OTSH 86: Journal Club - The Problem with Caseloads


OT School House Podcast Episode 72 journal club how much of school is fine motor anyways?

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Welcome to the show notes for Episode 86 of the OT School House Podcast.


In this journal club edition of the OT School House Podcast, we are examining the 2020 Seruya & Garfinkle article about the current workload trends in school-based OT.


We will discuss the findings from a survey of 571 OT Practitioners working in the schools just like you and talk about the real-life implications your caseload can have on your practice.


Spoiler alert: Your Caseload is likely holding you back, but listen in to hear how you are not alone and what steps you can take to move forward.


Also, stay tuned until the end for a special announcement and giveaway from Jayson.



Links to Show References:





Transcript

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Jayson Davies

Hey there, and welcome to this journal club episode of the OT School House podcast. My name is Jayson Davies. And I am so happy to have you here joining me from wherever you are. As you might have noticed, we're starting this podcast off like we have a few in the past where we do the intro first. And then we're going to cue that intro to the music that we all love so much in just a moment. But first, I just wanted to let you all in that this episode is a very important episode because we're talking about something called a caseload and a workload and how those differ how they're similar a little bit. And we're actually bringing in an article from the American Journal of Occupational Therapy to kind of show where we're at today, or actually where we were at in 2020, right before the shutdown of everything. But anyway, that's a different story for another time. So I'm excited to have you here this entire, this entire episode is going to lead to something bigger I have an announcement as well as a giveaway at the end of this episode. But I really want you, to listen in to this entire episode because it all comes together at the end for one big announcement that I'm super excited about and cannot wait to share with you. So let's go ahead and cue the intro. And when we come back, we're going to talk about an article titled caseload and workload current trends and school-based practices across the United States. Alright, I will see you in just a moment right after this intro.


Amazing Narrator

Hello, and welcome to the OT School House podcast, your source for school-based occupational therapy, tips, interviews, and professional development. Now to get the conversation started. Here's your host, Jayson Davies, class is officially in session.


