How to Determine Frequency and Treatment Durations of Occupational Therapy services in ACUTE CARE

Triaging who gets seen first for evaluation typically is driven by both joint commission standards (we address OT consults within 24 hours of receipt) AND how fast it is predicted for clients to leave the hospital setting.  

More likely, clients will not stick around the hospital long; that is why we need to be strategic about HOW we triage evaluations.

In acute care, we know evaluations are king…but what about frequency of treatment and the duration at which we should spend time with clients?

Here are the basics to get you started. 

Let’s first take a look at the five basic components of determining frequency and duration of clients seen in the acute care setting: 

Skilled client needs

Discharge placement security

Diagnosis

Length of stay

Readmission risk

All of these work alongside each other and not as one or the other.  Each is a puzzle piece to a triage formula for determining who, how often and how fast.

Skilled Client Needs

Q: Who determines this?  

A: We do as OTPs as in any setting!  As the OT practitioner, we determine duration and frequency based on the client’s skilled needs (not a supervisor, manager, director or caseload number).

Questions to ask ourselves:

Do they have skilled needs?

“Is the client appropriate for OT services at all or are they at baseline?” 

“Do the standardized assessments we have done shown their skilled needs?”  

“Does the patient have goals?”

Determining whether we sign off at OT evaluation, select 5x/wk treatment, or choose 2 follow up sessions before the client discharge is influenced by skilled need.

Whether clients stay 2 days or 2 months; what the client needs is what matters.

That is why we indicate the true frequency needs. Even if the caseload is so slammed and you know you will not get to them for that 5x/wk for treatment, that treatment  frequency represents what the client will require to recover in occupational performance when they leave us. 

Q: What are some cases where treatment may be minimal to no needs?

A: Client is going toward a comfort care approach (with no hospice measures indicated). When the client does not tolerate therapy for the duration we anticipate to see them that day.  Or, we may be trialing our services for 2x/wk before determining a greater frequency because of poor tolerance for treatment or uncertainty in client ability to meet goals.  

There may also be times where we may sign off the client case completely when they do not have goals at all.  Despite our attempts made over the course of their stay with us in acute care, we together (OT and client) cannot come up with any additional goals to progress occupational performance.

Q: How about evaluation complexity codes. Do we factor those into skilled needs determining treatment frequency?: 

A: The evaluation complexity codes are chosen based on the clients number of occupational performance deficits, extent of occupational profile and overall complexity criteria.  When it comes to determining treatment frequency however, code choice actually will play less of a role when the length of stay, discharge placement and readmission risk influence the circumstances.

We may find a client only has a few things to be assessed for with more detail treatment to follow…or lots of things on evaluation to assess are found with less detailed treatment to follow.  

So many factors determining skilled needs.  Truth is, it takes many years of practice to work alongside your client and determine skilled need frequency and duration of treatment (give yourself grace with this).  

Discharge placement security

Questions to ask ourselves to determine how secure discharge setting is (with or without OT services) for our client:

Does the client have a caregiver?  Does that caregiver have the time, availability and amount of assist level necessary for this client’s physical, cognitive, psychosocial needs at discharge setting? 

This will influence what we recommend (and may be necessary information to determine how involved we are in treatment during the client’s stay for training or justification to a higher level of care)

Will the client be returning to skilled service at prior discharge setting?

No acute or infrequent acute needs until their return back.   Example: coming from and going back to a skilled nursing facility.

Does the client have a discharge setting to go to and will they be functional for that setting by the time they discharge?  

The client may be in limbo as to where they will go.  When we do find out, we have to determine if they have enough caregiver assist there and whether they need OT when they go. 

Examples of this:

#1: Client will be going to an assisted living facility (ALF) but, they do not have 24 hour hands on assist (it is supervised level of assist).  We find now after their hospital admission that this client needs physical assist to prevent a fall.  We may be more involved in training the caregivers, or having increased contact with care coordination, to help facilitate their treatment needs going forward when they discharge the hospital.

#2: Client is homeless and there is question as to whether they can discharge back to the streets with those multiple fractures they just sustained.  It is uncertain if they can get home health OT at a shelter but, we would be prioritizing their treatments to maximize their skilled therapies while we have them in the hospital.

