A therapist sits down to write a progress note. She must assess her patient’s progress towards a set of goals that were established when they first started therapy. In this document that is sent off to the doctor, the parents, and often the insurance company, the therapist must report if the patient met their goals, made measurable progress towards their goals, or maybe she’s just hoping her therapeutic jargon will effectively explain why it appears that nothing changed.
Let’s say her amazing patient met their short term goals. Hooray! Does that mean she should progress their goals and work towards a new challenge? Or has the patient met age-appropriate expectations and/or maximized their therapeutic potential?
The therapist has to carefully weigh this information, because this is the point she has to make a judgement call: are continued therapy services recommended?
Let’s first set up the scenario where the child has met their goals and demonstrates age-appropriate participation in their daily living skills. In this situation, skilled intervention is no longer warranted.
This is great news, right? No longer requiring services? No longer showing a significant delay in skills? It’s the stuff of therapy dreams!
Well… that sort of depends on who you ask.
I’ve bounded up to a parent with the news of, “Wow, they are doing so well, on track to meet all of our goals together! I think it’s time we start to think about the discharge process.” Now granted, this shouldn’t be a big shock for families, as they should be in the loop as much as possible, but sometimes that magic word, “discharge,” can lead to a wide-eyed, terrified look.
“Wait, really? Isn’t there something else we can work on?”
“But what about next year? Second grade will be really hard!”
“But they love coming!”
“But this is so good for them, I want them to stay as long as possible!”
While the resistance to ending services in this situation might seem unexpected, it happens more than you think. And while we might take a selfish second to bask in the glory of a parent’s perceived value of our services (Hey, you can’t deny it’s nice to feel appreciated every once and a while!), the resolution of this issue can get tricky. Yes, it can feel like you are taking something away from a family. A therapist is a resource. A source of comfort, a place to “check in” and give reassurance and guidance. I’ll admit that this can be a difficult relationship to let go, even when it appears that things are going really well.
I suppose we should also add in the much more disappointing side of discharge. Not when goals are met, but when the child has plateaued in progress with no signs of change. You’ve tried every avenue, every frame of reference, every adaptive and compensatory strategy, every trick up your sleeve. You’ve switched therapists, switched treatment settings, tried everything in your repertoire and then some. This is the situation when the therapist determines that maximum therapeutic potential has been met. And if they are stuck in a stagnant treatment approach, it might also be the point the therapist realizes they aren’t actually providing skilled intervention anymore.
Now, in both of these situations – either goals being met or the maximum therapeutic potential reached, the parents might not be celebrating success, but instead facing feelings of worry and unpredictability. Those feelings might also sour them on their therapist’s opinions and recommendations – but allow me to explain from the therapist’s point of view.
According to the American Occupational Therapy Association’s Code of Ethics (2015), it is the job of the therapist to “…terminate occupational therapy services in collaboration with the service recipient or responsible party when the services are no longer beneficial.”
We also can’t continue to bill a client or insurance provider for services which are not skilled. (That means the services don’t require the knowledge of a professional with specific and specialized training.) If we continue to provide services which are not skilled, then we really decrease the value of our own practice. It begs the question – well, couldn’t anyone do this? Why should insurance be paying you?
The finish line is blurry in pediatrics due to the fact that the child isn’t necessarily trying to reach a specific baseline that they had before an injury or illness. In fact, they are learning new skills all the time. So the fear that the next skill might not develop as intended can be really scary. It can also feel as if a therapist is somehow putting a limit on a child’s future – something that is almost always perceived as limitless.
However, that’s where the clinical reasoning and judgement of the therapist comes in. They make assessments which determine the need for continued services. And if they recommend discharge, that’s not to say that they can never come back!
So if a child is coming in to therapy just to swing or to complete the same series of exercises without change, the therapist has to think – where’s the skilled part of this session? Weekly therapy should not be a substitute for participation in daily exercises, tutoring, or just a fun extra-curricular activity.
This also drives the importance of the idea that caregivers and family members should be implementing strategies at home that we teach in our sessions. In fact, that’s always a main goal of therapy – to have family members or patients become independent with their home exercise programs. Just because a child starts therapy doesn’t mean they’re in it forever, and also, just because they are discharged from therapy doesn’t mean they can’t come back if things change. The idea is to continually monitor and assess if skilled intervention is necessary.
It’s a messy topic, and like much of our jobs, not as cut and dry as we might like it to be. The therapist must make sure they aren’t misappropriating services or billing insurance for non-skilled intervention, and the parents want to make sure their child gets all the assistance they need. As holistic as occupational therapy practice is, it can be easy to find something else to work on, but in the end, it’s important to determine that our services provide appropriate and effective skilled intervention.
Occupational Therapy Code of Ethics (2015). Am J Occup Ther 2015;69