Occupational Therapy And Case Management: Focused On Holistic Care And Functional Outcomes Podcast

Editor's note: This text-based course is a transcript of the Occupational Therapy And Case Management: Focused On Holistic Care And Functional Outcomes Podcast, presented by Thomas F. Fisher, PhD, OTR/L, CCM, FAOTA; Dennis Cleary, MS, OTD, OTR/L, FAOTA.

**Please use the handout to complete the exam.

Learning Outcomes

• After this course, participants will be able to:
  • recognize the definitions of case management, disease management, managed care, and case manager.
  • identify the rationale for the increased use of case management in healthcare.
  • identify the case management process and certification through the Commission for Case Manager Certification to use the designation of CCM (certified case manager).

Podcast Discussion

Dennis: Hi, everyone, and welcome. My name is Dennis Cleary, and I'm a senior researcher and occupational therapist at Cincinnati Children's Hospital Medical Center in beautiful Cincinnati, Ohio. I am happy to be joined today by Dr. Tom Fisher, Dean Emeritus. Tom, thanks so much for joining us. I always like to start with this question. Are you really one of the hundred most influential persons of the first century of our profession?

Tom: That is true, or at least what they said at the 2017 AOTA 100th celebration in Philadelphia. Thank you for recognizing that.

Dennis: Absolutely. It is a great accomplishment, especially as there are a hundred of you, including the founders. As you mentioned, Philadelphia was when we had the 100th anniversary of our profession. Howe many of the influential occupational therapists are still with us?

Tom: I do not know the exact count. The last number I heard was 60.

Dennis: I know you have always had an interest in case management, so that will be the focus of our talk today. We are going to discuss occupational therapy and case management, focusing on holistic care and functional outcomes. I have always been amazed at the variety of practice settings and the different people you have worked with through the years. Can you tell us about your decision to become an occupational therapist and your career as a professor?

Tom: Sure. Like many, I did not know what occupational therapy was. I met with my advisor at Indiana University (in the mid-1970s), who said, "It looks like you took a lot of sciences in high school. Have you thought about the school of medicine?" I said, "I am not interested in going to college that long, so no, I'm not interested in becoming a physician." She shared with me that there was allied health within the School of Medicine at IU, and perhaps one of those disciplines would be interesting to me. The next semester, an Intro to Allied Health Professions introduced me to 15 to 20 different disciplines. I narrowed it down to occupational therapy and physical therapy.

I took a transporter job in a hospital in the rehab department in the summer between my freshmen and sophomore years in college, taking patients from their acute care rooms down to the rehab department. With that exposure, I saw that OT was much more compatible with my philosophy, as it looked at the psychosocial component. There were times when I went to the mental health and pediatric units, so I got to see a variety of different treatments. Not to minimize PT, but it seemed only physical in nature. I knew people had mental health and psychosocial components that made them tick.

I started taking the prerequisites to go to OT school, started in pediatrics, and the rest is history. 

Dennis: You had very interesting fieldwork. Could you tell us about that?

Tom: I did my mental health rotation out east back when you did nine months of fieldwork instead of six. I was at Sheppard Pratt Hospital in Johns Hopkins with many other students. I then did a physical disabilities rotation in Pennsylvania, and then my peds was in the Cincinnati Public Schools.

Dennis: You had a prominent fieldwork educator in Cincinnati if I remember.

Tom: I had two prominent ones, and many instructors taught us in the evenings. Ginny Scardina and Shelly Lane were my primary educators, and I spent three days with Ginny and two days with Shelly. The evenings were filled with classes taught by other sensory integration founders and people who led me to pediatrics.

I started in school systems but knew I needed a master's degree. I got a master's at Purdue and practiced for 18 years prior to going to higher education. I received my PhD from the University of Kentucky. Over my career, I practiced in all areas, including mental health and adults.

Dennis: You did a little bit of everything. Why did you decide to go back into your PhD?

Tom: I was in a hospital system that got acquired. It made me think about my future if an acquisition or joint venture did not happen. I was at an airport heading to a national conference with some faculty from Eastern Kentucky University who said, "You should go to academia. Then, if you get promoted and tenured, you are good to go. You are already halfway there." So that is what I did.

Dennis: You are in Kentucky. You were deemed one of the hundred most influential occupational therapists in our profession because you helped write the licensure acts in both Kentucky and Indiana. Do you want to talk briefly about what that experience was like?

