it really likely that strengthening her arms is going to make the difference in her ability to get about and manage in her home?
Please check to see if the patient is managing her medication. The PCP is aware that, at 92, missing even one medication or confusing meds can produce disastrous consequences. Please don’t shrug it off with “I don’t deal with meds” when the need is for a task analysis of a critical IADL.
Please don't let me down. More importantly, please don't let the PCP down. She's come to depend on the assessment and clinical judgment of an OT to help her do what's best for her patient. Please don't let the patient down by using “potential to improve” as your yardstick if her need is for occupational therapy to make staying in her home possible. Please don't let your profession down by not practicing at the top of your abilities--and your license. Please, don't let us down . . .
Thank you for a GREAT post!
I am sure we will be hearing more and more about OTs role in primary care as this is at the forefront!
Amen! Loved your article.
Thank you for your informative post I agree with every word! Your post contents just sparked a scholarly discussion in my community health OT class for RMUoHP OTD!