Read Full Text: Caseload and Workload: Current Trends in School-Based Practice Across the United States (This is a paid article, but we still thought it was important to cover.)
Journal: The American Journal of Occupational Therapy
Year Published: 2020
CEU Podcast: School-based OT Workload Trends with Jayson Davies (CE Course)
I was not expecting an article on OT caseloads to contain some of the most revolutionary concepts we’ve seen in the Club.
The article encourages school-based OTs to shift away from an individual, medical model “caseload” approach in favor of a “workload” approach—which hypothetically opens the door for greater focus on population health.
Is this a pipe dream? Or is it a real opportunity? Whatever your thoughts as you start reading this article, you will walk away with some concrete insights on how school OTs are spending their time—versus how they wish they were spending their time.
I’m so excited to talk about this on next week’s podcast with Jayson Davies, M.A., OTR/L, of the OT School House!
Let’s dive in.
Intro to caseload versus workload
The caseload-based treatment paradigm is pretty straightforward. This model is built around the number of clients you, as the practitioner, treat directly.
The workload-based paradigm, on the other hand, puts equal focus on ALL of the activities you do to support students—directly as well as indirectly. Instead of simply considering the number of students on your caseload, this model accounts for the time you spend documenting, attending IEP meetings, visiting classrooms, etc. This paradigm also allows you to expand your role beyond direct treatment in order to provide interventions that have an indirect impact on students, such as:
- Curriculum development
- Literacy programs
- Public health initiatives, such as multilayered systems of support (MLSS)
What research and writing has been done on the workload paradigm?
I’m going to take a little creative liberty in telling the story of this section, so please correct me in the comments if you believe my perspective is off base. Here’s how I understand the history of the “workload” discussion.
In 2004, Congress made many changes to the Individuals with Disabilities Education Act (IDEA), opening the way for things like:
The law also mandated support in the least restrictive environment (LRE).
This pushed therapists to consider providing their services IN the classroom. The legislative changes also provided avenues for therapists to work with the entire population as part of a screening process—and to improve curriculums (so ideally, fewer children would need services).
In response, national organizations started releasing statements about shifting our paradigm for school-based therapies to “workload.” That way, we could spend our time with entire school populations, target groups, AND individual students.
The idea was that a workload approach would be the model most likely to ensure compliance with IDEA 2004 requirements as well as state and local mandates. This led to the publication of statements like these:
- Workload Approach: A Paradigm Shift for Positive Impact on Student Outcomes (Joint Statement by AOTA, ASHA, and the APTA, 2014)
- Transforming caseload to workload in school-based occupational therapy services (AOTA, 2014)
- AOTA practice advisory on occupational therapy in response to intervention (AOTA, 2014)
These organizations and other entities eventually released guidelines for calculating workload:
- Service provider ratio and workload calculation (Ohio Department of Education, 2016)
- School-based service delivery in speech-language pathology (AHSA, 2016)
- Guidance in determining FTE and workload for occupational therapy, physical therapy, and speech-language pathology staff (North Carolina Department of Public Instruction)
This time period also saw the rise of the 3:1 service delivery model, where therapists spend three weeks delivering traditional services followed by one week of indirect services.
Let’s get real: Barriers to switching to a workload paradigm
Despite the national conversation that was going on around workload, there were barriers to actually making this paradigm shift. These included:
- High caseload numbers
- Differing perceptions of how therapists should spend their time
- Decreased administrative support
- Lack of resources
But overall, there is simply a lack of information out there to really understand the current practice patterns of OTs and the factors that have limited their ability to implement a workload approach—which leads us to this paper.
What was the purpose of this paper?
The intent of this paper was to examine the practice trends of elementary, middle, and high school OT practitioners across the US. The authors sought to explore:
- Caseload size
- Caseload attributes
- Workload responsibilities
- Involvement in whole-school programming
- Current service delivery models
- Knowledge of state and local policy
- Attempts to implement new models of practice
- Job satisfaction
What were the methods?
The authors used a researcher-designed online survey. Questions were informed by a literature review and this qualitative study about the perceptions of a workload-based approach.
The survey was distributed via social media and state associations.
What were the results?
541 practitioners began the survey, and 371 completed it. Here are some of the main results.
Information about the practitioners:
479 were OTs; 44 were OTAs.
- 86% were full-time
- 70% were hired directly by their school district
- 82% worked in a public elementary school
Information about their caseload:
Full-time practitioners averaged a caseload of 41–50. (Interestingly, 41–50 was also the most common caseload for part-time practitioners).
Here’s the percentage of full-time practitioners who reported having each of the following caseload ranges:
- 1.75% — 11-20 students
- 13% — 21-30 students
- 19% — 31-40 students
- 22% — 41-50 students
- 15.75% — 51-60 students
- 11.50% — 61-70 students
- 8.25% — 71-80 students
- 1.50% — 81-90 students
- 2.75% — 91-100 students
- 1.25% — 101-110 students
- 0.75% — 111-120 students
- 2.50% — >120 students
(Note: Due to rounding, percentages may not total 100.)
Practitioner perceptions of their caseload numbers:
- 60% indicated that the number of students on their caseload was UNREASONABLE.
- 55% reported they were NOT able to provide services mandated by IEPs due to other responsibilities.
- 61% believed they did NOT have clear guidelines governing the number of students an individual practitioner should have on their caseload.