Tom: I had not planned on advocating, but it became evident when I moved to Kentucky in the early 1980s. There were 68 of us total in the state. Needless to say, it was not a well-known profession, and the OTs were mainly located in the cities of Lexington and Louisville. At the time, some legislation was happening where another discipline was starting to mirror what OTs did, and AOTA was supporting that licensure should be managed at the state level.

We decided that we would launch licensure in Kentucky, and we were successful. When I returned to Indiana, OT professionals asked, "Can we tap you to help us? We are only certified in the state and would like to go for licensure. Are you willing to help us?" It is the same process in all states and was not challenging. We met with many people, including senators, from all over the state. When they arrived at the state capitol, they understood what OT was and why it needed to move from certification to licensure. Anyone on this call could do it. It is not that challenging, but you have to get involved.

Dennis: Most of our elected representatives are open to hearing from constituents.

Tom: That is right.

Dennis: You have worked in mental health and academia but also have some experience in worker rehabilitation and CARF, the Commission on Accreditation of Rehab Facilities. How did you get interested in that?

Tom: When working as the director of outpatient services at a rehab hospital in Lexington, I got exposure to CARF, the Commission on Accreditation of Rehab Facilities. During a site visit, two surveyors asked me whether I would be interested in becoming a surveyor because it seemed like I understood the standards when meeting with them. After I said that I would, they invited me to get trained. At that time, I was also moving from outpatient therapy services to occupational medicine that focused on return-to-work issues. At that time, we had a work hardening and a work conditioning program, which now is called occupational rehabilitation in the CARF system.

Dennis: Did you get interested in case management from those experiences? 

Tom: That is a great question. Actually, I became interested in case management when I was doing home health and had many complicated cases. In home health, you are the only provider in the home at any given time, unless your visits overlap. You may see another clinician in the driveway or on the street. You can pull over and talk with each other, but for the most part, you are on your own when you are there.

We often left notes for each other, but some cases were so complicated, I said, "Let's meet at the office to discuss." The team was usually the nurse, PT, and a speech-language pathologist. We would discuss that case, who was doing what, and how we could support each other.

Reading different materials, I understood this was "managing cases," or case management. I started exploring this area, and at that time, the Case Management Society of America was emerging. They were starting to form an exam that people could take. I was able to demonstrate that I had evidence of doing case management for several years.

I first got exposed to it by filling a need with the other practitioners, the patient, and their families. This made a lot of sense to the patients, and they appreciated that we were all trying to coordinate and support each other's services so we were not duplicating.

Dennis: Why do you think it is important for occupational therapists to understand what case managers do?

Tom: Case managers are front and center more than ever. Case management will continue because it is a strategy for managing the limited resources allocated to different cases. It is also a way for families to become more educated about their disease processes to take more control and self-manage their conditions.

With case management, there are fewer hospitalizations, which is costly. OT is similar to case management, as the principles are the same. Case management is holistic, and you must address the physical, mental, and psychosocial components or the social determinants of health. These are all the things that occupational therapists understand. Thus, it is a great build-on to your OT skills.

Different cases require the oversight of case managers. My area is primarily with traumatic brain injuries. I have also worked with workers' comp to help people with musculoskeletal strains and sprains to get them back to work as quickly as possible without re-injury.

Dennis: Did case management come out of workers' compensation?

Tom: Yes, it did. I believe Liberty Mutual was the first insurance company that began to use that model in the 1940s because people were getting injured on the job and not returning to the job, yet still getting compensated by their employers. Employers went to Liberty Mutual as an insurance carrier and said, "How can we get these people back to work?" That is how it emerged. Since it worked in that system, healthcare said, "Well, it should work in the healthcare industry as well."

This was in contrast to utilization review, which was the previous system in healthcare. This is where hospital nurses looked at patients in beds for too long and see if they could be transferred to home or another setting to free up beds. Case management expanded the utilization review component that many nurses were already in.

That is a quick history of case management.

Dennis: You did that in 90 seconds or less, so good job. We are now going to play "define some terms." How would you define case management on its own?

Tom: I would be remiss if I did not state how the Case Management Society of America, which is the leading professional organization for case managers, defines it. "Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs to attain the goal of quality and cost-effective care." It is a broad statement, but it is also how OTs think. 

Dennis: Can you translate this for the rest of us who do not have it memorized? How do you define case management?