Is the client going home with or without OT services?:

We may need to download all we know into the client and caregiver’s brains to best prepare them for their functional well being with a new diagnosis if no OT service is accessible to the them.

Example: 

Client is medically ready to leave the hospital on post op day #1.  They will not be getting home health OT services. Acute care OT needs to evaluate and provide treatment intervention all in the same day!  Even though the client’s occupational performance is graded at a low complexity - 30 minute anticipated evaluation - we may be with them for a whole hour total to cover all the basics in treatment before the client discharges.

Are we trying to justify for acute rehab services?:

This may require us to see them more often to justify tolerance for therapy and prove it to be beneficial in a critical rehab recovery time. 

Does the client have a good discharge plan for after they receive acute rehab services?:  

If they do not have a set discharge plan in place after rehab, this may play a role as to whether the client is accepted to an acute rehab. 

Sometimes we have to play the role of being their acute rehab services (even though we function like an acute care setting) because the client has a critical functional recovery window (such as in an acute stroke or acute TBI.  It may be time sensitive where the more frequently we can see the client, the better the functional outcomes.   

Diagnosis

Speaking of critical functional recovery windows…

Q: What diagnosis may indicate more frequent or longer durations of treatment in acute care setting?

A: a client who has sustained an acute neurological incident (TBI or stroke), cardio-pulmonary type surgeries, or clients who are on early mobilization protocol (ventilator weaning), may require prioritization for frequent treatments to maximize neuro, cardio-pulmonary and functional recovery.  

Benefit from greater frequency of OT services in acute care setting can also support discharge placement through our justification. 

Beyond functional recovery windows, seeing these clients more often proves their tolerance for therapy.  To fulfill the skilled need to be accepted into that LTACH or acute rehab, we up the frequency of treatment to better the client’s chances in getting into settings recommend for them.  

Also, those diagnosis that are known for not receiving our services (for example a client on observation for a pelvic fracture), may benefit from our visits more frequently and for longer durations of time during their hospital stay.

Q: What about diagnosis where the condition is terminal?

A: Some terminal diagnoses may have us determining less frequency for clients who are set for hospice or comfort care measures; this may lead to the client being signed off from OT services completely.  We of course have a role in a client’s trajectory of palliative care, however, those needs can be best met at the next level of care/setting.

Additionally, if we know what diagnoses are notoriously known for receiving OT services at the next setting, we may not prioritize them altogether and recommend they receive that upon their discharge.

Length of Stay

Knowing how long a client will stay in hospital will vary.  However, it plays a critical role in determining frequency of treatment.  This will help us prioritize treatment follow up.  

The first questions I ask myself are:

Is this client on an observation status, outpatient in a bed, or ambulatory status of care?

Is this client someone who typically goes home after their medical scans are clear but likely to be predicted to have critical self care and functional retraining needs?

While considering the discharge setting and follow up of OT services available to the client at the setting they leave us for, treatment duration may vary and more reliant on frequency need before they go.

Examples:

The shorter the stay in the hospital = the more frequent they will be seen for ADL retraining. 

The more frequent you need to see your client may also be a predictor in how long you stay for the duration of treatment on the first few sessions.

Some exceptions for short stay clients:

When you know they will be going back to skilled nursing with skilled OT services (or back home to resume already-in-place home health therapies).

Another component that is critical to consider in treatment is education.  Assume the first time you see your client will be the last. Ask yourself: 

Did I educate the family on the critical points for their loved one to be successful at the next level of care?

Did I go over and have them return demo (if able) all the critical points I can think of that may be impacted by their current diagnosis and acute stages of recovery?

Anything they should know to anticipate during their journey of recovery (to be able to advocate along the way?) 

Readmission Risk

Let’s first ask ourselves: 

Who is at risk for readmission?

1. Clients with acute on chronic conditions.  

Example: client with acute on chronic Congestive Heart Failure (CHF) admitted to the hospital due to fluid overload.  

The physician will take the fluid off of their body with medical treatment and send them home once medically stable.  

These clients may be back sooner than later if their symptoms are a result of client behavior, perception of medical treatment being a disruption to their daily occupations or other circumstances we find out in OT evaluation.  

