Role of Occupational Therapy in Case Management and Care Coordination for Clients With Complex Conditions

For the past three decades, the federal government has been initiating programs to control the rate of escalating costs of health care (Remington, 2015). The general belief, expressed most often in the Triple Aim perspective, is that the growth rate of care costs needs to decrease while the quality of care needs to improve to cost-effectively meet the needs of all Americans (Whittington, Nolan, Lewis, & Torres, 2015). This belief is especially strong in discussions of ways to meet the needs of those who are newly insured under the Patient Protection and Affordable Care Act (2010; ACA; Pub. L. 111–148; Gilmer, 2011).

Congress, federal agencies, health care policymakers, the insurance industry, and health care providers continue to discuss strategies and methods for controlling escalating health care costs while achieving improved outcomes and better societal health. The expectation in the 21st century is that the U.S. health care system must be transformed from one that promotes volume of service to one that promotes value of care. The changes happening now and anticipated for the future will require health care practitioners—including occupational therapy practitioners—to focus on sustained outcomes for the clients they serve. These outcomes need to include improvement in the client’s health and lifestyle, not just mitigation of illness, injury, or disease. Approaches to developing healthier behaviors, methods of increasing access to care, and improved care coordination over the life of the client are needed.

This new system is a game changer both for the insurance industry and for health care providers. These stakeholders need to be flexible and collaborative, embrace new roles, and think differently about client care. One group of providers that can be more than they are now is occupational therapy practitioners. Flexibility is basic to the profession of occupational therapy. Because each client’s circumstances are distinct with regard to health and life status, occupational therapy practitioners consider the context and situations of the client’s everyday life. Occupational therapy practitioners’ perspective, education, and skills are well suited to managing care to ensure clients’ full recovery, optimum health, and maximum participation.

Many methods have emerged that are proven to achieve savings in the health care system, but these methods will not result in sufficient savings with current demographic trends (e.g., aging baby boomers) and as newly insured people obtain access to care and services. The leg of the Triple Aim addressing the client’s experience of care received attention in the ACA; many pilot initiatives and new approaches begun through the ACA include significant attention to client satisfaction and engagement. With this policy push, the concept of client engagement as affecting health outcomes and compliance is gaining new attention and has reached virtually every part of the health care system (Greene, Hibbard, Sacks, Overton, & Parrotta, 2015). What is clear with the new approaches is that care coordination, implemented with promotion of optimum client self-management, is critical and must be a thread throughout all payment, reimbursement, quality, and outcomes reforms (Lorig, Gonzalez, & Laurent, 2006; Remington, 2015). Occupational therapy practitioners have the skills, knowledge, and capacity to play an important role in the changing systems, particularly with regard to case management and care coordination.

Golden (2015) suggested that case management and care coordination are essential in initiatives to help reduce costs to the health care system and noted that they are a part of alternative systems available through the ACA. Golden asserted that care coordination should include but not be limited to being client centered, supporting families and caregivers, using an interdisciplinary approach, bridging health and social services, and promoting access. Because complex health cases are so numerous and so costly, effective management, and not just coordination, of services must be the hallmark of case management in the future system (Anderson & Horvath, 2004). The Commission for Case Manager Certification (CCMC; 2013) described case managers as the conduit for facilitating care transitions for clients with complex conditions and lessening the possibility of these clients being lost in the system. According to Golden, “teams need to be coordinated and collaborative, recognizing the important perspective that each provider brings to the table—whether they’re a nurse practitioner, a social worker, an occupational therapist, or a direct care worker” (p. 22).

Case managers are collaborators. Occupational therapy was founded on collaboration. The founders of occupational therapy were from various disciplines, including medicine, nursing, architecture, and social work (Quiroga, 1995), so by nature of occupational therapy’s founding circumstances, the profession recognizes and values collaboration. Chapleau, Seroczynski, Meyers, Lamb, and Haynes (2011) noted that occupational therapy adds valuable contributions to team outcomes because it includes “services for health promotion, including self-care management, cognitive assessments, activity-based programming, and home safety evaluation and modification” (p. 71).

It is now an accepted goal of the health care system to better manage the care of clients and improve client response to and participation in care. Occupational therapy practitioners can bring critical value to these important processes and positions in case management, discharge planning, and related coordination activities. Occupational therapy can look to its history and revitalize many of the primary concepts on which it has been built to maximize occupational therapy’s contribution to achievement of the Triple Aim.