Tom: I would say it is getting the right services to the right person at the right time. For example, at certain points in time, PT, SP, or a specialist may be the appropriate service. In OT, we can do our own thing with a client, but eventually, we may need to refer them to a certified hand therapist or a driving rehab specialist. It is getting the right services, care, and setting which lowers the cost. Therapy at home or outpatient will be less expensive than being hospitalized.

Dennis: The next definition is care coordination.

Tom: Care coordination is basically the same as case management. It is sometimes used interchangeably. As case managers, we have decided it is also managing in addition to coordinating, which is the difference.

Dennis: Disease management is next.

Tom: Disease management has surfaced because certain diseases now have become identified as the most expensive, like diabetes and neurodegenerative disorders such as Parkinson's, ALS, or multiple sclerosis. As health professionals, we understand these disease processes are going to take their own course. It becomes more of a teaching education piece for the case managers and therapists working with those clients to understand their disease. They can manage it if given the information on how to manage it and are aware that there will be remissions and exacerbations. What do you do when your symptoms start to get worse? It is managing that disease process.

Dennis: Everybody's favorite topic is managed care. Could you talk a little bit about managed care?

Tom: Managed care is not as popular as it once was. A certain pot of money was given for certain diagnoses, and the burden was on the case managers and/or the insurance companies to try and contain the services within that capped amount. There was a bid that happened each year for those managed care products. If you went over that, the premiums for those enrollees would increase. If it was under, which typically did not happen, then you were able to cover services that you had not had prior to that. This was good, but it did not happen as frequently as it should have. In fact, health maintenance organizations (HMOs) or prospective payment organizations (PPOs) were developed to predict what a person with this condition will need. This model worked for a very short time, but because of the complexity of humans and their compliance with their programs or medications, et cetera, it did not work as well. Humana and Medicare Advantage have these products, but fewer people are using that.

Dennis: I think some state Medicaids have that too.

Tom: If Medicare does it, Medicaid and other insurance typically follow.

Dennis: I know some hospitals have done well and others have not. Their anticipated allocation of services and whether they hit those benchmarks are always interesting.

Tom: It is difficult to predict and manage care successfully. 

Dennis: Do you think we will continue to see an increased use of case management in healthcare in the coming years, or do you think it's leveling off? 

Tom: I think it will increase. I say that primarily because at our case management meetings, we keep hearing about the demand for case managers and different employers looking for these individuals because they have evidence that it has decreased the amount spent. Additionally, as someone is overviewing a case, if it is not moving in the right direction, things can be adjusted. Otherwise, the case can linger and not have closure. Meanwhile, more cases are opening.

It is a way to control the costs, and the settings where people are getting served, move them back and forth and transition them into post-acute care at the right time. Predictions are pretty clear that this controls services, especially for those that are uninsured and whose services would not be covered.

Dennis: I work with adults with intellectual and developmental disabilities.  Many Medicaid products have case managers to help coordinate services and start to look at other social determinants of health. It looks to see what support somebody may need to find and maintain a job and use fewer healthcare resources. How can OTs help case managers for the benefit of the client? I do not know whether you have seen that in some of your experiences.

Tom: There is what is considered an internal case manager, someone in the system trying to navigate a person within their own system. There is also an external one that may be hired by the family or insurance companies to give some ideas about how to help a person. This is thinking from a different perspective and has a much broader understanding of health systems.

Again, I think OTs understand the health and human systems. We are in healthcare systems and in the community. Using the workforce challenges that all employers have, it is important to know that persons with traumatic brain injuries, intellectual deficits, and developmental disabilities are reliable and want to work. They may not be able to work full-time because they may run the risk of losing their disability, but three people doing part-time work may fill a position. You are also giving back to these individuals who want to work, need to work, and are quite good at many things they have been trained to do. Where before, families did not think that they could do that. They were assuming that they needed to stay at home or be institutionalized. Now, employers and families look at this differently. 

Dennis: Absolutely. What challenges do you think the healthcare system will continue to face that case management can help with?

Tom: I think the pure volume of persons that are going to need case management is indisputable. I think the quote is that 10,000 Americans are turning 65 every day from now until 2030. Many older persons may not have family nearby, yet need some support to navigate our complicated healthcare system. At one point, I was approached by insurance companies because of my certification as a case manager. "I've got a client who lives in Georgetown, Kentucky, but their daughter lives in Seattle, Washington, who cannot get back frequently to help. Can you help this person navigate their doctor's appointments and check on them?" Many arrangements, such as this, will occur in the future as many people are willing to pay for it privately. It gives them peace of mind to have a professional checking in and managing health care appointments for their family member. This will also help to manage costs.