We as occupational therapy practitioners get to figure that out and decrease their risk of being readmitted.  That is why our interventions with them on day one will be so critical. 

Sometimes our treatment are the resources we provide to them that are available to the client in the community.

2. Complex medical cases. 

With these cases, I sometimes find myself in unknown and uncharted territories as an acute care therapist.  This is because their readmission risk factors are more dynamic than one diagnosis need; think of it like PEOP model on steroids (the environment influences the person and the person influences the environment.  Both influence their performance and the occupation.   Also, the place at which they occupy space is influenced and interchangeable).  

Some examples include:

• co-morbidity of significant obesity (including beyond BMI and standard scales)
• homelessness
• frequent alcohol intoxication with withdrawal
• social admissions (family can no longer care for their loved one) 
• psych diagnosis
• history of falls
• dementia without placement into a memory care

In our own implicit biases or uncertainties of how to assist these clients, we tend to defer these cases for a variety of reasons.  However, these clients are still at risk for readmission.  

I wonder and ask you:

So how do we play a role in their recovery to decrease their incidence of returning to the hospital?  

How frequent do we get involved in interdisciplinary care for these clients?

When do we wean down our treatment frequencies?  

These clients tend to stick around the hospital for a while due to barriers in discharge; it is a question I ask myself regularly but know in my OT heart we have a role.  

I begin with an occupational therapy profile to get started on what treatments and interventions should be addressed.  

The interventions take time to build upon themselves to truly make an impact on clients with these chronic circumstances.  That is because our interventions in acute care are not overnight fixes for this client population.  We are used to treating with one to few sessions in this setting ( such as training the client on how to use of a sock aid for that posterior hip replacement).  With complex medical cases however, there are many years of layers we need time to pull off to get to the client’s ability to perform self care well.  When the client leaves and it is a question as to where they can receive those treatments and interventions elsewhere, what can we do in the short to help them with the long term outcomes?

If you have ideas, I would love to know myself.  Write them below in the comments.

Hope this breakdown of determining frequency and duration of treatment in acute care has served you well to get you started.  There are many more factors to consider beyond this post.  If you have additional questions you would like me to talk about, email me at info@alexisjoelle.com 

Until then, see you in my IG stories or live video feed

How Listening to my Client Improved My OT Skillset

I remember that day when I was told by nurses and physical therapists that client X was "in a mood" "upset" and "not participatory."

I was told they were "independent" because they could navigate their oxygen and intravenous lines themselves; demonstrates untangling them around their body to transfer to a chair from the nearby hospital bed.

So I did a chart review to screen to see if I would evaluate one time only, based on the report I received from my colleagues.

When I walked into the client's room, I didn't introduce my name or discipline.  I first greeted them hello and asked "how are you doing?"

They proceeded to tell me "I'm fine; what do you want?"

I followed up by saying "I want to find out more about you.  I see you were admitted to the hospital for exacerbation of symptoms associated with cancer.  I would like to get to know you a bit more to see if  there is anything I can do to support your recovery to compliment what you are already doing now for coping with symptoms. Would that be okay with you?"

They began to tell me their story:

...how long they have had the diagnosis
...what they have been able to do and not able to do in daily activity because of fatigue and pain
...what roles and responsibilities they played in the community and to family

Then they began to share their concerns the more I listened:

...their difficulty delegating tasks they didn't like to do in their day to day
...their difficulty organizing tasks in the day and feeling overwhelmed easily
...their report of finding themselves irritated often
...their report of forgetfulness
....their upset with doctors, nurses and therapists stating "they don't hear me. They listen but they don't hear me.  Instead, they tell me what they want from me."

After hearing all the client's thoughts, perspective and concerns over a 45 minute period, the client turned it back to me to state "thank you for hearing me; what can I do for you?"

I paused for a moment: all I wanted was to help them fill in the gaps they perceived as the obstacles, barriers or stumbling blocks to accessing meaningful activity.

So we worked together to identify all the things that we could work on.  Two things came out of it:

Identifying what we have control over
Asking what can we take action on now

I felt slightly out of my element that session because I walked in thinking I would interview and discontinue from OT services...maybe see if the client needed energy conservation and work simplification strategies for an exacerbation of respiratory related symptoms and fatigue.  Instead, I was taught the lesson that when you truly hear your client, you pick up on what they really need.

