How to Deal When Your Patient Is Inappropriate for Therapy Services
Is it possible to care for a patient when you know they really do not need occupational therapy services?
Unfortunately, this is a common ethical dilemma occupational therapists face on the job.
There are times where you will find yourself torn between advocating for a patient but you know they are not appropriate for therapy.
Typically this happens because management loses sight of what is most important – helping people that truly need OT. In order to meet targets for productivity and profits, sometimes patients are recommended for OT that truly do not need it.
Because of this, I wanted to provide you with a case study showing an inappropriate OT referral along with tips that you can use if a situation like this arises.
The following scenario is based on an incident that actually occurred, with some minor changes for the sake of confidentiality on behalf of the patient and the facility:
Joseph was a 79-year old male patient admitted to a skilled nursing facility for the third time in the last year. In the past, he had been receiving regular chemo and radiation therapies for an aggressive cancer that was attacking his right femur and hip.
Upon his recent admission, he decided to stop both treatments, but did not opt for hospice care. Because of his insurance situation as a result of being a war veteran, the policy of the skilled nursing facility was to provide all rehabilitation therapies including speech, physical, and occupational therapy.
Here is the kicker: Joseph sustained a complete fracture in his right femur due to necrosis of the bone. His doctor ordered a non-weight-bearing status on his right leg and instructed that he not participate in any standing tasks whatsoever. He could only sit up in bed up to 45 degrees and no further for 15-minute intervals.
The occupational therapist went in to evaluate Joseph for rehabilitation services. He failed his mini-mental exam. He was falling in and out of sleep due to severe malnourishment. The patient admitted that he hadn’t eaten a solid meal for several days due to some dental problems and being too weak to chew his food. Speech therapy placed the patient on a thickened liquids and puree diet just to be safe. Although the patient had a personal goal to eat better, he did not want to address anything else due to severe pain and fatigue.
Four days of OT services for self-feeding went by and the patient’s condition was worsening. The patient was desaturating during treatments and experienced severe leg pain to the point where prescription drugs were no longer remedying the issue. He could only muster enough energy to stay awake for about five minutes of each session.
As his participation levels decreased, the facility’s demands to get more treatment minutes increased. After 5 treatments, the OT decided that she’d had enough, thinking that her services were causing more harm than good. She reported her concerns to her team leader, who put in a request for a medical hold on all therapy services.
The very next day, Joseph passed away.
This is an unfortunate and all too common scenario that can be seen in acute care, inpatient rehab, or sub-acute rehab, just to name a few settings. To prevent this type of situation, read on for actionable tips.
When Patients Are Inappropriate for Therapy
There are multiple medical and non-medical reasons why certain patients/clients should be considered inappropriate for occupational therapy services.
This could include severe conditions, like in the case study, where therapy actually causes more harm than good. Other examples include that the patient continuously provided verbal refusal to participate in therapy services or the patient is too high-functioning in all treatment areas.
Conducting an Honest Evaluation
For brand new clinicians or Level II fieldwork students, it may be difficult to answer this question:
“Did I complete a thorough enough evaluation or is this patient really NOT in need of my services?”
To answer this question, it is important to look into the details of your assessment.
Did you cover everything relevant to the patient’s functional goals and everything within your scope of practice according to the Occupational Therapy Practice Act?
“Evaluation of factors affecting activities of daily living (ADL), instrumental activities of daily living 10 (IADL), education, work, play, leisure, and social participation, including: 11 1. Client factors, including body functions (such as neuromuscular,sensory, visual, perceptual, cognitive) 12 and body structures (such as cardiovascular, digestive, integumentary, genitourinary systems). 13 2. Habits, routines, roles, and behavior patterns. 14 3. Cultural, physical, environmental, social, and spiritual contexts and activity demands that affect 15 performance. 16 4. Performance skills, including motor, process, and communication/interaction skills” (OT Practice Act, AOTA, 2007).
With years of practice, even the best clinicians box themselves into just ADLs and therapeutic exercise failing to see other intervention approaches.
However, if you have made a good faith effort in your evaluation and come to the conclusion that the patient is inappropriate for therapy, then it is time to take a different route.
If you have concluded that the patient is NOT qualified for occupational therapy services, follow these steps to make sure the case is handled appropriately and professionally.
1. Take your concerns to your team leader or rehab director
Keep in mind that you’re going to have to make a case for your decision. Facilities are under constant pressure for reimbursement since in the real world, good healthcare comes down to money. It is your job to support your patient with optimal healthcare, but it is administration’s job to run a business.
2. Walk in with the right mindset
Remember that it is not about you, it is about your patient. Do not approach your boss in a combative way while imagining what your resignation letter will look like if they force you to take this patient onto your caseload.
If your team leader is generally an understanding individual, then be ready to have a discussion. Yes, your boss will question your evaluation but consider it a good way to keep your skills in check. You’re a clinician, but you’re also human and sometimes OTs can miss things on evaluations.
3. Prepare your case based on the evaluation findings
OTs, like any other healthcare providers, like quantitative data to support their clinical findings. Display to your boss what your evaluation revealed about your patient in the most standardized way: Cognitive assessments, manual muscles tests, pain scales, range of motion, vitals at rest and with activity, etc.
Note all assist levels for all relevant ADLs and IADLs. The proof is in the numbers and can go two ways: either the patient is the epitome of health and won’t benefit from additional intervention or the patient’s condition is too dangerous to be addressed by therapy.
Don’t be surprised if your team leader takes your findings to the primary physician for dispute in order to access a medical hold. Just because your patient is inappropriate for services now doesn’t mean that won’t change further down the road.
4. Lay down the law
This should only happen if your team leader is forcefully placing the patient on therapy caseload despite your argument. If you feel that your patient is still inappropriate for therapy and that your boss is making you take on the patient for insurance reasons, verbalize or write down your legal standpoint. Although you are advocating for your patient’s health, you must also remember that your license is on the line if you cause any harm!
Review the OT Code of Ethics as well as the AOTA OT Practice Act. The Code of Ethics may be “guidelines”, but such guidelines are carefully woven into the Practice Act for licensure which means you can still be subject to legal action for violating those ethical codes. Consult with regional managers if the dispute continues further.
While this is a very difficult situation, you should not feel forced by your company to commit unethical practice when your patient is inappropriate for occupational therapy.
Remember that you don’t have to do it alone. Find other OTs you can trust and raise serious concerns to the regulatory board. It is the best thing you can do for yourself, your profession, and above all else, the patient.