Learnings From a Complaint About Equipment Funding

(Disclaimer: this is a hypothetical case scenario; outcomes will differ from case to case.)

Background

Ashwin is an occupational therapist working in the community.  He is working with Estelle, a 72-year-old client who suffered a stroke 8 years ago, has osteoarthritis in both knees, and some mild memory difficulties. While Estelle has recovered fairly well from the stroke, she is now experiencing increasing pain in her knees, decreased balance and fatigues easily. She has been using a cane to walk but now finds herself less stable and has recently experienced a few falls at home.

Estelle lives alone in a small one-level house. Grab bars and a bath chair are set up in the bathroom and a bed-assist rail is set up by the bed.  She was previously able to walk to a nearby store for her groceries but can no longer walk the distance. Estelle’s goal is to be safe moving around her house and to use a power scooter to get to the store for groceries.

Initial Assessment

Ashwin visits Estelle at her home, completes his assessment and recommends the following:

• A rollator walker to increase safety with functional mobility.
• Community support services for meal/grocery delivery and accessible transportation.
• Energy conservation techniques and fall prevention strategies for activities of daily living.

Intervention

• Ashwin explained that there is some funding available for the walker through the Ministry’s Assistive Devices Program (ADP). Estelle said she looked into walkers and scooters at a local equipment vendor and already knows about the ADP program. Ashwin arranged with the vendor to trial a walker at home, conduct the walker assessment and complete the ADP funding application.
• Ashwin informed Estelle that ADP approval may take several weeks after he submits the form. The vendor allowed Estelle to keep the trial walker for use while waiting for funding approval of the new walker.
• Ashwin explained that she is not eligible for power scooter funding through ADP, but that there may be alternative funding or used equipment purchase options through other community organizations. He provided Estelle with names of these organizations, and she could inform him if she needed assistance to pursue further.
• Ashwin reviewed strategies for energy conservation, fall prevention, and provided written information sheets about grocery delivery and community transportation options.
• Ashwin explained that there is no need for further occupational therapy visits at this time as the funding application takes time to process. He discontinues occupational therapy service and closes the file.
• Six weeks later, Estelle gets a call from the vendor informing her that the ADP funding for the walker was approved, and they will deliver the new walker. Estelle asks about the power scooter, but the vendor says they do not have record of an ADP application for a scooter.
• Estelle is upset that she did not get approval for a power scooter as she expected. She immediately calls Ashwin with her concerns who explains the ADP eligibility criteria for mobility aids and why she did not meet the criteria for power scooter funding. He reiterates the community support options for getting groceries.
• Ashwin offers to open the file again to do a follow up visit to check on her use of the new walker, but Estelle declines.
• Frustrated by this outcome, she files a complaint with the College.

The Complaint

The College received a complaint from Estelle about the services she received from Ashwin.

When the College receives a complaint, they help the complainant identify each unique concern about specific issues they have with the occupational therapist’s practice using more standardized College language – this is called the confirmation process. The College confirms the complainant’s concerns as follows:

1. The occupational therapist failed to meet her occupational goal of using a power scooter to go to the grocery store.
2. The occupational therapist relied on the vendor to do his job. The vendor delivered the new walker and provided training for its use.
3. The occupational therapist made recommendations for meal and grocery services which had nothing to do with the equipment she needed for her occupational goals.

The Investigation Process

The College has an obligation to look into these concerns to ensure that the occupational therapist met the standards of practice. The College explains to all complainants what the College’s process can do and what it cannot. They explain to Estelle that they cannot require that Ashwin re-do his assessment or submit an ADP application for a scooter. The College does not have authority over other organizations or funding agencies. The College’s investigation and decision will focus on Ashwin’s actions and his practice.

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Learnings from Ashwin’s Practice

Concern #1: The occupational therapist failed to meet her occupational goal of using a power scooter to go to the grocery store.

• Ashwin’s documentation indicated that he spoke to Estelle about ADP’s funding criteria and that she was eligible for a walker but not a power scooter. It was not clear whether any additional information (such as written notes) was provided. Ashwin’s role is to make recommendations for safe functional mobility and help support the application for equipment funding. However, as an occupational therapist he does not control the eligibility criteria of funding agencies and whether funding gets approved; these are determined by the funding organizations.
• Ashwin’s documentation  indicated that he spoke to Estelle about alternative funding beyond ADP and other sources of obtaining a scooter.    
• The decisions on College complaints are made by a committee (the Inquiries, Complaints and Reports Committee). The committee would be aware of ADP’s funding criteria as well as the limitations that come with working with funding agencies.
• Occupational therapists are expected to be clear in communicating their role, scope of services, and if assisting with funding applications, be clear about funding criteria and program requirements. 