In this client's case it was two things:

1. a way to let go of some of the responsibility they took on (having too many occupations that weren't serving them well).

2. how to get organized and keep on the tasks they identify as important or of value.

It turns out the client had an pre-existing brain injury as well that was not identified in their medical history; the client told me that 40 years prior they sustained a TBI and never received any OT services for this.

So we worked on cognitive strategies to address the client's needs (not my plan or the other staff's plan, my client's plan).

The client expressed significant gratitude to have an intervention that fulfilled her request.  Not only could she plan a better system to be less hindered by fatigue emotionally and physically, she was heard.

Wait...You Can Pull Off Over 90% Productivity??

If this is you and you are an Occupational Therapist, please speak now or forever hold your peace in this mastery of an unheard skill.

New value-based OT evaluation codes were released in January and some occupational therapists claim they are able to meet 90% productivity (and higher) when being asked to accomplish this at some settings! Can you believe it?

I am scratching my head at the confusion...this is so 2016 shenanigans.

We have been reminded that we get the permission to go back to our roots of what occupational therapy truly is, as well as being able to have the say of:

HOW LONG we spend with clients for evaluation sessions

AT WHAT COMPLEXITY LEVEL we evaluate them at (based on the complexity of their case) and....

no other non-OT person has the right to make this decision.

(and if you are a OTA, hang in there with me, this applies to you too!)

I was curious about the claims I read in social forums related to pulling off 90% + productivity...so I explored the break down (seen below) for the time allotted in a typical day to do evaluations and/or treatments for clients in a post acute setting:

8 hours in a shift (480 minutes)

90% productivity met would be 432 minutes in a shift which would equal 7.2 hours

For California therapists: add on two mandatory 10 minute breaks to that - now we are hitting 452/480 minutes in the shift leaving us with 28 minutes to do a few un-billable things:

🔁

1. SELF CARE: water and pee ( or #2) breaks

2. EDUCATION and information gathering where the client is unable to be present:

This could be discussing education or occupational performance with:

The client's nurse who is running around the floor getting medication for their other patients

The doctor who is not in the building

Other disciplines working directly with this client who is not immediately present in the room at exactly the time you are having your session or caregiver/family involved.

3. SUPERVISION AND GUIDANCE: of OTAs you supervise...and for the OTA themselves:

-the time for the OTA to be able to ask for guidance
-the time to provide feedback to the OT supervising them regarding upgrading and downgrading (or meeting) goals
-the time to receiving the coaching they are allotted as well

am I missing any scenarios?

OH YEAH....

4. DOCUMENTATION and INTERPRETATION OF ASSESSMENTS that cannot be completed when you have your hands on treatment with your client

If you are able to physically master documentation on an IPAD while doing ADL treatment in a bathroom... or in the patient room while treating them, you MUST share your secrets with us. As OTs we have impressive talents including adapting devices and their user-ability.

...I wonder how this so when the patient requires contact guard assist for standing balance while progressing their dynamic access to grooming at the sink side

...or needs MAX redirection cues for safe participation in lower body dressing at the edge of the bed

...or needing to monitor their vitals while the client takes that rest break.

...or is impulsive in their movements during a cooking activity at stove top/ meal prep and needs the therapist to have two hands ready at any moment

...or that hands on assist for that safe shower transfer training

...or they have an aspiration risk that needs our eyes on them for the whole meal they are being trained to feed themselves with.

...or it's their first time handling that razor to shave themselves for grooming and their cognitive awareness isn't quite up to independent standards.


Other additional things like transporting a patient to and from our evaluation/treatment space of choice (when this is not conducted in the client's room), clean up of materials and etc can likely be delegated right?....hmmm not sure if there is a designated rehab aide in all settings yet but, having an assistant is helpful when we cannot do it all.

Here's the flip side...
(I am all about seeing each side of the coin and I do forewarn you on the real talk):

1. SELF CARE: I see the burnout and lack of self compassion for my occupational therapists who are my students, colleagues and clients of mine.

