What more could an OT have done?
An article in Aging Well Magazine1 tells the story about an elderly woman named Margaret who, for nearly 8 years, managed to stay in her own home despite strenuous efforts to assign her to long-term-care (LTC) "before her time".
The article describes Margaret as an intelligent woman with strong self-advocacy and creative problem-solving skills. She hired the author, a social worker named Carol Heape, to help her continue to live in a house that Margaret had bought and remodeled according to her own specifications while she was fighting to be discharged from a nursing home. OT was never mentioned in the article, so there's no way to know if any of the adaptations or assistive devices Margaret was using had been chosen with any input from an OT.
I'm not going to summarize the article; please read it for yourself online. Meanwhile, I'd like you to consider how an OT in Ms. Heape's Geriatric Case Management (GCM) position might have responded to some of the challenges Margaret faced:
- Margaret couldn't afford more than a few hours per day of personal care assistance, so "was out of bed and in her wheelchair only a few hours each day". If the GCM had been an OT, could s/he have helped Margaret develop ways to spend less time in bed?
- Margaret had a voice-activated phone set up, but it wasn't close enough to her bed - where she spent so much time - for Margaret to be able to use it. I believe an OT-GCM could have helped Margaret find a better EADL match than that - either by finding a different type of communication device within Margaret's limited budget, or creating a more functional user-environment-device interface with the device she ended up with.
- Margaret left her front door unlocked when she was expecting visitors. How might an OT-GCM address this safety and security risk?
- Sometimes Margaret's scheduled care provider would fail to show up, and Margaret would phone Ms. Heape in a panic. Could an OT-GCM have helped Margaret devise some fall-back strategies to make such incidents less of an emergency?
- Occasionally, Margaret would be hospitalized with pneumonia. Could an OT-GCM been more effective in helping Margaret develop functional and occupational adaptations that would help decrease her risk of pneumonia?
- Margaret received a holiday gift basket and "sent a handwritten thank you note that we all knew had taken her an hour to write with her crippled hands." An OT-GCM could've helped Margaret with joint protection strategies and inexpensive adaptations.
- Ms. Heape helped Margaret evade a return to LTC placement for nearly 8 years. Could an OT-GCM have staved off the placement even longer if some of the issues listed above had been addressed in uniquely OT fashion?
Margaret's limited finances apparently precluded a referral to "official" OT services in her home (and I assume Ms. Heape ruled out Margaret's eligibility for home-health OT under Medicare). But some challenges don't require "medical model" OT interventions, with the rules about physician referrals, frequency and time units, etc.; but rather can be addressed as they come up during "general purpose" interactions between a case manager who's also an OT, and the people the OTCM is serving. In my career as a case manager, I have had many opportunities for "single-visit" OT interventions that addressed challenges my clients mentioned in the course of a CM visit, and which we solved before I left that appointment. I'll save those examples for another time; but I think Margaret's story provides a good frame of reference from which to understand how OTs practicing under case management job titles can continue to practice OT "as we know it".
1 Heape, C.S. (2009) "A Lesson in Determination" AgingWell 2(2) March/April 2009, 42