Occupational therapy as community primary care
AOTA President Alyson Stover visits UND and envisions how OT can be primary care for the entire community.
In September 2024, Alyson Stover, president of the American Occupational Therapy Association (AOTA), sat down with Sarah Nielsen, Chair of UND’s Department of Occupational Therapy, and Kara Welke, founder and owner of Home Therapy Solutions, LLC, and Next Level Occupational Therapy, LLC, in the UND School of Medicine & Health Sciences Occupational Therapy (OT) laboratory classroom to discuss OT education and practice with North Dakota Medicine. What follows is a condensed version of the trio’s conversation.
Interview conducted and edited by Brian James Schill
Welcome to Grand Forks, Alyson. This is your first visit here?
Alyson Stover (AS): Yes. We just landed in Fargo and zoomed up here just a few hours ago.
I know you’ve visited UND’s OT program in Casper, Wyoming, but what are your first impressions of our UND facilities? When you hear the words UND and OT, what comes to mind?
AS: I come into it with a little bit of bias, just because of last year and being with you all in Casper. When I hear UND and OT, one of the students I met in your Casper program comes to mind: she was an exceptional professional who knows how to be bold with empathy and humanness and that you want to have a relationship with. And that is OT. Occupational therapy is being bold and empathetic with humanness. When I hear UND, I think of her.
Our Casper College program was one of the world’s first distance OT programs and helped us grow our reputation nationally. What, in your mind is UND’s broader reputation?
AS: In one southwestern state, for example, there is one OT program in the entire state, and you have OT clinicians who go to that school, graduate from that school, and live in that state, but still choose to work in different states. Meaning, there’s something that is missing in the community – there’s a gap between wanting to stay and work and serve in an area where you were trained. But what I see is UND really doing an excellent job of [retention]. I hear the cries – there are schools and faculty all over that call in red alerts to AOTA. You don’t hear that from UND. Your excellence brings us back to North Dakota. It’s a state that is recognized as getting it right.
So, we’re chatting in this OT laboratory classroom – which has a functional living space embedded in the classroom. I take for granted that this is how it is everywhere in OT education, but is that true?
AS: What’s really interesting about UND is that students have a living space integrated into their learning space. I could be teaching up here about doing laundry and I could literally have four students go back and trial something. And to me, that is really powerful. I heard a woman once say that the reason nobody gets the OT elevator pitch right is because OT isn’t defined by words – it’s an experience. So learning how to do OT sometimes can’t be done through words. It has to be an experience, and it has to be in that moment. I’ve never seen this kind of openness and ability to fluctuate and move. You can truly be mid-lecture and get up and try something, and that fluidity – that’s how you really learn OT.
Sarah Nielsen (SN): Yeah, we can actually get people wet for the client transfers in our lab’s bathtub.
AS: And I will say that washers and dryers are not common. So, even this space, yes, I could envision that there are houses in North Dakota that you walk in, and the room looks just like that. And every everywhere else I’ve been has a little bit of that flavor – that you’re in a learning environment, not a home.
SN: One thing Alyson mentioned during her talk to our students is the need for OT practitioners “to think in the gray.” So a lot of times we think about healthcare providers being in small niches, and so she was advising students of the importance of thinking in the gray. She spoke about practitioner shortages – whether it’s OT, PT, or speech – and the need for students to collaborate and work together. Hopefully that happens at all schools, but the two values that we bring out most at UND are thinking in the gray and being collaborative, and also preparing people to be rural. We are preparing them for the reality that there may not be a speech language pathologist or a PT in a certain setting – you might be the one that needs to do a lot of this work so the client can engage and participate.
AS: And I will say that not everybody is doing the interdisciplinary collaboration in a way that I think leads to meaningful integrative healthcare. There are some great activities that people do – don’t get me wrong – but they’re not preparing most students for what it’s really like. What is it really like when it’s you and the nurse and the nurse says, ‘Look, I live this far away, so I’m only going out once a week. This person has this many visits. You live closer. I want you to take four of those, but by the way, change these colostomy bags while you’re there too.’ I do see integrative health and primary care becoming more prominent as we start to move into new healthcare models. But I also see that the generalist is going to become incredibly valuable because of that. So, we need to know how to do a little bit of everything, and that’s where OT has always shined. We’ve always been this jack of all trades – and I would say master of them too – where if there’s the gap, you can put us in. UND is a great place to do that. This is also one of the only schools that I’ve seen where you’re in a building with med students.
Kara Welke (KW): I was on an interdisciplinary health panel that you had here on Friday, and with our practice we do exactly what you say. We don’t have enough PTs to meet the need for PT referrals in the area. Many PT referrals can be addressed by OT. So, we are always playing the gray day-in and day-out. And in our rural setting, with the lack of providers and the big need for people getting services, we play the gray a lot. Hopefully UND continues that push for an interdisciplinary approach, because it’s huge. We have to learn to work together and collaborate in order for us to grow. And having the med students as part of that is key, because they need to learn to embrace what we can bring to the table.
To that point, what changes have you noticed in OT as a practice, or the way it’s been embedded in healthcare, in the years you’ve been practicing?
