Sequence and Transition of Care of Occupational Therapy Settings in the Healthcare System

Occupational Therapy Healthcare Settings

How does the public typically receive occupational therapy services in the US healthcare system? This post will describe a common progression of settings that patients/clients will experience from admission to discharge.

Emergency

A patient, family member, or bystander activates 911 and the emergency response system to call for an ambulance or a patient may be privately transported to go to the emergency room.

Occupational therapists may screen and see patients in the emergency room after receiving an order from a MD. As patients have a high chance of becoming discharged, occupational therapists often to not conduct a full evaluation or perform multiple treats. OTs may educate patients and refer them to resources that they may benefit from.

Acute Care

From the emergency room, the patient may be admitted to various acute settings: directly to surgery (such as with a MI), ICU, general med surg, or a particular unit (cardiac/tele, neuro, ortho, psych, etc.). Occupational therapists often initiate OT services in this setting after receiving an MD order for OT.

Frequency and duration of treatment varies based on client condition, how close they are to baseline, prognosis, funding, and even OT staff availability. If OT is short-staffed, lower acuity (less sick) patients may get bumped until the next day when more OT staff is available. Treatment can be eval and discharge, 1x only, every day, 5x/wk, 3x/wk, 2x/wk. Duration typically averages 1 – 2 weeks. Patients are often discharged before treatment orders expire due to improvement (best scenario), transferring to another facility (e.g., SNF), or leaving against medical advice (AMA).

OTs may conduct screens, full evaluations, treatments, re-assessments, co-treat, or discharge. OTs working in acute care consider discharge plans as early as first interaction as they can go to many different settings:

  • Remain in acute care and continue OT
  • Discharge OT completely
  • Transfer to ARU/IRF (important to consider if patient is an “ARU candidate”)
  • Transfer to SNF/LTAC
  • Continue OT in home health
  • Continue OT in outpatient
  • Referral to other OT settings and services, e.g. driver rehab

Inpatient Psych

Patients may transfer to an inpatient (locked) psych unit and receive psychosocial OT. Patients learn and receive interventions for OT in BADLs, IADLs, social skills, work/school, community reintegration, coping with symptoms, group therapy in conjunction with counseling, psychologists/psychiatrists/LMFTs, MD, nursing, and substance programs.

ARU/IRF

Patients typically admit to the Acute Rehab Unit/Inpatient Rehab Facility from acute care. Acute care OTs play an important role in referring ARU candidates to ARU by communicating with doctors, nurses, case managers, PT (basically the entire team). Most of the team is often in agreement because patients in ARU are required and expected to meet certain requirements (under Medicare — gold standard for insurance):

  • Be able to tolerate 3 hours of therapy/day, 6-7 days a week.
  • LOS 1 week – several weeks (based on reassessment).
  • May D/C early if progressed and has met goals.
  • Patients may experience a “bad day” and be exempt from a day or more and OT would document a medical exception in ARU.
  • Therapies are typically OT+PT+SLP, but can also be OT+PT (speech is not justified or discharges — in which case OT + PT see patient for a combined 3 hrs/day).
  • Patients are typically under the care of a Physiatrist.
  • Patients receive services from nursing, nursing aides, case management, social workers, other doctors and specialists (as indicated), dieticians, psychologists/psychiatrists, and other disciplines in the hospital.
  • Patients may receive outpatient consultations from other allied health professionals and vendors, e.g. wheelchair, prostheticist while in ARU.
  • OTs typically document with the CARE TOOL/CMS IRF-PAI (which replaced FIM).
  • Patients may transfer back to acute care (exacerbation of condition), discharge home (best scenario), to skilled nursing (SNF), or another outpatient setting (e.g., live-in neuro skills program).

Skilled Nursing Facility/LTAC

Patients may get transferred (typically by EMTs) to a SNF where they continue OT services. The documentation is forwarded to the OT at the SNF who will conduct a new evaluation and set new treatment goals, frequencies, and duration. SNF LOS is longer than ARU and can be weeks/months/years (rare).

Home Health OT

Patient would typically be driven home or be transported by EMTs to their home (or a safe environment temporarily until they are safe to go back to their own home). Patient may discharge home (if deemed safe by the team) or receive the assistance from caregivers (personal, friends, neighbors, hired). Hired caregivers are typically very expensive and many patients without financial resources often cannot afford to hire. Case management would initiate a smooth transition of services including the home health to come (when available) – varies, can be a delay of start of OT based on location and availability of HH-OT and insurance. Frequency and duration varies but is much less than acute care, ARU, and SNF – several days a week for a week or several weeks and discharged.

Patients receive home health OT typically because they are homebound. Going to outpatient OT would either be unsafe or not clinically indicated. Patients may transition from home health OT to outpatient OT if these barriers are overcome (personal, environmental, caregiver, medical condition, availability of services).

Outpatient OT

Patients were discharged home and do not meet homebound criteria. Patients may drive themselves or be driven to appointments. Duration and frequency also varies and can be several days a week for a week or several. OP-OTs also conduct their own evaluations, treats, re-assessments, and discharges.

Other Outpatient Settings with OT

Ideally, patients are identified as candidates for such settings as early as possible so that appropriate personnel can consult and screen patients for these settings. This can occur in acute, ARU, SNF/LTAC, outpatient, or in home health. An example of a setting is Centre for Neuro Skills: Traumatic Brain Injury Rehabilitation where the client lives on site and receives rehabilitation until discharged in the community.

Homeless clients may be discharged to homeless shelters (no OT).

Patients may transfer to mental health settings including inpatient psych or outpatient behavior health (e.g., CBT program) and receive psychosocial OT.