Where's the OT advocacy in LTC?
I've seen several articles this year that make me wonder how many OTs working in Long Term Care (LTC) settings are incorporating advocacy into their daily practices.
Advocacy is an integral part of OT practice in several domains and processes described in the second edition of Occupational Therapy Practice Framework: Domain & Process1 ["Practice Framework" for short]. I consider OT advocacy in LTC to include intervention planning and implementation that makes sure that every resident of the LTC really has no other options but to live out his/her life in LTC. Every OT - especially those serving people already living in institutional settings, no matter how "home-like" - should be keeping the Olmstead decision2 in mind with every interaction s/he has with clients and team members, and advocating for services that will result in the least-restrictive living environments for clients, as mandated by Olmstead.
We're all familiar with people's wide-spread fear of being sent to a nursing home and getting "stuck" there. None of the articles referenced in this essay offers anything to debunk or assuage such fears.
There have been two articles in my local newspaper 3,4 concerning people whose need for LTC placement resolved, but no one within the LTC seemed to do anything to help them get discharged to more independent living situations. In the first article, the person "suddenly" became able to return to community-based living when the money paying her conservators ran out. In the most recent article, "a court is keeping Isabelle Jessich in a nursing home even though a doctor says she's sane, sober and fit to leave."
OK, I can hear you saying, "but stuff in the news is usually extreme examples: sensationalism sells papers." In response, I steer your attention to articles in OT publications:
- Magasi and Hammel's5 article in AJOT about women living in LTC when they could've still lived in the community
- Phyllis Erhlich's column in ADVANCE6, about a fellow OT's advocacy (and case management) activities that made it possible for a person in danger of being placed in LTC to remain in his home. Erhlich characterized her colleagues' efforts as going "above and beyond" an OT's "typical" responsibilities. I strenuously disagree that such interventions are "above and beyond" any OT's "typical" responsibilities; the Practice Framework and the Olmstead decision support my position.
I acknowledge the sometimes yawning chasm between what OTs know they should do and the systemic constraints that are placed on them. But OTs need to do more to help doctors, payers, local governments and the general public realize how OTs can help identify cost-effective solutions to the challenges of aging and acquired disabilities - and helping to keep people out of expensive LTC is a very visible place to start!. These types of activities involve case management (CM), either provided by the OT, or as a result of the OT's recommending that a case manager become involved, and with ongoing communication and cooperation between the OT and CM. As the AJOT article (and indeed, entire issue) emphasized, OTs are at the forefront of promoting occupational justice5. The Olmstead decision supports the concept of occupational justice, even if no such terminology is used. Maybe the current economic crisis and political attention to the flaws in U.S. health care will force people to think more creatively about alternatives to expensive institutionalization. Maybe the political crisis will also make institutions more supportive of OTs who can actually come up with implementation plans!
I want to emphasize that I have a lot of respect for OTs - and their co-workers/teams - providing services in LTC. Without all of them, life in LTCs would be as bleak as the stereotypes and sensationalist articles make it out to be. But OTs can do a lot more to make more LTC stays only temporary. Erhlich's article describes a fine example of OTs doing "what comes naturally." As such, the article echoes what I preach from this blog pulpit about case management being an integral, yet specialized, part of holistic, person-centered OT practice.
A future blog post will be a narrative of how I dealt with some LTC placement challenges when I worked in that setting.
References:
1American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
2Olmstead v. L.C., 527 U.S. 581 Sup. Ct. (1999). See also: Cottrell, R. P. F. (2005). The issue is-The Olmstead decision: Landmark opportunity or platform for rhetoric? Our collective responsibility for full community participation. American Journal of Occupational Therapy, 59, 561-568.
3Shiffer, J.E. "2 years and $672,808 gone" Minneapolis Star-Tribune, 2/15/09
4 Shiffer, J.E. "Whistleblower: 'I Feel Like I'm in Jail'" Minneapolis Star-Tribune, 8/23/09
5Magasi, S., & Hammel, J. (2009). Women with disabilities' experiences in long-term care: A case for social justice. American Journal of Occupational Therapy, 63, 35-45.
6 Ehrlich, P. (2009) Above and Beyond ADVANCE for Occupational Therapists