Jean: Good morning, everyone. I am absolutely delighted to be with you today. This is a presentation about how to go about delivering services in your school district.
I. Defining Caseload v Workload: History, Rationale and Perspectives from the Professions
Problems With a Caseload to Workload Approach
What problems are we trying to solve when we examine service delivery in schools based on a caseload to workload approach? What we are trying to affect with this transition from caseload to workload is efficiency and effectiveness in service delivery. This includes the ability to implement evidence-based service delivery and to increase the availability of therapists for participation in campus-based team collaboration to support general ed as well as special ed interventions.
It is also important is to make sure that there is adequate therapist staffing with minimal turnover. One aspect of the problem is successfully recruiting and retaining related services personnel. This is critical to each school district's or charter school's ability to implement student IEPs. IEPs, for those of you who are not school-based practitioners, are individualized education programs. IEPs are the responsibility of the team.
Texas Study of Personnel Needs in Special Education, May 2006.
There is very little published evidence on the topic of what impacts recruiting and retaining related services personnel. I am going to share with you one data source from a statewide survey that was conducted in Texas in 2006. The top five barriers that were identified by related services personnel responding to the survey were:
- Overwhelming amount of required paper work
- Legal complexities of working in special education
- Job stress due to conflicting demands of the job and work overload
- Multiple-campus assignments
- Excessive Caseloads
This study included OTs, PTs, special ed counselors, orientation mobility specialists, et cetera. The number one reason for turnover was the overwhelming amount of required paperwork. Number two was the legal complexities of working in special education. I think this is often a surprise for people who come into school practice. There are a lot of policy issues and compliance issues. Job stress due to the conflicting demands of the job and an overload of work is also a barrier to retaining related services personnel. Multiple-campus assignments were problematic for some who responded to the survey. Finally, excessive caseloads also were a significant barrier identified by related services personnel in this particular study.
Defining Caseload v. Workload
Let's take a look at the definitions of caseload and workload approaches, and the history of their application in school practice. We are going to begin today with a little bit of history of how we got to a point where we needed to transition to alternative methods of service delivery.
President Ford signed federal legislation in 1975 that brought children with disabilities into public schools. It was called the Education for All Handicapped Children Act sometimes referred to as EHA. It specified a procedural process for the development of an individual education program, the IEP, for each student. The law said that the IEP had to include documentation of the special ed and related services needed to support student progress at school. Occupational and physical therapy were listed in the federal regulations as related services that must be provided if a student needed them in order to make progress. EHA and its regulations did not speak to how OT and PT practitioners should go about serving students with disabilities. Those, among the first to move into school practice in the late 1970s, brought with them the approaches they employed in other pediatric settings. For those of you who have worked in other settings, you will recognize them. First, all goals and objectives focused on remediation of an impairment. A focus particularly on the child and trying to remediate whatever aspects of the disability were getting in the way of their success at school. Most of the IEPs looked only at direct services, meaning one-on-one intervention, or a therapist working directly with the student with a hands on approach. Other aspects of service delivery were not included in the amount of time in the IEP. Services were typically written for once or twice a week of therapy, and scheduling was done with back-to-back therapy appointments or sessions, much like you would see in a clinic, or hospital, or rehab setting. Services were almost universally what are now referred to as pull-out. In other words, children were removed from their classrooms during the day for therapy, and taken perhaps to the stage, into the hall, or into a motor room, if you were lucky enough to have one. I know about this because I came to school practice in 1988, and this is exactly how the people that I worked with were practicing and how they taught me to practice. Included with this was no recognition or allowance in IEP time for planning, documenting services, consulting or training school personnel, fabricating materials on behalf of students, or meeting with campus team members. Another cluster of activities were going on at the time, often called indirect services, but they were not included typically in IEP time for a student.
Also, contextual factors were not considered. Think about the differences between a clinical setting and a school. The whole purpose of the school environmental design is to facilitate learning. Caseload referred to the number of students with OT and/or PT on their IEPs, had services assigned to them by the IEP team, and typically a count of how many services. Over time, the therapists began to question whether this approach was having a positive impact.
Problems and Concerns With This Approach (adapted from Williams and Cecere, 2013)
- Why aren’t student successes seen during my therapy session generalizing to the classroom/playground/cafeteria/restroom?
- How can I become part of the team?
- Why isn’t my full scope of practice utilized?
- Is this the best I can do for my students?
- Why aren’t student successes seen during my therapy session generalizing to the classroom/playground/cafeteria/restroom?
- How can I become part of the team?
- Why isn’t my full scope of practice utilized?
- Is this the best I can do for my students?
Let's take a closer look at some of the issues. Therapists wondered why the successes seen during therapy were not generalizing to the classroom, the cafeteria, the restroom, et cetera? The child was doing just fine, but the teacher was not seeing anything close to the results that the therapist was getting. Therapists also wondered how to be part of a team if they were pulling kids out of the classroom, working in the cafeteria, or working on the stage? No one was seeing what they were doing, and they were not seeing what the teachers were doing. They did not feel like they were part of the activities going on at school. Therapists found their full scope of practice was not being utilized., including psychosocial skills and skills for health and wellness. Those things were not tapped. Therapists were getting siphoned off into certain niches based on people's expectations of what a therapist might do. Therapists also wondered whether this was the best they could do for their students.
- What about Least Restrictive Environment (LRE)?
- What about the design of workflow and the environment (contextual factors)?
- Is what I’m doing ethical?
