Telehealth and the System of Schools
As an occupational therapy practitioner the school setting, we operate as our own system as a related service provider within the larger system of the school. The school is a component of the even larger system that is the school district. There are several different levels of input, throughput and output. The occupational therapy subsystem has substantial resources (input), a clear therapeutic process (throughput), outcomes (output) and feedback mechanisms.
In my present workplace, there are there are a variety of resources for the occupational therapist. This includes both human resources, and nonhuman resources. The human resources include other occupational therapy practitioners, the physical therapist, the speech therapist, the school psychologist, the autism specialist and learning specialists, the teachers both special and general education and many other professionals to learn from, consult and collaborate with. The nonhuman resources include technology such as laptops, tablets, assistive technology, an occupational therapy webpage and internet access, which allows us to access information beyond the walls of our school, and diffuse that information to teachers and parents. In addition, there is funding for special programs and services through federal grant programs, and other federal agencies. For example, the Department of Agriculture may fund a program on nutrition and along with the use of a specific grant, we are able to support a school garden project, which can be incorporated into therapy sessions, allowing children to address sensorimotor needs in an organic way. Financing for direct occupational therapy services comes from state educational funding and through Medicaid reimbursement, although there is distinct criteria for qualification of services, eligibility, and funding that may present barriers to access (Shi & Singh, 2015).
The therapeutic process includes establishing a baseline and initial goals for a student through an evaluation process including standardized testing, record review, informal assessments and clinical observations. Following qualification and identification of therapeutic need, a formal Individualized Education Plan (IEP) is developed, and becomes the binding legal document for the student. In schools, occupational therapy establishes goals in educationally related occupational performance areas (social participation, ADLs, play, leisure). Goals are addressed through direct service or using a collaborative model with the classroom team and family, incorporating a variety of activities with the resources available that promote the skills identified as insufficient (Case-Smith, J. & O’Brien J., 2014).
The outcomes are reviewed both informally on a quarterly basis through student report cards and formally at the annual review, where the status of goals is reviewed, new goals are developed, and a new IEP document is developed and created. Goals may be reviewed at additional points during the year if a team member requests it, or feels that the plan is no longer appropriate. Focus has shifted to how the student is presenting in the educational environment, and this clearly demonstrates the importance of measuring functional outcomes in addition to standardized testing. This comes into play as a part of the triennial assessment, which takes place every three years for each student with an IEP. The purpose of the triennial re-evaluation process is to measure the progress of the student, and what areas those gains are in. Expectations are that the student will experience significant improvements and that these improvements translate into everyday function. One feedback mechanism that I appreciate in the schools is the use of the IEP team. Although the occupational therapy progress and outcomes are presented at the annual review, feedback is presented at the meeting and the revision of the student’s plan is made as a team, based on the feedback and discussion of the team members at the IEP meeting.
Separate from the student’s progress, the competence of the therapist also must be considered as a part of this system. Thus, the outcomes of the effectiveness (competence, professionalism) of the therapist and feedback for the individual therapist are reviewed twice per year. There is a midterm review where feedback is given to the therapist so adjustments can be made. Areas of strength and areas that need improvement are identified with the therapist by a supervisor, and this midterm is reviewed again at the end of the year. Additionally, a meeting with the special education director to review the occupational therapy program is completed annually. At this meeting, adjustments are made to the program based on feedback from the therapist, the school administration, the superintendent, and more recently the state budget. This information indicates the outlook for the future of the occupational therapy program as well.
An emerging area of service delivery that could be implemented in the schools is Telehealth. Technology is the future, and I feel that schools underutilize this resource. If a student health portal was created online, the IEP document, and other health evaluation results could be available and accessible to the team. Parent feedback and provider input could be collected and reported on remotely. Meetings could be held with providers present by logging in to the live-streamed meeting remotely, or via a video call. Re-evaluation, intervention, consultation, and collaboration could also happen remotely through video calls. Trainings for students, parents, teachers, and staff could be made available online through the school’s website. These alternative ways of communication and instruction improve access to information and may even help streamline and enhance multiple aspects of service delivery (Kramer, 2010). Allowing a remote option reduces travel time, opens up availability and is more cost effective. Digital age technology can also contribute to the development of a universal curriculum and materials that could be more easily accessed by all students (Kramer, 2010).
To implement these changes, the approval from the superintendent, as well as trainings for how to use the new system for staff and families would be required. The resources for the diffusion of this technology are already in place. The student portals exist but would need to be modified. Privacy of information would need to be discussed, as to create a solution to limit access to private information and to create security for the online system. Although Telehealth is relatively new, it would maximize the use of the school’s resources, improve the service delivery and it would be a much more proactive way to reduce costs.
References
Case-Smith, J., O’Brien, J. C., (2014). Occupational Therapy for Children and Adolescents (7th Ed.). St. Louis, Missouri: Elsevier Mosby.
Shi, L., & Singh, D.A. (2015). Delivering healthcare in America: A Systems approach (6th Ed.). Burlington, VT: Jones & Bartlett.
Kramer, P. (2010). Frames of reference for pediatric occupational therapy. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