AS: Even 20 years ago we were still fighting for people to even know who we were. And really what you saw was OT was practiced in an acute care medical model that filtered us out because it made sense in the acute care medical model, and so the only referrals you got were referrals that the physician understood that “this person isn’t in the hospital, but has hospital-like needs.” It was really fighting for the idea that, actually, this individual will likely not even have to be [readmitted] to the hospital if you get them OT first. And I do think that we are seeing a little bit more of that. I will say that there were some beautiful programs that existed in the 70s and 80s, and they had incredible outcomes. But it was faster and cheaper for the insurance company to cover a medicine visit than OT in the home, and so you started to see us doing what we worked for, up to the 70s and 80s. Then insurance wanted to start cutting, so then you saw us splinter apart. Again, we need to be in a space where I think the distinct value of OT is that we do practice in the gray – I can look a bit like a PT here, and you can watch me over there and I look like a social worker. We’re still fighting the barrier of: do physicians know when it’s good to call us on the team? That overarching physician knowledge is not always there. CMS [the U.S. Center for Medicare and Medicaid Services] is the same way. We’re not a quantitative outcome measurement profession. We are a qualitative. They don’t understand how to measure us. But in 2016 a study came out that said when you invested more in occupational therapy during the acute care phase of a hospital admission for congestive heart failure and a few other diagnoses, readmissions go down. We were the only profession that reduced hospital readmission. In the medical model, you must “get well to do,” and we say “you must do to get well.”
SN: On the education side, I would say that when I was educated, there was a lot less evidence that informed OT practice. But we’re more evidence-based now and the field has progressed in that way. I do think it comes back to the fact that we are a profession that invests our time in doing, and that hasn’t always been valued – fixing has been valued. And I think Alyson said it best. Doing was our core then, 100 years ago, and it still is today. We still see the environment, we see the person, we see what they want to do, and we’re going to make it happen. That’s the same as always. Only the “how” and the knowledge we have has changed.
KW: At Home Therapy Solutions, we’re in the home in their natural environment where we can work with the clients and their caregivers and families. For many of our clients, we’re with the families and the clients for life. You didn’t see that happen before, and some people still don’t understand or believe in that model. But there are so many clients we work with who, if we weren’t part of their life, they would have passed away years ago, or they’d be in the nursing home or assisted living. Doing what we’re doing in the home and working with the client and the caregivers, we’re helping them all navigate the complex healthcare system that no one else is doing. We’re in the home, and we see everything that’s going on. We see the 500 medication packets that they’ve never taken. We hear the frustration where they don’t understand what the doctor told them or that they didn’t know they had a prescription because they have a cognitive deficit, and no one told the caregiver. That’s where I feel OT needs to be, and we need to be in the home and community. But we also need to get doctors and other professionals to realize that it’s okay to refer to other providers outside of their healthcare system or network, because we are only going to help them be better at what they do, because we can be their eyes and ears, since they can’t do it all.
SN: “Doing” goes beyond helping clients go to the bathroom and get dressed. That isn’t usually what brings people meaning and value, and I think community-based care is what allows for that. And it has a quality of life and it extends life for that reason.
KW: I’m taking Alyson tomorrow to visit a client on a farm. This client was in rehab and did not want to go to the nursing home or to a long term care facility. The family found us and we were able to see the client at his home on the farm. We were able to use his daily activities and surroundings to get him back up in that combine, in the tractor, doing the things he did. And I can still firmly guarantee that he’s a totally different man than he would have been if he was put in a long term care facility.
AS: In the end, that’s what saves money, right? But you have to spend on OT first, and then you save in the long run from the outcomes we produce.
Do you have a vision for the profession, as the president of the AOTA, for the next 5 or 10 years? What do you want to see OT become?
AS: When you hear the term “PCP” you think primary care provider. And I want you to think OT. When you want somebody to stay well, you make sure they’re participating with their primary care physician: get their annual physicals and ask health questions. I want it to be OT. And I want it to be not go to your PCP, I want us to come to see you. For the profession, my hope is that we’re bold and that we’re loud because we are natural collaborators. We don’t pat ourselves on the back. We very much say we walk alongside our patients and their successes are theirs. Team successes are the team’s and we very much limit the story that shares what we contributed to the team. My hope is that we become bold and loud and crazy-confident in the work that we do.
KW: One hundred percent agree with everything Alyson said.
AS: OT could be the physician to your “system problem.” OT could be the primary care provider to what’s wrong with the Fair Housing Act. It could be what’s wrong within the culture of your organization. It could be how to make your community experience just better for health and wellness. When an OT builds a community garden, they don’t just build a community garden. They look at who’s in the neighborhood and think about “We should build it this way, because this person doesn’t have the endurance to walk as far, so it should be closer to their house. But this individual – he’ll walk farther, but he has really poor use of his hands, so let’s make sure we have these kind of plants and tools there.” The reason people use what we build is because we build it so that they can use it. We not only know how to do the intervention, but we know how to make it accessible to everybody. I want to be the primary care for a community – for the grocery store, for large organizations that want change, and for my daughter and your grandma.
SN: The reason we’re gray and the reason we’re collaborators is we were formed by a social worker, a psychiatrist, an architect, and a nurse. So I think that’s critical to understand, because it’s why we’re trained the way we are. And obviously our founders saw a need for somebody to understand the whole – not just this this slice or that slice. This group of people said, “We should form this profession that really reflects doing, participating.” They saw it from all of those lenses. And those people coming together, saw a need for something that was more than just their individual way of thinking.
KW: That’s why the power of us being primary care providers would be so immense to our communities. Because when you go into a physician, it’s usually about one issue and the physicians don’t always have time to explore deeply enough to determine what is probably leading to that issue. When we get into the home and work with the client and caregivers, the social worker comes out of us, the healthcare worker comes out of us, the architect and nurse come out of us. We can take the time to figure out what’s going on and help in many different ways rather than just prescribe medication or a set of exercises. There’s so much more involved.
