PROMOTING QUALITY PRACTICE

Practice Case Study – The Reality of Managed Resources

College of Occupational Therapists of Ontario
Spring 2002

The Reality of Managed Resources, Spring 2002 – what steps can OTs take when client needs and available resources don’t match up? This scenario looks at accountable practice in changing times.



Consider the following basic scenario, one that occurs many times every day, and in every area of clinical practice:

An OT is asked to complete an assessment and make recommendations for intervention with a client. After completing the assessment, the OT completes a report that identifies several performance issues along with corresponding strategies and expected outcomes. A number of treatment sessions are recommended in order to accomplish the identified client goals.

Until very recently, and maybe still in a few isolated pockets of practice, the conclusion to this scenario would have gone some-thing like this:

The OT initiated treatment as discussed with the client and they worked on each goal until both the client and OT were satisfied that the client had achieved the fullest potential level of function, and therefore lived happily ever after…

In today’s environment the scenario more often plays out differently. Treatment planning rarely remains exclusively with the OT and client. Other individuals are actively involved in the decision-making, be it other team members, supervisors, case managers or third party payers. Treatment decisions and expected outcomes are often negotiated and ultimately determined by someone else who has responsibility to manage and deter-mine the available resources. As a result, the scenario may look more like this: The OT is advised by the case manager that only three of the four identified goals fall within the mandate of the service and half the number of requested visits will be allowed.

This conclusion to the scenario raises several questions:
  1. To what extent should the client be advised of the “gap” in recommended versus actual service delivery, and who should do so?
  2. To what extent is the case manager accountable for client outcomes and does the involvement of the case manager change the OT’s accountability?
  3. Can the client choose to “enhance” the limited service with private services? Can the same OT provide the additional service?
  4. What if the OT disagrees with the case manager’s decision? Can the OT refuse to treat?
While the fairytale description of the first ending suggests the previous system was preferable, the College does not believe that to be completely true. Increased accountability and reliance on evidence based out-comes and intervention is not a bad thing. Like anything, however, without a thoughtful, systematic and fair approach, the outcome may not lead to positive conclusions. In the last issue of On The Record, the College asked therapists to provide comment on issues related to working in a climate of managed resources. While some helpful strategies were received, not surprisingly a common feeling of concern and frustration with the system was expressed.

Most often OTs expressed concern about the degree of involvement they maintained in the decision-making process and the extent to which the necessary information was used to inform the decision. The responses also suggested considerable distress about the extent to which clients are fully informed of treatment decisions.

While the College supports the need and indeed potential benefit of a systematic approach to manage available resources, it also believes that clients should continue to receive professional, quality care. In the above scenario, the College would see it as appropriate for the OT to share the initial recommendations including intervention strategies and expected outcomes. It would also seem reason-able to expect the OT to discuss the process for decision-making and provide the client with some understanding of the OT’s recommendations with respect to treatment frequency and duration. Transparency at the outset not only supports a respectful and trusting relationship, but also opens the door for further dialogue about service delivery options. In the event the plan needs to be changed, the client will have been prepared and the OT can openly discuss the various options and establish the most appropriate means of accomplishing the goals with the available resource.

Accountability is shared throughout the system. Case managers are responsible for their own decisions, but the OT also maintains accountability for the information pro-vided to support the decision and for the delivery of service following the decision. Within a systematic and collaborative environment, the case manager’s decision would be based on the most relevant and necessary information. Therapists can help to ensure informed decisions by recommending treatment plans based on evidence and specific and realistic client outcomes. OTs can also contribute at a policy development level by providing current evidence related to expect-ed outcomes, interventions and/or discharge criteria. Once the parameters of the service have been established the OT should work with the client to achieve the best possible outcome given the available resource.

Therapists should be prepared to deal with requests from clients to secure addition-al service beyond that which is offered to them. Although employer policies and conflict of interest issues would need to be considered, the College does not directly prohibit service delivery models that allow for “top-ping up of service”. It is possible for two therapists to work with the same client if a coordinated approach with transparent and clear communication is established. More challenging, although not impossible with trans-parent practices, is a system in which the same OT provides service under two different payment structures.

The College recognizes there has been a real shift toward managed resources and that therapists, clients and health care service in general have been affected. The Council continues to explore the related issues and intends to provide further direction over the next year. In the meantime, occupational therapists should always use their professional judgment to guide their practice and serve the best interests of their clients. Although the practice environment has significant impact on OT practice, therapists should remember that they are members of a profession that supports and expects autonomous practice.