- What about all the other contributions I could make beyond being “the motor person?”
What about a least restrictive environment? For those of you who are not school therapists, this is a legal term that comes straight out of the law. It is a requirement that students be educated in the least restrictive environment. This is one of the foundational tenets of EHA, later the Individuals with Disabilities Education Act, or IDEA as it was renamed. This is part of the civil rights thrust of this legislation. It is not about segregating kids with disabilities. It is about educating them alongside their peers in the least restrictive environment that will meet their needs. What about the design of workflow and the environment? The contextual factors are unique to a school situation. For example, this includes going in and out of one room and transitioning to another, both in terms of the mechanical logistics and the sensory aspects of that activity. Kids have to line up in the hall where there is a lot of noise. Kids have to go through the cafeteria line. There is a playground to play on. This is nothing like a clinical setting. Therapists started to wonder whether they were being ethical. They wondered about other contributions that they could make beyond being the motor person or the handwriting person, which is a niche that OTs found themselves in.
Concerns From Other Members of the Collaborative Team
- What exactly are the therapists doing???? (Does it have anything to do with school?)
- Why doesn’t the therapist know the curriculum – what kids need to do to be successful?
- Why don’t we see any change in participation and/or academic performance?
- Why doesn’t the therapist join us for collaboration?
Along with concerns that the therapists had, there were also concerns from other members of the collaborative team regarding what the therapists were doing. In particular, the teachers had a lot of questions. They wanted to know what the therapists were doing. "They come to the classroom, they pick up a student, they take the student somewhere, do something, and bring the student back to the classroom." Are they doing anything related to what we are trying to do in the classroom? Does the therapist know the curriculum? Does he or she know what the students in my classroom need to do to be able to be successful? Why are we not seeing change in participation and/or academic performance? I cannot tell you how many times I heard that about my own practice, and later on when I was supervising other therapists. "The therapist tells me that she sees improvement in the child's visual perception, motor skills, or in navigational abilities, but when I try to put the student in those situations and apply the things the therapist tells me she is doing, I am not seeing any change or improvement." They also wanted to know why the therapist was not collaborating with them. Why are we not talking together?
Other issues that have come up.
- Why isn’t the therapist part of the IEP development and deliberations at IEP and team meetings?
- What about LRE? Inclusion? Why aren’t the therapists helping us?
- How could the therapists help us help our students participate to a greater extent and improve academic achievement?
Why isn't the therapist part of the IEP development, and why isn't she or he helping with deliberations at IEP and team meetings? In the early years, therapists did not routinely attend IEP meetings where discussions were held about programming. They would send in their recommendations in a paper format. The IEP team reviewed them, but the therapists were not there to take part in the discussion. This also meant they were not there to hear about a broader view of the child's performance than what they had been able to ascertain prior to the meeting. What about least restrictive environment? If they are pulling the child away from my classroom, then the child is missing instructional content. This is not least restrictive environment. They are not here with their same age peers. What about the concept of inclusion, which became very important in the 1990s as part of a civil rights thrust? Why are the kids being segregated, and why are the therapists not helping us help the children participate in their classroom? How could the therapists help us help our students participate to a greater extent and improve academic achievement?
Concerns from Administration Regarding Therapy Services
Finally, school administrators at both campus and district levels had questions.
- How much service is required to promote positive student outcomes? Isn’t there a formula for this????
- What can therapists help us with in addition to 1:1, hands-on services?
- What about LRE? Inclusion? Why aren’t the therapists part of it?
- How many therapists do we need?
- What staff mix do we need?
- How will I know when a therapist has reached his/her limit of work?
How much service is required to promote positive student outcomes? Is there a formula to figure this out depending on a child's disability, age, and how long they have had services? How much service do they need now? We do not know anything about therapy. We do not know how to schedule or plan for services. What can therapists help us with in addition to 1:1, hands on services? Are there other things they could do? Administrators in particular were interested in a least restrictive environment. What about the way they are serving and delivering services to these students? Is that consistent with least restrictive environment? What about inclusion? Again, the students were being pulled out. Why are the therapists not part of our inclusion effort? On top of all of that, the biggest challenge of all for administrators was trying to figure out how many therapists they needed. They could tell you how many teachers they needed based on formulas and strategies that they had used for years, but they could not tell you how many therapists they needed. And they certainly did not know what the staff mix should be. Do we need assistance? Do we need more PTs or do we need more OTs? Finally, how will I know when a therapist has reached his or her limit of work? I have one therapist that tells me that she is losing her mind because she has too many kids, while another has more kids than the first one, but she is having a grand time. She loves her job. How do I know when enough is enough? These are the kinds of issues and questions that came to the forefront in the first 10-15 years of school practice.
Over Time We Learned...
Adding IEP students required more...
- More time for student documentation
- More time for collaboration
- More meetings to attend
- More time for travel
When we were adding IEP students to our caseload, it was not just the numbers that got bigger, but there was more required in many different areas. There needed to be more time for student documentation that was required by law. More time was needed to make an effort to collaborate with other members of the student's campus team; the teachers, the speech language pathologist, the counselor, and the assistant principal. With more students, there were more meetings to attend, like pre-IEP meetings or staffings as they are called typically in public schools, where the planning occurs. And then, there was the IEP meeting itself. In addition, there might be other meetings with parents. This all required more time for travel. If you had more students added to your caseload, and particularly if they were at a separate school, you were going to have to put time in your schedule to get to that school for meetings.