For almost a century, occupational therapists have developed intervention plans promoting clients’ optimum occupational performance in life activities despite any physical, mental, environmental, or attitudinal barriers. Optimum interventions include wellness and prevention strategies, promotion of self-sufficiency, and skills training to achieve independence (American Occupational Therapy Association [AOTA], 2014; Christiansen, 1991). Occupational therapy practitioners are educated to help people “achieve health, well-being, and participation in life through engagement in occupation” (AOTA, 2014, p. S4). As they do with their clients, occupational therapy practitioners themselves are always looking for new opportunities to do things differently. With their multiple skills and knowledge in activity analysis, psychosocial interactions, disability, disease progression, and daily life habits and routines, occupational therapy practitioners are well prepared to recognize opportunities to use their education and abilities for new purposes.

Contemporary and competent practice is expanding in case management, health promotion, education, and self-advocacy (AOTA, 2014). A premise of occupational therapy is that clients should engage in their own health care, which fosters participation and promotes quality of life. From an occupational therapy perspective, occupations “are various kinds of life activities in which individuals, groups, or populations engage” (AOTA, 2014, p. S19) and include activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014; Quiroga, 1995). Research supports the assertion that occupational therapy intervention and the activities it promotes help clients achieve better mental and physical health and improve cost outcomes (Clark et al., 1997, 2001; Hay et al., 2002).

If the new health care systems are to be effective, they must take into account clients’ self-identified goals, their various medical conditions, and their social and environmental situations and supports. In the past, the strict medical model of addressing only acute disease did not provide a holistic approach to client care. Little or no attention was paid to the social and environmental factors influencing the health and well-being of clients. Occupational therapy hit a bull’s eye well before it became generally recognized that the health system needed to change: The discipline has always specifically identified the importance of both environment and social participation in the context of occupations; social participation is “the interweaving of occupation to support desired engagement in community and family activities as well as those involving peers and friends” (Gillen & Schell, 2014, p. 607).

As the changes in health care began, Baum and Law (1997) discussed this holistic perspective of occupational therapy. In a relatively early call to action, they reminded occupational therapy practitioners to continue using their sociomedical approach and to build healthy communities where they are employed, regardless of the population (Baum & Law, 1997; Roberts & Robinson, 2014). This call to action is a perfect description of how to fully achieve the Triple Aim with the front-and-center involvement of occupational therapy.

Occupational therapy practitioners are providers of health education and promotion and case management and coordination to clients with chronic diseases; education on these topics is required by occupational therapy educational accreditation standards. Practitioners’ specialized education in physical and developmental disabilities and pathology, mental health and psychopathology, environmental assessment, assistive technology, management, advocacy, and practical clinical experiences prepares us to be case managers. Krupa and Clark (1995) suggested that occupational therapy practitioners’ training and skills in functional assessments, task analysis, environmental assessments, adaptation, compensation, and remediation all enhance successful and satisfying performance in occupational therapy clients, uniquely positioning practitioners to assume case management and care coordination roles. These general topics in didactic education create a baseline of knowledge and ability to analyze performance that translate in practice to interventions that address issues related to chronic and complex conditions, such as energy conservation, work simplification, and self-regulation.

All entry-level occupational therapy professional educational programs, to meet accreditation standards (Accreditation Council for Occupational Therapy Education^® [ACOTE^®], 2012), must show evidence that students are educated to have the following skills:

• Use sound judgment in regard to safety in the context of environment, occupational performance, and self-management during the occupational therapy process (Standard B.2.8)

• Express support for the quality of life, well-being, and occupations of all they serve, promoting biopsychosocial health and prevention of injury and disease while considering context and environments (Standard B.2.9)

• Provide training in self-care, self-management, health management and maintenance, home management, and community and work integration (Standard B.5.5)

• Monitor and reassess the effect of occupational therapy intervention in collaboration with the client, caregiver, family, and significant others and the need to continue or modify intervention (Standard B.5.28)

• Demonstrate safe and effective application of modalities as a preparatory measure to manage pain and improve occupational performance (Standard B.5.15)

• Demonstrate knowledge of prevailing health and welfare needs of populations with or at risk for disability and chronic health conditions (Standard B.1.6)

• Understand the role of occupational therapy in care coordination, case management, and transition services in all practice environments (Standard B.5.27)

• Explain how occupation influences promotion of health and prevents disease and disability for individuals, families, and society in general (Standard B.2.5).

Fisher (1996) was an early proponent of occupational therapy practitioners being appropriate for the role of case manager. He suggested that occupational therapy practitioners consider employment in case management because they are expansive and holistic in their approach and focus on function, independence, productivity, and participation. Baldwin and Fisher (2005) found that the educational premises and standards taught in occupational therapy programs paralleled the fundamental concepts of case management as defined by the Case Management Society of America, including holistic (i.e., medical, spiritual, and psychosocial) management of chronic and complex conditions. They concluded that case management concepts and principles are provided to most occupational therapy students during their professional training and should be incorporated into the academic standards. Many of the recommendations of these authors were incorporated into the 2011 ACOTE accreditation standards (ACOTE, 2012).

