Once mainstays in psychiatric institutions, many psychosocial OTs left the mental health arena when psych treatment moved en masse in the 1980s to the community-based agencies that now serve the psychiatric population.
Drug-based treatment and much shorter stays have driven even more of them out of psychiatric hospitals over the past 10 years. And with increased costs due to new drugs, states are struggling to keep their hospital and community-based programs afloat.
By now occupational therapy has lost so much of its traditional psychosocial involvement that other practitioners in mental health settings, including insurers, don't recognize it belongs there unless they personally know a mental health OT.
Only 5 percent of occupational therapists, on average, now practice in the mental health arena, according to practice statistics gathered by the National Board for Certification in Occupational Therapy (NBCOT). Yet OTs provide valuable services to mental health clients. In outpatient settings, however, many of these therapists do not bill for "occupational therapy," as most insurers will not reimburse for it. The OTs bill for specific modalities they use.
Are these therapists' background and training simply being overlooked as they struggle to maintain their professional identity? Or are they operating in a system stacked against them?
Over the past eight months, AOTA State Affairs Group manager Charles Willmarth and his team have been analyzing differing mental health statutes in each state to see where occupational therapy stands among them. Results of the survey, as well as recommendations for action, are expected to be ready for the AOTA national conference in Milwaukee in May.
Willmarth's group was charged with the assignment at last year's conference. Arizona therapist Cindy Hahn, MOT, OTR/L, had introduced a motion to the Representative Assembly (RA) to promote recognition of OTs as "licensed mental health professionals."
"In Arizona we thought we were listed, and we found out we weren't," Hahn told ADVANCE. "If we thought we had it, then other states might think they do too."
Currently, Arizona public health and safety statutes define a "mental health provider" as "any physician or provider of health, mental health or social welfare services involved in evaluating, caring for, treating or rehabilitating a patient." This language neither specifically includes nor excludes occupational therapists.
But Hahn herself has felt the crunch. She moved to Arizona several years ago to run the psych OT program at a hospital. Within a year and a half, she was cut back to eight hours a week. She felt forced out of the position, and so made the move to full-time academia. She now serves as the AMOT program director and associate professor in the OT department at A.T. Still University of Health Sciences in Mesa, AZ.
"If we want to try to re-establish ourselves in psych practice, we need to make sure we are recognized in the state," Hahn explained.
But the job is not so easy nor so simple. The task force debate on Hahn's motion revealed that most practitioners had little knowledge of how states regulate mental health practice. The RA defeated the motion (on the task force's recommendation) but passed a substitute motion which merged Hahn's motion with a similar MHSIS report motion. The substitute motion charged AOTA to develop resources and tools to help states trying to increase opportunities for OTs in mental health practice. Investigating OT's place in state MH statutes and regulations was part of that charge.
A Slice of the Pie
Inherent in the move to community-based treatment is a change in the way mental health service providers get paid.
In state-run psychiatric hospitals, OT and other rehab services were and still are generally included in the daily rate. Providers are on the state payroll.
But in the late 1970s, as many state facilities closed, their residents transferred to community clinics as outpatients. These clinics were funded under Medicaid programs that operated independently in each state. To keep control of quality and costs, Medicaid generally defined who was able to provide mental health services. Today, if you're not listed as a certified Medicaid provider, you won't get paid, at least by Medicaid, in mental health settings. There also are regulations related to the provision of care under insurance statutes and even in criminal law.
Separate statutes and regulations also define who is able to legally provide mental health services in each state. Many state statutes or regulations borrow from the definition of "core mental health professional" as listed in the U.S. Code of Federal Regulations, the definitive collection of permanent rules published by the federal government. This federal code specifically names only psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists who meet specific definitions.
In state parlance, regulations frequently borrow this definition, though they use different names. In Tennessee, for example, a very similar list of professionals are considered "qualified mental health professionals" as defined in statutes of the department of mental health and developmental disabilities. In Ohio, they are called "mental health treatment providers" and are defined under probate court statutes. (For purposes of clarity, we'll use the terms "core professionals" and "non-core professionals.")
That is not to say that these core professionals are the only ones who can provide mental health services. Rather, core professionals are able to do some job duties that non-core professionals cannot, such as diagnosing psychiatric illnesses or making involuntary commitments to inpatient psychiatric facilities.
OTs are not explicitly listed as core professionals in any state, regardless of what the state calls it. However, OTs are listed in many states as non-core professionals. Under Tennessee's Medicaid program, called TennCare, OTs with master's degrees and/or clinical training in mental health are explicitly listed as "licensed mental health professionals."
No state explicitly restricts OTs from practicing in mental health.
The Best Way Back In
Whether-and how-occupational therapy is included in state MH statutes and regulations can determine, even prejudicially, which jobs OTs can hold and who will or won't reimburse them.
In California, for instance, OTs are listed as non-core professionals in mental health, but the law does not restrict them jobwise. Nevertheless, employers seem to believe that only core professionals can or should hold managerial positions, and so hire accordingly.
"It limits OTs who are [non-core professionals] from moving into leadership positions," said Deborah Pitts, MBA, OTR/L, CPRP, chair of the Menta Health Special Interest Section (MHSIS) and clinical faculty in the occupational science and occupational therapy department at the University of Southern California.
Those leadership positions do not usually require core professional skills. "Most [core professionals] are not doing psychiatric diagnosing; they are running programs," Pitts said. "That may not only be restricting OTs but other professions as well."
Since California law is on the OTs' side, the strategy is simply to educate other mental health professionals. "We are making sure that organizations know they can hire OTs in leadership positions," said Pitts, "[and] educating individual OTs to position themselves to get those leadership positions."