Jayson Davies

Alright, welcome back. Thank you again so much for being here. I want to start off by sharing a little bit of the demographics I guess you can call it the information about this article that we're discussing today. The title is "Caseload and Workload: Current trends in School-Based practice across the United States". It was published in the AJOT, the American Journal of Occupational Therapy back in 2020. So it is relatively new. And the authors who I just admire so much are Francine Seruya and Mindy Garfinkel, more on them in just a bit. The full citation can be found down in the show notes or at otschoolhouse.com/episode 86. I cannot believe we're on episode 86. This has just been a whole blur from episode one to Episode 86. And thank you so much for being along for the ride. So I want to talk to a moment about Seruya and Garfinkel, Mindy, and Francine they had been so instrumental in supporting occupational therapy practitioners working in the schools. This article as well as some of their other articles have been my go-to Resources. When it comes to thinking about what the next step in occupational therapy within the schools is. They have published articles about workload and caseloads and where we're at and maybe where we could be in the future. They've also looked at the three to one model, which some of you might know as being a model where you provide direct therapy services for three weeks and then you have that fourth week of the month to kind of do other things like maybe get into the classrooms to observe those students that you would regularly pull out and see also to maybe complete those evaluations maybe participate in some RTI or MTSS tiered intervention. So that is the type of thing that Seruya and Garfinkel have been pushing forward, almost kind of the next step for occupational therapy, how we can move from where we are today to where we can be in the future to support more students, more teachers with potential even less time. So I want to get into that. But first one last time, I want to give a huge shout-out to Francine Seruya and Mindy Garfinkel just for all the work that they have done for occupational therapy practitioners working in the schools. So let's go ahead and dive into some of the key terms some of the background information that this research article actually starts with. They identify a few things that we really need to know about in the first is caseload versus workload. They do define caseload as basically the students that are on your list of students that you have to serve. So the students that you serve, whether they're on an IEP or 504, the students that you are directly responsible for that is your caseload. We'll talk about the average caseload in a little bit. Now they define the workload as going beyond that more than just your caseload. But all the responsibilities and the time that those responsibilities take throughout your week or throughout your month, that's your workload. How many hours do you put toward RTI, toward driving, toward seeing the students on your caseload, toward maybe training teachers and working with staff, all of that is part of your workload. And as we get further into this study, you're going to see how many are using caseload but they're not using a workload approach. And when you're not using a workload approach that could potentially kind of skews what the numbers look like your caseload just simply doesn't tell the whole picture. And then they go on to talk about how this is really a paradigm shift. And switching from a caseload model to a workload model would in theory allow for occupational therapy providers to provide occupation-based interventions within the natural environments such as within the classroom. As you'll see in a little bit, most occupational therapists are using a pullout model, partially because that's what we have kind of schedule for us, you know, it's very easy to control a pullout model service, it's a little more difficult to control that push in. And therefore, it does take a little bit more time in order to actually prepare and complete that push-in model. In fact, we discussed this a little bit in the most recent episode, Episode 85, at OT School House podcast with Megan, right, we talked about how the struggles are so real when it comes to moving from that pullout model to more of a collaborative type of push-in model. And there are a lot of barriers involved in moving from that pullout, traditional pullout model to a push-in model. And one of those is that we are using a caseload-based model, that really just assumes that every student needs 30 minutes of services. And that's not always the case. And it does take a little bit more time when you have to plan to go into the classroom. And you have to figure out what time to go into the classroom. All those barriers that we talked about in episode 85, with Megan, are all relevant to what we're going to be talking about right here within episode 86. And moving from that caseload context to a workload approach. And then there's one last thing before we jump into our goals and hypothesis, and that is that the researchers know within their background of this article that while there are state guidelines, and even some district guidelines that have been published related to caseload and workload approaches, some states have even gone as far as putting a soft cap in place. But there have been no general standards implemented at the national level. And even at the state level, many of those guidelines, they're not law, and so they're not enforceable. And so you have districts kind of using them when possible feature with a cap, you know, a cap might be 55 kids, but then it says at the end of that when possible. Well, what does that mean? When possible? I mean, does that mean Oh, right. You know what, we have four therapists and we have 300. Kids? Sorry, it's not possible to keep your caseload at 55. So you all have to take on 70 kids? Well, no, that means you should be hiring someone, right? The district should be hiring. But because it's not a national law, or because it's not really enforced at even the state level, that isn't happening. And that is what is leading to some of our caseloads, continuously expanding, or maybe your caseload isn't growing, but your workload is growing, because you're getting more duties such as tiered intervention than your team wants you to be a part of. Or maybe you're being asked to be in more IEP meetings or longer IEP meetings. Well, that includes your workload, without actually increasing your caseload. Your caseload might still be 55 kids, but your workload, the time that you actually need to complete your job is growing. And so nothing related to national guidelines for that really exists. There are guidelines from AOTA and even ASHA, the American Speech and Hearing Association that say we should be moving to a workload approach. But again, they're just guidelines. There's nothing forcing that we do that. And there's nothing forcing the school districts to make us do that or allow us to do that. And so that brings us to our goals of this, this research and what the purpose of this research was by Seruya and Garfinkel, well, they wanted to reach out to occupational therapy practitioners working in the schools and find out what their caseloads were, and what activities were a part of their workloads. They didn't necessarily ask, Hey, how many hours of student direct therapy time do you have? But they did ask what do you have to do other than direct therapy time? And you know, documentation and evaluations writing up evals but also tiered intervention, all that is part of the workload. So they ask them what is a part of your workload? They also wanted to know the why behind who was using a case of the model and who was