Considerations for occupational therapy practice:

• Explore and provide information to help clients understand all of their options and make decisions about their goals. 
• Providing supplementary written information may help clients with understanding and retaining this information. Taking the time to clarify and answer client questions may help to prevent any misunderstandings around eligibility criteria and any guarantees of funding.

Concern #2: The occupational therapist relied on the vendor to do his job. The vendor delivered the new walker and provided training for its use.

• Based on Ashwin’s role as an occupational therapist and as an ADP authorizer working in home and community care, it would be expected that he would assess, recommend, provide training and follow up for the safe use of a new walker.
• Ashwin documented that he provided education and training to the client on how to safely use the trial walker as he completed the ADP assessment and funding application. It was not clear in the notes whether he planned to follow up with the client once funding is approved and when the new walker is delivered by the vendor.
• Upon receiving Estelle’s call with concerns, Ashwin did offer to re-open the file and provide a follow-up visit, but it is evident that Estelle did not understand Ashwin’s role and the role of the vendor.

Considerations for occupational therapy practice:

• Occupational therapists must ensure they are clearly communicating their intervention plans with clients, including their role versus the vendor’s role. Some funding programs (such as ADP) have specific organizational policies and procedures that occupational therapists need to follow. Occupational therapists are expected to ensure they are in compliance with these policies and communicate their obligations to all parties involved.
• When discontinuing services, clients should be informed of any follow-up plans and the process for re-initiating occupational therapy services should there be a need in the future.

Concern #3: The occupational therapist made recommendations for meal and grocery services which had nothing to do with the equipment she needed for her occupational goals.

• It may not have been clear to Estelle what Ashwin was working on in relation to the occupational therapy goals. Ashwin documented in the notes that the goal was to help Estelle access groceries since she could no longer safely walk the distance to the grocery store. As a result, he suggested meal/grocery delivery services and options for community transportation, but Estelle may have misinterpreted Ashwin’s intentions.

Consideration for occupational therapy practice:

• It is good practice for occupational therapists to explain their rationale for the recommendations made and review the goals being addressed on an ongoing basis. Clear communication is key to preventing misunderstandings and unmet expectations. Documentation of these communications help to support the occupational therapist’s work.

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Decision from the Investigation

Based on the nature of the concerns submitted and the information included in Ashwin’s documentation, the College’s committee concluded that the occupational therapist met the relevant practice standards and decided to take no action in this case. The committee can appreciate that the outcome of the services was not what Estelle had initially expected, but Ashwin’s actions made clear his intention was to address his client’s needs within the confines of what the ADP funding would allow. Ashwin documented his assessment, his recommendations, his clinical reasoning for his planned actions, and what happened throughout the file. Ashwin also communicated with Estelle to the best of his ability and documented those communications. After reviewing this information, the committee did not have concerns about his practice and provided a copy of its written decision to Ashwin

*Please note that each case has unique circumstances and decisions may vary based on those circumstances.

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Conclusion

Even with the best intentions of occupational therapists, complaints can happen especially in situations when clients do not end up receiving the funding or equipment, they feel they need. Helping clients understand what will happen during an assessment, equipment trials, and how the funding criteria and process works may help them be more prepared for the possible outcomes. These situations may be complex, involving multiple parties such as the occupational therapist, vendors, funding organizations, and other community agencies. Taking the time to clarify each person’s roles and responsibilities, providing alternative options, including supplemental information (such as 1-pagers, or brochures), and answering client questions will be key to preventing misunderstandings.

Anyone can make a complaint to the College about an occupational therapist. In every case, the College takes concerns seriously and follows a fair and objective review process. It’s important to know that each situation is different, and therefore outcomes and decisions may vary based on the circumstances. Even in cases with miscommunications or misunderstandings, the College is obligated to review to ensure that occupational therapists are following the Standards of Practice, that the documentation is comprehensive, organized, include all communications, and provide clear rationale to support clinical decisions.