Practice Settings, Dosing, and Discharge in Adult OT

What does dosing in occupational therapy (OT) refer to?

The specific combination of frequency, intensity, duration, and type of intervention provided to a client.

What are the key components of dosing in OT?

Frequency, intensity, duration, and type of intervention.

What is frequency?

Number of treatment sessions over a given period such as sessions per week or month.

What is intensity?

Length of each session

What is duration?

Total length of intervention plan

What is type?

What interventions are being applied (FORs)

What factors influence dosing in OT?

Client factors, evidence-based practice, reimbursement/setting requirements, and goals of therapy/expected progress.

What are the primary practice settings for OT?

Acute care, inpatient rehab, skilled nursing facility (SNF), subacute rehab, outpatient, home health, community practice, work site, and telehealth.

What is the role of OT in inpatient settings?

Education, initiation of rehab process, and consultation

Education includes...

Safety precautions, activity analysis, and caregiver/staff training

Initiation of rehab process includes...

Early mobility and occupational engagement, beginning rehab for patients who will have institutional discharge, preventing institutional discharge all together

Consultation includes...

Discharge disposition recommendation, discharge equipment recommendations

What is the duration in acute care?

Dependent on length of stay and diagnosis. Highly variable and not usually stated outright in POC.

How often are patients typically reassessed in acute care?

Every 2 weeks.

Intensity of dosing in acute care

Highly variable based on diagnosis, unit, and patient activity tolerance. Average 30-60 mins but not typically stated outright in POC.

What patients typically require more prep time and rest breaks?

ICU patients

Frequency of dosing in acute care

1-7 times per week depending on certain factors.

Type of dosing in acute care

FORs include biomechanical, rehabilitative, sensorimotor, and cognitive disabilities with heavy emphasis on task specific training.

What is inpatient rehab?

Hospital based rehab for patients who are medically stable, not physically ready to return home yet, and are able to tolerate 3 hours of therapy per day.

What are patient requirements to qualify for IPR?

Able to tolerate 3 hours of therapy per day and must require at least 2 rehab disciplines.

What is OT's main role in IPR?

Rehab in all areas of occupation to facilitate discharge home.

What is the typical duration of stay in inpatient rehabilitation?

Typically 1-3 weeks, dictated by payer source.

What is the minimum frequency of therapy sessions for patients in inpatient rehabilitation?

Patients must be seen a minimum of 15 hours per week (5-7 days each week).

What is the dosing of intensity of IPR?

30, 60, or 90 minute sessions.

What types of interventions are emphasized in inpatient rehabilitation?

Biomechanical, rehabilitative, sensorimotor, and cognitive disabilities with a focus on task-specific training and high repetitions.

What is subacute rehabilitation?

A short term, more intensive form of care than typical SNF long term care to bridge the gap between acute care hospitals and home or skilled nursing facilities.

What are the Medicare requirements for subacute rehabilitation?

Patients must have had at least a 3-day hospital stay and be admitted within 30 days of discharge from acute care. Medicare A (max 100 days).

Frequency of subacute rehab?

Minimum of 5 days of therapy per week but can be divided between all rehab disciplines.

Intensity of subacute rehab?

No minimum for this setting. Will vary on pt needs but typically 30-60 mins.

Dosing type in subacute rehab?

Similar to IPR

What is skilled nursing?

Long term, provides ongoing nursing care, assistance with daily tasks, and rehab therapies to maintain a good QOL.

Duration in a SNF

No fixed limit. Must demonstrate medical necessity with each episode of care.

Who pays for therapy in a SNF?

Medicare B

What is the frequency of therapy sessions in skilled nursing facilities?

Will vary depending on pt needs and rate of progression.

Intensity of SNF?

Varies depending on pt activity tolerance, diagnosis, and anticipated progress but typically 30-60 mins.

Dosing type in SNF?

Similar to IPR

What is outpatient rehab?

Provided in hospitals and freestanding clinics to clients who reside at home. Medically stable patients and able to tolerate a few hours of therapy and travel to clinic. May be adjusting to a new disability of functional status and equipment related issues.

Dosing in outpatient is heavily dictated by what?

Payer source

Most adults under 65 use ______ in outpatient settings.

Private insurance

What would cause Medicare B to deny pay in outpatient settings?

If the pt does not demonstrate medical necessity

What is the typical duration of therapy sessions in outpatient settings?

Typically 30-60 minute sessions, 1-3 times per week, for several weeks (4-12 weeks or more).

What are the primary roles of OT in home healthcare?

Rehabilitation of ADL/IADL performance and environmental/home modifications.

What is required for a patient to qualify for home healthcare OT services?

The patient must be homebound, require intermittent care, and have a physician order.

Duration of OT in home health

POC must be recertified every 60 days to demo medical necessity

Frequency of home health

Typically 1-3 times per week

Duration in home health

30-60 min sessions

Type in home health

No specialty equipment in this setting will affect treatment choices available.

What is ALF?

OT services provided on consultative basis to foster and enhance the habits and routines necessary to remain housed in this environment, which often includes personal care skills such as dressing, grooming, hygiene, and simple home care tasks.

What is dosing in ALF?

Similar to outpatient environment since reimbursement is similar

Community based programs include...

Community centers providing health promotion and social engagement for all ages, workforce development programs for job readiness, homeless shelters and transitional housing for independent living skills, public health initiatives focused on wellness and disease prevention, and organizations like those that perform home modifications for seniors.

What is reimbursement in community based programs?

Out of pocket or charity based.

Dosing in community programs

Highly unique to clients needs and program objectives because they are not bound by traditional payer sources.

What is the definition of telehealth in OT?

The application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technology.

Role of OT in telehealth

Help clients develop skills, incorporate AT and adaptive techniques, modify work, home, or school environment, create health promoting habits and routines.

What are the benefits of telehealth in OT?

Increased access to services, improved access to specialists, prevention of delays in receiving care, and sharing expertise between practitioners.

The OT must be _____ in the state they are practiiving, and state that client is receiving services

licensed

Dosing in telehealth

Similar to outpatient, however, type of service being offered will be limited. Patient must be able to engage in meaningful treatment activities either independently or with assist from caregiver with OT providing skilled guidance/education.

What are the reasons for formal discontinuation of OT services?

Return to baseline level of function, goal achievement, plateaued progress, or alternative resources.

What is the primary role of OT in discharge planning during acute care?

To recommend discharge disposition, supports, services, and equipment.

What types of equipment might be recommended during discharge planning?

High back reclining chairs, quad canes, platform attachments for walkers, hip kits, and various types of wheelchairs.

What is the ultimate goal for patients in inpatient rehab and subacute rehab?

To discharge home.

If discharge from IPR/subacute rehab is not possible, then...

long term solutions must be established (SNF, ALF, etc).

Even if discharging home, ______ may still be indicated

Follow up services such as outpatient, home health, community programs, etc.

What is emphasized in discharge planning for inpatient rehab and subacute rehab?

Caregiver training to encourage safe transition.

What is the role of case management in inpatient settings?

To coordinate all discharge recommendations, including ordering equipment and organizing discharge location. Can be RNs or LCSW

What is the role of OT in community-based settings like assisted living facilities (ALF)?

To provide consultative services to enhance habits and routines necessary for residents.