Since 1992, the CCMC has provided the certification examination that has become the national gold standard for case management credentialing. Occupational therapy practitioners are among the many professionals who have added Certified Case Manager (CCM) to their credentials. It is clear that the underlying education of occupational therapy ensures competency in the critical areas emphasized by the CCMC. Skills and knowledge in coordinating care, managing multidisciplinary teams, and achieving better care transitions are, as noted, components of occupational therapy education. The ACOTE academic standards promote educational curricula that well prepare occupational therapy practitioners to move into roles as case managers specifically for clients who have chronic conditions (physical, mental, or developmental disabilities).

Occupational therapy practitioners with or without the CCM credential can and should assume positions and roles as case managers because they understand pathology, the complexity of medical issues and care, and the ways complex conditions disrupt everyday functioning. For these reasons, occupational therapy practitioners are able to identify obstacles preventing access to effective care, to participate in that care, and to help clients maintain healthy behaviors at home. The CCMC (2013) has defined case management as the process of managing client wellness and autonomy through advocacy, communication, education, and identification and facilitation of services: This is occupational therapy.

Occupational therapy practitioners may not consider applying for positions in case management if the job advertisements request a nurse or social worker and do not specifically ask for an occupational therapy credential. Anecdotally, compensation for case managers typically is not competitive with traditional compensation for occupational therapy practitioners, who generally are paid more than nurses and social workers (Bureau of Labor Statistics, 2015). However, occupational therapy practitioners are frequently sought out to consult with case managers because of their expertise in understanding how people function in their homes and communities and perform independently at home, work, and school (Chapleau et al., 2011). Occupational therapy practitioners must take advantage of opportunities to consult and thus promote the broader case management skills they possess to further interdisciplinary knowledge and awareness of occupational therapy.

In some settings, the provider of case management cannot be a direct provider of services. Being a direct provider and doing case management for the same client is believed to impede the practitioner’s ability to be objective and provide fair and equitable case management. This division of labor does not mean that the direct service professional is not qualified to provide case management; it simply means that the service provider for a particular client is not able to be that client’s case manager. A change in attitude toward recognition that direct service occupational therapy practitioners are qualified to provide case management would pave the way for many more practitioners to move into case management roles when not providing direct services to clients. Occupational therapy case managers can always pursue an appropriate referral to another practitioner to meet any identified occupational therapy treatment needs.

As noted earlier the holistic principles and philosophy of occupational therapy are closely aligned with fundamental concepts of case management, and the case management approach is fundamental to the profession. Occupational therapy practitioners work with clients using a wide lens to understand, identify, and then address occupational imbalance; seek to understand their experience of function and dysfunction in context; and use the tools of client-centered approach and therapeutic use of self to better understand clients’ unmet needs (McColl, 1994). Occupational therapy practitioners are well prepared to assume case management and care coordination roles because basic occupational therapy education includes the comprehension and understanding of the transactional relationships among the person, his or her engagement in valued occupations and roles, the environment, client factors, and the performance skills needed for successful participation in everyday life (AOTA, 2014).

Occupational therapy practitioners are positioned to provide case management for clients with chronic diseases because the profession’s entire existence has been dedicated to working with these clients to address their pathology; psychosocial capacities and needs; and the important components of roles, behaviors, and routines. For example, for a mother who has rheumatoid arthritis, practitioners understand the importance of time management, pacing, energy conservation, work simplification, and disease-specific equipment; attention to these needs must be embedded within traditional case management services (Hand, Law, & McColl, 2011).

Last, as reported earlier, ACOTE (2012) educational standards ensure that entry-level practitioners possess foundational case management knowledge through specific education about prevailing health and welfare needs of populations with or at risk for disabilities and chronic health conditions and about the role of occupational therapy in care coordination, case management, and transition services in all practice environments.

Another key aspect of case management, and an element critical to achieving the Triple Aim, is the achievement of successful transitions at a variety of points along the care continuum. According to CCMC (2013), “guiding clients to the care they need, when they need it, lies at the heart of case management and is critical in the new approaches to care” (p. 1) and to moving clients into new roles and to new situations. This approach is familiar to occupational therapy practitioners, who are educated in coordinating transitions and making referrals when needed. Moreover, the Occupational Therapy Code of Ethics (AOTA, 2015) obligates us to refer clients to other providers when needed to facilitate appropriate transitions (ACOTE, 2011; AOTA, 2015).