- 64% felt they had a great deal of influence on decisions around setting service mandates for students on their caseload.
Most frequently delivered services:
Participants ranked services according to how frequently they provided each one. Services are listed below from highest frequency rate to lowest frequency rate:.
- 64% — Nonintegrated pull-out
- 23% — Integrated push-in
- 19% — 3:1 model (3 wk/month on traditional services; 1 wk/month on indirect services)
- 16% — Consultation or collaboration
- 9% — Coaching
- 8% — Block scheduling
- 3% — Telehealth
Workload versus caseload:
Here’s the breakdown of approaches reported by practitioners:
- 45% — blended workload/caseload approach
- 33% — caseload approach
- 20% — workload approach
Interestingly, 76% indicated a desire to use a workload approach.
Below is the percentage of practitioners who reported performing each listed activity as part of their workload. (Practitioners were able to select all that applied.)
- 99.22% — Documentation
- 98.96% — Direct student intervention
- 97.41% — Staff consultation
- 94.04% — Report writing
- 91.71% — Scheduling
- 91.19% — Evaluations and re-evaluations
- 89.90% — Team meetings
- 82.12% — Student observations
- 80.83% — Travel between sites
- 75.91% — Family or caregiver consult
- 75.65% — Professional development
- 75.65% — Screenings
- 75.39% — Material development
- 74.61% — Medicaid paperwork
- 70.98% — Staff education
- 69.95% — Behavioral support
- 63.21% — Committee on Special Education meetings
- 41.19% — Participation in events (e.g., back-to-school night)
- 40.41% — Outside provider consult
- 39.64% — Multi-tiered systems of support
- 21.24% — Advocacy
- 18.13% — Research
- 17.62% — Participation in school committees
- 11.92% — Grant writing
(Note. Survey respondents were able to select multiple responses.)
Transitioning to a workload approach:
61% of practitioners indicated they had advocated for the transition to a workload approach, but that their efforts were UNSUCCESSFUL.
Of those who advocated for this transition:
- 66% talked to administrators and other stakeholders
- 41% provided evidence to administrators and stakeholders
Barriers reported included:
- 51% — Lack of administrative support
- 48% — High caseload numbers
- 39% — Lack of time
- 35% — Uncertainty over how to make the transition
Job satisfaction:
77% of practitioners reported feeling very satisfied or somewhat satisfied with their current job. Here were the top-reported factors to increase their job satisfaction:
- 55% — Lower caseload numbers
- 50% — Better salary and benefits
- 36% — More resources
- 29% — Fewer workload responsibilities
- 22% — More opportunities for professional development
Conclusions and discussion
OT practitioners have a high level of interest in moving to a workload approach, and 20% of those surveyed have done so already.
While OTs feel they have a great deal of influence on IEP recommendations, their efforts to change their system of work to a workload approach have been less successful. This may indicate that their influence is strongest within the current system.
Because advocacy at the local and district levels has met so much resistance, more state and federal advocacy may be needed.
Another interesting takeaway from this research was that 64% of OT practitioners still use pull-out services as their primary service approach, even though best practice guidelines encourage integrated push-in services. The authors cite the following article from SIS Quarterly as a reference for those interested in getting started with push-in services:
Implementing contextually based services: Where do we begin
Implications for OT practitioners
The authors indicate that this study has the following implications for OT practitioners in the school setting:
- OTs need more resources and training in advocacy and evidence-based practice.
- Advocacy efforts must be directed toward state and federal policy making agencies.
- Further research is needed to demonstrate improved student and practitioner outcomes through the use of both workload and contextually based service delivery models.
Takeaways for OT practitioners
(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)
1. This is a revolutionary move away from the medical model.
Call it what you want—workload, 3:1 service delivery, RTS, MLSS, or MTSS. The important thing is that all of these models encourage OT practitioners to take the hard-earned knowledge they’ve gained from working with individuals and apply it at the population level.
This pushes us to look at the upstream causes of the issues we are seeing—and to spend some of our time addressing them. (Ideally in a way that leads to fewer students ending up on our caseloads.)
I love the theory behind this strategy—and I think school-based OTs are uniquely poised to test the effectiveness of this approach.
IDEA seems to encourage this type of practice. And because reimbursement for school-based OT isn’t closely tied to the hours spent with clients—as is the case for many OTs in the traditional medical model—they are better able to adopt this truly holistic approach!
The change to workload may not be happening as swiftly as many would like, but make no mistake—a quiet revolution in how OTs approach their care is in the works!
2. The theory behind this approach seems solid, but more evidence is needed.
As I combed through the citations in this article, they certainly skewed toward opinion pieces, position statements, and online surveys. What I really wanted to see were some traditional research studies that objectively demonstrate how this approach helps the kids we are serving.
I wanted to know: when practitioners did SUCCESSFULLY advocate for a move to a workload approach, what evidence did they use?
Please, fill me in if I am missing any landmark studies behind workload, RTI, or MTSS! I may have focused too narrowly on OT research—and I’d love to keep the conversation going.
Here’s the full APA citation for this article:
Seruya, F. M., &; Garfinkel, M. (2020). Caseload and workload: Current trends in school-based practice across the United States. The American Journal of Occupational Therapy, 74(5).
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Jayson Davies. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!
! We need to call it something like “Every Student Succeeds with OT.” 
