Intervention Plans and Orthotics

Following my column of April 17, 2006, "Being True to Who We Are," I received a letter from a reader questioning the reality of the need for OTs to create a treatment plan for every client. The writer stated that a "one-time-only" order, such as that for the provision of an orthotic, should not require the creation of a treatment plan, since there is no need to see that client again.

In another example, the writer described a case where a client with a particular diagnosis may receive an orthotic device at one visit, but would not receive actual treatment until several weeks later. How, they asked, can an OT write two treatment plans and charge for two initial evaluations, one for the device and one at the start of treatment?

To answer the first concern, there are several official AOTA documents (Standards of Practice of Occupational Therapy, Scope of Practice, and the Occupational Therapy Practice Framework: Domain and Process) that explicitly state that treatment or intervention provided by an occupational therapist follows an initial evaluation accompanied by an intervention (treatment) plan.

In other words, OT practitioners are not vendors; we do not simply give a device to a client without first determining if that device is appropriate for the diagnosis or for the occupational needs of the client. We must ensure that a device is appropriately fitted and that the client is appropriately instructed in its use, care and precautions. If a therapist neglects to address even one of these areas, he or she is behaving like the clerk behind the cash register at the corner drugstore.

This does not mean that creating an intervention plan for a "splint only" visit indicates that the therapist must provide ongoing intervention. It is absolutely possible to create a plan that is intended to involve no more than one formal visit and that leaves the door open for possible future adjustments and design modifications. An intervention plan such as this is relatively short but reflects the findings of the assessment, conducted to ensure that the device is appropriate.

I am certain that most, if not all, therapists do engage in the process of assessment and intervention planning, but are not viewing the process or the paperwork as an actual intervention plan. Therapists must remember that a plan might not include formal ongoing treatment; this is acceptable. "Client will demonstrate the ability to correctly don and doff device. Client will verbalize wear schedule of orthotic device" are examples of appropriate goals for a one-time visit plan of care.

What must not be missing is the assessment piece to ensure that the type of goal and "one visit only" is appropriate.

What would happen if a therapist simply handed a pre-fabricated wrist immobilization splint to a client, charged for the device and two days later received a visit from an irate client who had developed a significant pressure ulcer? By providing and billing for that device, the therapist is a responsible party for the well-being of that client.

Therapists enter into an ethical and legal agreement with clients as their caregivers; that responsibility cannot be taken lightly.

One might argue that to assess a client is to charge him for a service that he may not actually require. If that is the case, the client should have gone to the corner drugstore to purchase the device. When a client receives a device from a therapist, he is receiving "therapy" and is being charged appropriately for the service. The corner drugstore or other non-therapist provider does not offer the same quality intervention.

The second concern involved a client who was referred for the fabrication of an orthotic, but due to the nature of the diagnosis did not require ongoing treatment for several weeks.

The fact that the client will not receive ongoing treatment immediately does not mean that the initial evaluation or intervention plan should wait. The fact that the therapist is providing a device is the beginning of intervention. In this scenario, the therapist should evaluate the client as appropriate, provide the orthotic and write an intervention plan.

The plan should outline the expectations for the coming weeks, including orthotic monitoring and general goals for final outcome. therapist providers will be there to simply sell a device.

Debbie Amini, MEd, OTR/L, CHT, is director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC.

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