They are conforming to a non-OT rule to the way of evaluation, practice and treatment. Sure there is business to be done, we HAVE to get paid to put food on the table and a roof over our's and our family's heads... and I am not even talking about this being about having "no other choice." It is to point out that some disregard themselves as even being human, imperfect and doing their best...and that human I speak of (you!) must come first to truly serve your clients.

2. CARE FOR COLLEAGUES: we want them to be their most successful in assisting their client and decrease their burnout as well. They flourish from our guidance and training to facilitate our client's access to their life occupations. Take that time to say "how are you?" "How can I help?" Connect with their human self.

3. CARE FOR CLIENTS/PATIENTS: Their occupations are at the center of our practice ...

and yet, are they getting their value's worth for the evaluation, practice and treatment we provide them?

Is it truly client-centered....a life occupation based practice...

...or is it a day at the rehab gym?

(is it me or have many client's taken up the hobby of cone stacking, arm biking and T-band pulling?)



What do they (your client) want to get back to? Do they want to:

Care for their dog?

Spend social time with their grandchild?

Get back into their golf swing?

Write that letter to their best friend on the other side of the coast?

Put on their make up every morning?

Pull the weeds from their garden?

Wipe their tuchus on their own despite being incontinent so they can live with their children at home and not worry about them cleaning up after themselves?

Play their favorite instrument again?

Make it to their Mah-jong game on time?

This is why I love and live off my copy of the Occupational Therapy Framework because I know if I get lost, there will always be it's guidance in getting back to my client's occupations.

I am also super grateful for my California State and National occupational therapy associations because they not only advocate on behalf of me to do be able to do my job...

They keep me in the loop about resources to use to defend my intention in everyday practice, as well as provide the up-to-date info impacting our profession AND when I need to step up and act to protect it

(and, and... let me tell you this much):

we need to protect our profession even when, and especially when, things are going right.

So here is some real talk ;) :

1. Go easy on yourself...you are productive when you are with your clients working toward their occupation based goals.

AOTA provides you with a copy of an occupational profile template to use with your clients to accomplish this.

2. Stay true to your value-based evaluations in choosing accurate codes to best serve your client

Didn't get formal training at your site for this?!

Here is the OT evaluation worksheet I compiled to help you figure out the formula of what code to choose for which patient (not every client or diagnosis fits all).

3. Ask yourself when your gut instinct cries and screams at you:

"what other resources are out there that can help me shift from defeat of ethical dilemmas to champion mode?"

Here is an additional document to use in defending your case to administrators of facilities/ parties that say you should do it differently than you have decided clinically (when you in fact, are in the right):

Consensus Statement on Clinical Judgment in Health Care SettingsAOTA, APTA, ASHA

My closing thoughts about this high productivity? I go for the goal of being 100% productive:

 when in an actual session...

From the time I enter a client's presence, to the end of that session, I am accomplishing one goal: 

understanding their occupations to their fullest, jam packing my assessment and intervention with therapeutic use of self and seeing them flourish on their own to access what is meaningful to them.

REMEMBER: productivity does not equate billable time; make either effort occupation based.

Two things I kindly ask of you:

1. Leave your comments below on ways you feel productive in a one-on-one session by answering this question:

When it comes to OT, what makes your heart sing?

2. Share this with your fellow OT colleagues as we don't know what we don't know and sharing the resources is mandatory so they too can do what they do best in practice.

Thank you for stopping by,

-Lex

To stay up to date with resources, course release dates and other tools to be heard, utilized and recognized as an OT practitioner, sign up for updates at creatingconfidentots.club

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Like OT Related Podcasts?

Screenshot is from Scott Harmon's twitter page at ScottHarmon7

I had the opportunity this summer to speak with Scott Harmon on his podcast.  He is owner of Therapy 4 Kids, 2 private pediatric clinics in Arkansas. He is one of the many occupational therapists that have crossed my path on the journey to serving other therapists through the online sector.  A big thank you to Scott for not only serving other OTs, PTs and SLPs that want to start a physical practice but, inviting me to chat.  

 Be sure to stop by the episode to take a listen of snippets of my journey in travel therapy and mentoring.  This is only a fraction of what's to come! 

LISTEN HERE