Thursday, March 02, 2017

A request for honesty about modern day practice in long term care facilities

Follow-up to Ethical occupational therapy practice in nursing home care

Studying historical phenomenon is helpful for framing modern problems - and so I would like to draw attention to an article that appeared in Modern Hospital in September 1922.

The author of the article, Christine Newman, was Head Aide of the Howell State Sanatorium for Tuberculosis in Howell, Michigan.  The facility is described as "a self-sufficient entity that aimed to meet the patients' and employees' every need with a working farm, apple orchard, convenience store, post office, water and heating plants and kitchen staff."

This model of 'self sufficiency' was common among asylums and sanitariums in the 19th century.  I would like to recommend Dr. Katherine Ziff's book Asylum on the Hill as well as her blog; these resources are invaluable to understanding a model of asylums during this time period and offer a counterpoint for understand modern institutions.

Ms. Newman's article, entitled "Defending my commercialism in occupational therapy," reminded me of the self-sufficiency model described in Ziff's book.  Ms. Newman's article describes the way that she views the occupational therapy service in 1922 and provides a justification for her perspectives and methods.

To start, she overtly states that the purpose of her occupational therapy work has both a "money and therapy aim."  She is decidedly pragmatic in her approach, believing that occupational therapy can serve both a therapeutic and financial benefit.  That is an unusual approach and occupational therapists today are not commonly heard discussing financial revenues so openly.

She outlines an interesting sequence of thinking to support her interest in both aspects.  Her core hypothesis can be represented in this sequence:

This would represent the therapeutic aspect of her thinking - but she layers on top of this the pragmatics of having the patient work on projects that she has need of.  Specifically, she expressed having a need of items that can "sell as fast as we can make them."  She is concerned that many aides were selling their items too cheaply and that this was a disservice to the people who were sick, whose labor should be recompensed as much as any well person.

Again, pragmatics are a guiding force in her approach, as she states
An occupational therapy aide particularly needs clever things [merchandise] because she is too poor to put her valuable labor on things that will not sell.  I know this sounds very commercial, but I still maintain there is just as much therapy in a number of salable things as in the same number of unsalable things, and I can do far more for my patients if my department is on a paying basis.

In ten months of work she incurred $1197.30 in expenses which included her salary and cash received by sale of goods produced was $818.35, leaving $378.95 that the sanitarium had to pay in order to maintain the OT department for the full year.  She was very hopeful that in the second year the OT department could pay for itself.

I was impressed with her argument and presentation, even if the underlying economic focus was troubling, because she at least had some core philosophy (see sequence above) that was  based on why she was doing certain activities.

That got me thinking about modern day occupational therapy in many long term care facilities, where the therapy is often reductionistic, biomechanically oriented, and not attendant to the patient's occupational needs.  There does not seem to be much of a theoretical focus on why a therapist chooses an upper extremity ergometer over repeated exercises with a cane or dowel with weights attached.  I also don't see anyone defending these methods.  Occupational therapists just do them.  And a lot of revenue is generated.

What is even more interesting is that there does not seem to be too much open conversation about the gross profiteering that goes on in those departments.  I am left wondering: what is the financial surplus of occupational therapy efforts in those facilities?  Are the departments self-sustaining?

Instead there are some general conversations about how therapists are supposed to be concerned about ethics in these environments and how different professional organizations get together and have concerns (AOTA/APTA/ASHA, n.d.). The purpose of this collaborative statement is to "emphasize clinician's responsibility to understand payers' policies and regulations, as well as their obligation to act ethically and to report inappropriate practices." (Brown & Hemm, 2015).

It is all very vague - and no one seems to be hitting the issue directly.

We all know that a lot of money is being generated by modern day occupational therapy, and that money is going somewhere.  So where is the modern day article from the clinicians in the field that is entitled "Defending my commercialism in occupational therapy?"

As I am interested in seeing such an article in the modern period, I implore one of my colleagues to write it.

Please incorporate a theoretical justification for the work being done in long term care facilities, even if the economic aspect will remain a primary focus.

I wonder if I will ever see such an article.  Perhaps people were just willing to be more honest about things in 1922?


embedded links, and...

AOTA/APTA/ASHA (n.d.) Consensus statement on clinical judgment in health care settings: AOTA, APTA, ASHA.  Downloaded 3/2/2017 from

Brown, J. & Hemm, M. (2015, May). ASHA, NASL address concerns in skilled nursing facilities.  The ASHA Leader, 20(5), 8. doi 10.1044/leader.NIB1.20052015.8

Newman, C. (1922). Defending my commercialism in occupational therapy. The Modern Hospital, 19(3), 250-252.

Ziff, K. (2012).  Asylum on the Hill. Athens, OH: Ohio University Press.

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