Dennis: You have a certification, Certified Case Manager. Since you are an occupational therapist, I assume that case management and occupational therapy are compatible. Can you talk a little bit about that? Where is there an overlap in skills?

Tom: As I stated earlier, case managers use a holistic approach. OTs learned this from day one. It is not just about physical needs but also psychosocial and cognitive ones. We look at social health determinants, housing, transportation, and other things that are important for people. It is what they want to do, need to do, or are expected to do as occupational beings. It is a perfect fit.

I needed to get much more comfortable with medications to take the exam. As OTs, we may know about certain medications depending on our work areas. For example, I learned many cardiac meds while working in a cardiac unit. I also learned about other meds when I switched to other areas. However, I did not have a good overview of all meds. When talking with other OTs that are CCMs, this was identified as the area that required the most study. I got flashcards and memorized medicines, side effects, et cetera. 

In contrast, thinking about the environments people have to live in after a disability was not challenging for me. I also understood the ADA. Meanwhile, nurses had a harder time with these types of questions. 

I did workshops about encouraging OTs to consider case management, as it is a nice transition once you have your foundational knowledge of disease processes and the systems. It is a way to have a gestalt picture of the whole person, their families, and their homes. Case managers do this, but it is not a huge change in how OTs are educated. 

Dennis: Would you say that the roots of case management are in nursing? If so, we would not have quite as much preparation and medications as a nurse would. And other than nurses, what other professions might be involved as certified case managers?

Tom: That is a good question. When you apply to sit for the exam, there are two categories. One is just for nurses, and the other one is for non-nurses. The next largest category is social workers and then vocational rehab counselors. Occupational therapists are probably the fourth largest. PT and speech therapists are also considering this field.

Because of their education, I think nurses understand medical and surgical cases. However, when it moves into the rehab phase, unless certified rehab RNs, they do not understand the rehab process or the different disciplines as OTs would. 

Dennis: There are fewer Certified Rehabilitation Counselors (CRCs). I imagine they are involved in more of the workers' compensation or employment types of case management. Again, this is a great opportunity for an occupational therapist, but not the best first job. People need a little seasoning underneath them before they work in this area.

Can you talk about the skillsets that an occupational therapist or assistant would bring to the job? Additionally, can you talk about the difference between a case manager and a certified case manager and the roles that an OTA would be able to perform?

Tom: Anyone could be a case manager, even those who are not health professionals. I think it is more challenging, and I do not believe many of them get hired, or at least that is what I have seen. To be a case manager, you must have people skills, be able to interview, read reports, and know how to move a person along the continuum.

Occupational therapy assistants can be case managers or internal case managers inside skilled nursing or assisted living facilities. To become a certified case manager, the Commission for 30 years has clearly stated that you have to have a professional license where you are independent of someone else supervising you. Non-nurses believe that the nurses did this so that LPNs would not enter the certified case management world. Thus, only RNs can be case managers. This is similar in other categories where professionals like occupational therapists and social workers have independent autonomy in their licenses. This is one of the first criteria to be able to qualify to sit for it. 

You also need, at a minimum, two years of experience. It used to be five, like CHTs (now three), but it is now two as people complained about that requirement. Case management must also be 20% of your job; an employer must verify that.

There are cases where some people are supervising case managers, that are not CCMs. These people can only do that for a year.

Finally, the requirement of years can be reviewed if, say, a nurse with Anthem Blue Cross Blue Shield nurse was not a CCM but managed the case management division where she was supervising CCMs. She understood conceptually what the case managers were doing, so they gave her a break.

I encourage anyone thinking about a case management role to go on to the website to see if the criteria for sitting for the exam have changed.

Dennis: Sometimes things like that change from time to time regarding requirements and whatnot. Are there specific things that occupational therapists bring to the table as a case manager? And, do they primarily work in rehabilitation types of fields?

Tom: Some work in acute, intensive, and cardiac care. I know two on the West Coast managing cases in outpatient, primarily those with strokes, spinal cord injuries, or heart conditions with compromised breathing. In these cases, they wanted a different type of case manager so an OT with case management background seemed to be a better fit than a nurse. OTs may know how to get someone back to work or to a different work category.

Dennis: With long COVID, I have not heard much about how an occupational therapist within case management might better understand the long-term effects. That might be interesting research. That could be your next article, occupational therapy and long COVID.

Tom: This is especially true with mild cognitive impairment. We know that there are some challenges there.