In Tennessee, however, "it became apparent that we are going to have difficulty getting reimbursed as mental health professionals," said Ann Nolen, PsyD, OTR, chair of the OT department at the University of Tennessee and a board member and mental health liaison for the Tennessee OT Association (TOTA). In fact, as far as Nolen is aware, no OTs in Tennessee are getting paid through Medicaid.
"We have two positions [funded by grants] here at the university for community [mental health] OT services, but grant money doesn't last forever." Nolen hopes to find OTs who are willing to "do a trial run."
TOTA's lobbyist recommended that the association seek support from the state department of mental health for a bill to get OTs listed as core professionals. When Nolen sent a letter to the department's commissioner in mid-February, however, the commissioner told her that the term "qualified mental health provider" (the title used for core professionals in Tennessee) applies in a variety of contexts throughout state statutes defining mental health practice, but in particular to "individuals who can provide certificates of need for emergency involuntary hospitalization, provide mandatory outpatient services, etc. The department determined that occupational therapists are not educationally and experientially equipped to do these things that are more clinical in nature than the training reported for them."
When Nolen met with the commissioner's representative's at the end of February, the representatives recommended that OTs in Tennessee instead seek credentialing under TennCare's BHO (behavioral health organization), where OTs are already listed as non-core providers. The representatives emphasized that "pursuing legislation for [core provider status] will not get what you want?reimbursement," said Nolen. To get reimbursed by MCOs (managed care organizations), she added, each will need to be dealt with individually because each has a different reimbursement structure for mental health services. The outlook, Nolen admitted, seems "dismal."
Scope of Practice
Indeed, the definitions of core professionals in some states do include some job tasks that OTs may not be qualified to do. So being listed as a core professional may be outside the occupational therapy scope of practice in some states.
In California, for instance, making psychiatric diagnoses is one of the responsibilities of core professionals. "I would be surprised if we want to do psychiatric diagnosis, and I don't think we would get support for doing it," said Pitts.
So far, Willmarth's review of regulations indicates that most core professionals have at least a master's level education, if not higher. But even when it comes to a master's level OT program, the requirements are very different. Education programs for social workers, psychiatrists and others considered core professionals generally have much more extensive coursework in psychology than does occupational therapy.
"The ACOTE standards come into play," added Willmarth. "OT's education standards are quite broad. When the legislature asks us to show them our educational standards, that could be an issue for us. We need to be able to build our case within the literature and within our training that this is an appropriate area for us to practice. We can't just go to the legislature and say 'we've always been in mental health.'"
This touches on another controversial issue in the occupational therapy profession-whether to go back to requiring psychosocial fieldwork, which hasn't been specifically identified in education essentials since 1948 (neither is physical disabilities fieldwork a specific requirement under the Standards.) Some OTs feel that the loss of that requirement negatively affects occupational therapists' ability to argue that all OTs are mental health professionals.
"This is so because AOTA no longer requires all OTs to undergo MH fieldwork education," wrote Steven M. Gerardi, MS, OTR, in a letter in the Feb. 9, 2004, issue of OT Practice. "?The best that can now be said is that some OTs are MH professionals."
Gerardi also may have hit on a significant problem with terminology. Just what does the profession consider a "mental health professional"-anyone with the potential to use psychosocial skills in general practice, or someone who specializes in mental health practice?
In a response to Gerardi's letter, MHSIS Standing Committee member Jeanenne Dallas, MA, OTR/L, informed readers that to give the issue more attention, AOTA members can submit motions to the RA addressing MH fieldwork. Additionally, ACOTE is currently accepting comments for the review of its education standards. You can submit opinions on mental health fieldwork requirements directly to ACOTE through the AOTA website (www.aota.org).
Outgoing AOTA President Barbara Kornblau has decided take that initiative. At the AOTA conference, she is submitting a motion to the RA through her president's report recommending that "the Representative Assembly endorse reinstatement of a required mental health fieldwork experience for all entry-level occupational therapists and occupational therapy assistants, and urge the Accreditation Council on Occupational Therapy Educate (ACOTE) to consider amending the fieldwork standards to include a required mental health fieldwork experience."
'It Needs to Start with Every Clinician...'
Should OTs be seeking core-professional status in their states? Is that the most appropriate way to open up opportunities in the mental health arena? The findings and conclusions of Willmarth's group will shed more light on this at the AOTA conference.
Pitts proffered some possible alternatives:
? Change the definition of "core professional," so that questionable areas like diagnosis would still be restricted to psychiatrists, etc, but allow OTs to take more leadership roles.
? Include a qualification that an OT would need a certain level of experience or training to be considered a core professional.
She advised every state association "to come to understand how [mental healh service provision] has been determined in their state and how mental health services are funded."
Nolen agreed. "We have no one to blame but ourselves that we lost this in the first place," she admitted. "You really have to be on top of the legislation. It is so important that members stay involved in their state organizations and stay on top of these issues."
OTs also need to start making friends in the mental health community at the federal, state and personal levels. Pitts recommended that OTs get involved in their states' mental health commissions, which monitor mental health services there.
"We need to be more visible," said Hahn. "It needs to start with every clinician, whether you are doing mental health or general rehab.
It is something that Hahn takes to heart. She frequently attends and presents at conferences for mental health professionals, "just so I can go in and talk about OTs in mental health."
OTs following Hahn's lead and Pitts' advice may be able to open up more opportunities for themselves in the mental health arena. If that happens, both Pitts and Nolen believe that many OTs will want to pursue those opportunities.
Jill Glomstad is ADVANCE senior associate editor. She can be reached at firstname.lastname@example.org.