Care transitions, which include transfers to the next care setting or to previous levels and places of function, should be effective, safe, timely, and complete (Case Management Society of America [CMSA], 2010). Practitioners in everyday occupational therapy practice identify key occupations of importance to clients and their caregivers and are cognizant of the variety of struggles that affect regaining independence. Thus, they are primed to look at these important areas when planning for and implementing transitions. Other areas of concern for clients in transition are daily activities, financial and legal issues, issues of independence, lifestyle choices, relationships and social activities, time management, transportation and driving, and work and education (Turner, Ownsworth, Cornwell, & Fleming, 2009). Occupational therapy practitioners are trained to identify and examine all of these elements; knowing and understanding these areas of concern make practitioners’ skills valuable and useful in bringing about successful transitions for clients (Orentlicher, Schefkind, & Gibson, 2015).

Our understanding of occupation, occupational performance, and client factors allows us to use that knowledge to identify the transition location and needed supports most likely to be successful. Occupational therapy practitioners need to know what services are available in different communities and treatment settings and to identify the specific services that will support the client who is ready and motivated for the next level of treatment with the goal of moving the client closer to independence.

Another important area in care transitions is expanding interdisciplinary teams to include not only the client, the identified support system, and the current health care providers but also representatives from community-based professions, agencies, or next sites of care (CMSA, 2010). Occupational therapy practitioners do this frequently by assisting family members and caregivers with goals, education, and support and communicating with the previous provider (e.g., the hospital therapist) or future provider (e.g., in an outpatient setting). The occupational therapy case manager focuses on assisting and supporting caregivers to have the necessary self-efficacy to care for and support their family member and contribute to a successful transition (Mellon & Northouse, 2001).

Gitlin, Marx, Stanley, and Hodgson (2015) found that tailored activities for community-dwelling clients with dementia and their caregivers minimized unwanted behaviors that could lead to nursing home placement and reduced caregiver burden. A study on the impact of occupational therapy on children with a wide range of disabilities, including neurological and degenerative disorders, and their caregivers in relation to independence and caregiver satisfaction showed a statistically significant improvement in the children’s level of independence and the caregivers’ satisfaction with services.

Occupational therapy practitioners are well rounded and know that a combination of supportive and educational strategies appears to be most useful to caregivers. Work with caregivers includes education, emotional support, problem solving, referral to helpful community resources, and training in strategies to better cope with client-related issues such as cancer-related fatigue or maintenance of sobriety (Gitlin et al., 2015; Thinnes & Padilla, 2011).

Occupational therapy practitioners are well suited to move clients through multiple levels of care to achieve optimal levels of health and well-being, which is the goal of transition case management (CMSA, 2010). Practitioners are well versed in promoting health and wellness and quality of life; these outcomes of occupational therapy are explicitly stated in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014). Occupational therapy has contributed a great deal to the understanding of how to bring about change in clients.

Underpinnings of the occupational therapy profession include understanding of the stages of change (Prochaska, DiClemente, & Norcross, 1992): precontemplation, contemplation, preparation, action, and maintenance. For example, with regard to substance abuse treatment, a study found that the amount of progress a client made after intervention tended to be a function of their pretreatment stage of change (Prochaska et al., 1992). Efficient self-change depends on doing the right things (processes) at the right time (stage of change). Occupational therapy practitioners’ knowledge about human change uniquely facilitates all clients’ self-change, both in their natural environments (school, home, community) and in the treatment environment at all stages of care throughout the health care continuum.

Occupational therapy practitioners have distinct value that can contribute to achieving the Triple Aim because of the foundation on which the profession was established; the comprehensive formal education required by ACOTE standards; and the profession’s commitment to address the person in context, considering his or her capabilities and individual strengths and not simply his or her disease, injury, or other conditions. This foundation sets us apart from the medical model case manager. In case management and care coordination, occupational therapy practitioners look at all aspects of a client’s life, including occupations, roles, environments, social supports, goals, and community options and supports. This approach is best practice case management and care coordination and is also in sync with the principles of occupational therapy’s philosophy, values, and beliefs.

No other profession comprehensively addresses concerns such as daily living activities, issues of independence, lifestyle choices, social activities, time management, public transportation, and community reintegration, including driving, social participation, work, and education (Turner et al., 2009). Knowledge of occupational performance (function) and consideration of client factors in the context of their roles and the environments in which they live, work, and play are distinct to occupational therapy. Now, with changes in the health care system recognizing the importance of outcomes that reflect high quality of life rather than simply absence of disease, the health care industry has caught up with what occupational therapy practitioners have known to be important from the profession’s inception in the early 1900s: not just treating a disease or condition but also promoting optimal performance, building environmental and social supports, and strengthening the client’s existing competencies (Quiroga, 1995).

Occupational therapy practitioners bring distinct value and expertise to case management and care coordination. They have medical, psychosocial, and human development knowledge as well as practical clinical experience in analyzing occupational and human performance that enables skillful identification of barriers and needed supports to help clients resume the highest quality of life.