Dennis: Do certified case managers work independently, or are they contracted to organizations?

Tom: Health systems and insurance companies can hire them, or like me, some work independently with a private practice. I get referrals from people I worked with or who know my work and prefer a particular case to be handled by someone who has this area of expertise.

There are case managers in the penal system, domestic shelters, et cetera. The sky is the limit. This is why I am delighted that you asked for this particular podcast on occupational therapy and case management.

Dennis: I am not trying to stereotype anyone or be ageist, but this could be a great profession for older therapists. I have back and knee issues, and doing many transfers is not a great option. What are your thoughts on this being an option for therapists as they become seasoned or want a new challenge?

Tom: Absolutely. I recognized this as I moved into this area. There are many older nurses in this area as well. After many years, you understand the disease process, but you may no longer be physically capable of doing things. A case manager still uses an OT or an OTA skillset in a new and different way.

Dennis: Even in the mental health system, there is a shortage of nurses. Nurses are also being paid a lot more to do bedside nursing. This shift in nursing practice may be a nice opportunity for occupational therapy therapists and assistants (depending on the requirements) to move into these case management positions.

How are case management jobs posted? How do you recommend an occupational therapist apply for some of those positions?

Tom: You can query case management or care coordinator, and those opportunities will pop up. It may say a nurse, but you can ask, "Are you only looking for a nurse? I am a CCM, but I'm an occupational therapist CCM." You can sell yourself, your education, your experiences, and what you can bring. This is similar to what I said to OT students who thought they wanted to work in mental health, but they found people were only looking for recreational therapists. I told them to say, "Although I'm not a recreational therapist, I am an occupational therapist, and here's what I would bring to the position. OT is also reimbursable through a lot of private insurance." They will not ask you about your experience unless you tell them.

Dennis: I think we need to sell ourselves, especially with the shortage of nurses. If someone thinks of this, how can they start prepping themselves? 

Tom: If they feel like you want to do or are already doing care coordination, you can ask your supervisor, "I think that 'X, Y, and Z' activities qualified me to be considered a case manager. Would you be willing to put that in writing so that if I decide to go down that path, I have documentation that a percentage (20% ideally) of what I did this year was care coordination or case management?" See what they say. You then have that crucial documentation that you need.

Dennis: I would think that a rehab manager in a healthcare system, for example, would want to potentially see one of their staff move into a case management role. While we love our nurse friends, and I know your wife is a nurse, OTs becoming case managers can grow and advocate for our profession. And, when we need to call someone from an insurance company, we may get an OT instead of a nurse. That may make things in rehab easier.

Tom: Absolutely. We have similar language or nomenclature.

Dennis: You can also visit the Commission for Case Manager Certifications website for the requirements. We should be keeping track of our continuing education hours. You stated that you need two years of experience, and then what percentage of time within that?

Tom: Currently, it is at least 20% of your job over the past two years to be in case management. You also have to be a person of good moral character, licensed, and meet whatever the standards are. 

Dennis: Did you pass on your first attempt, or were you grandfathered in? 

Tom: I did. Everyone has had to take it.

Dennis: What are some general topics that are part of that? You talked about medication. What other types of things do they ask you about?

Tom: They want to know about different conditions, both mental health and physical. They also ask about environments like halfway houses, group homes, and other post-acute care settings. The guide helps prepare you, and there are also workshops. It is another credential you can earn, and then, you must keep up with continuing education requirements.

Dennis: What are the continuing education requirements to maintain that?

Tom: I think it is 80 CEUs every five years. It is not challenging because, as a member of the Case Management Society of America, many free CEUs are offered at the local chapters. You can also get many CEUs at the state and national conferences.

Dennis: If an occupational therapist is interested in becoming a CCM, what initial steps would you recommend they take at this point?

Tom: Again, I would try to start to do case management at your current job. You can think broadly about formally pulling people, including the physician, together with a case agenda and talking points. What environment is the client in? Do they have a job? How can we get them off a vent or eliminate some lines to get them up and moving? What did this person do for a living prior to this accident, injury, or illness? Is working part-time or virtually an option? Again, your role in this case management can be used for future roles.

Dennis: Great. Well, Tom Fisher, one of the hundred most influential occupational therapists in the United States in the last hundred years, we appreciate your time. Thanks for all you have done for the profession of occupational therapy and certified case management. 

Tom: No, thank you for the invitation. I enjoyed it thoroughly.

References

Available in the handout.