using a workload model. Why were therapists using the caseload model versus their workload model? Or vice versa? Why were they using a workload approach as opposed to a caseload model? So we'll talk about some of the data that came as a result of that. So then, let's have a look at the participants who completed the survey who participated in this. Well, there were actually 541 Occupational Therapy practitioners that started this survey. I am proud to say that I was one of them. Many of you probably also completed this. They did have therapists from all over the country participate in this of the 541 Occupational Therapy practitioners that started the survey 371 completed the survey. So what We kind of round-up, that's four out of six therapists that completed it. So that's about 66% of the therapists who started the survey also completed the survey. And in case you're wondering if the 541, occupational therapy practitioners that started the survey 479, were occupational therapists and 44 were occupational therapy assistants. There were a handful of others who are not US based, or they're not currently working, and they were excluded from the survey results. Demographics from this participation group showed that most of the therapists were working in a full-time job, meaning that they were working either 30 hours or more per week as an occupational therapist, going even a little deeper than those therapists who participated came from all over the country and had various levels of experience, if I remember, right, the most therapists came from the northeast, I think it was around 20%. And then about 20% also were within the one to five-year range. Within experience. However, there were therapists who had many more years of experience than those, who also participated in the study. So that covers the demographics of the participants. And of course, this is a survey so the word no interventions used, and the results are directly related to the survey conducted. So let's go ahead and take a look at the results. We're going to start with some key results here, and that is that therapists reported working in anywhere from one to 10 schools, and the average caseload was identified as 41-50 students, there's actually only one therapist, I think, that reported working at 10 schools, most of the therapists reported working in one to four schools. And despite having schools across the gamut from elementary to middle and high school, a majority of the therapist did work within the elementary range. Diving a little bit deeper into the caseload, I mentioned that the average caseload was 41 to 50 students. However, as we know, the average is not always what everyone has. So I want to share a little bit of the extreme. Looking at the graphs in the article, it's actually a little shocking, because you see that 10 therapists reported as having a caseload of greater than 120 kids. So 10 therapists, and more than 120 kids on their caseload, it does not identify as to whether or not they had an occupational therapy assistant, working to help them with that 120. But still, 120 is a lot, even if you do have an occupational therapy assistant working with you. Maybe if you have two or three OTAs working alongside you, then maybe that's a little bit more manageable. But that wasn't identified here. Going a little bit deeper, because we all know that 120 is a lot, but so is 80. And if we look at any other therapists who had 81 students or more on their caseload, 35 therapists or almost 9% of all respondents had 81 or more kids on their caseload. That's a lot of kids, I've been there, I've done that. That is a lot of kids, especially if you are trying to do that by yourself, it almost makes it impossible to see kids on a weekly basis, you can only see them on a console, maybe on a twice a month basis. Now, again, if you have an occupational therapy assistant, it does make it a little bit more manageable. But that is what was identified here in the research. Now with such a high caseload size, it's not difficult to understand this, but 60% of the surveyed therapist reported that their caseload was not manageable. And 55% of all of those who were surveyed noted that they were not always able to meet the mandated IEP minutes for the students on their caseload. That means that over half of us are not able to see the students that we need to see every week. That's pretty crazy. Because we are, that's our sole purpose. Even if you're going by a caseload number and you don't have any RTI going on on the side, your sole purpose of being on campus, is to evaluate students, and provide them the minutes of therapy that they need, right? That's like the basics of IDEA. And so to say that 55% of us are not even meeting the minutes that we are, "prescribing or recommending", if you want to say that, that's kind of a scary thought because we're saying these students need services, and we're not meeting those services. That's also a liability for the district. If parents knew that half of us were unable to see all of our students, can you imagine the uproar that would be happening among the parents, they'd be questioning whether or not their students actually getting the services that the occupational therapist recommended, and it might extend beyond occupational therapy might extend to speech therapy, physical therapy, adaptive physical education, who knows? Now getting beyond the average caseload, when asked to rate their most frequently used model of service delivery, 63 and a half of us occupational therapists who work in Schools rated non-integrated pullout as their most frequently used treatment model. The second most used model was integrated pushing services. So I think that was kind of expected. I think, at this point in 2021, where we're at or even 2019-2020, when this survey was conducted, I think that's the case most of us are using a pullout service as our primary model that we use as the students. Now, I do think that it is a bright point in the research though, that about 70% of therapists rated push in collaborative pushing services as being their most or second most used treatment model. That means that most of us are using a push-in service, in addition to a non-integrated pullout service, which is kind of cool, right? That means we're kind of choosing one of those two, as you get into collaboration, consultation, those numbers really start to drop, I have a lot of data. So I'm not going to go over all the data. But you can obviously check it out in your AJOT, the American Journal of Occupational Therapy, access that and you can find all the data, all the tables, and whatnot. Now, what we didn't get here that I would have liked to see is how many of those who are using a push-in model, or really any model for that case, felt comfortable using that model because I hear a lot from therapists on Instagram and in my email inbox that people aren't quite comfortable with that push and model. They don't know how to do that and be effective. They know how to go in and observe, but they don't necessarily know how to go in and actually provide therapy to the students within that context. So I would actually like to see another survey where we're able to see, do they feel comfortable with doing that. Now, another bright side to this research, in my opinion, was that about 50% of therapists reported being a part of 504 and servicing students that were on a 504 plan. I think that is awesome. I was actually a little surprised by how high that number was, I did not expect it to be at a 50% clip. Also, about 38% of therapists noted participating in some form of tiered intervention, which as you know, I'm a huge advocate for so that is also great to see. In the next section that we're about to discuss, I really consider this the bread and butter of thi