Q: How do I explain graduation from services when it’s clear that a student would need it again in the future?

 

 

A: The short answer is by practicing and explaining multiple episodes of care. Here’s the longer explanation:

 

 

Episodes of Care in School-based Related Services

 

 

First let’s define “episode of care.” An episode of care is service provided for a specific health condition(s) during a set time period (APTA, 2020). While the term “episode of care” is more commonly used in the medical setting, this concept should be best practice for school-based services, especially as we consider that many students with lifelong disabilities will need our support at different periods in their life, and not need our services during other times.

 

An episode of care has the 5 features below. Let’s discuss each of them in relation to school-based services under IDEA:

• • • Meaningful Outcome: this would be an IEP goal
    • Specific Need: when the team has decided that related services of OT, PT, or Speech is needed to enable the child to achieve their IEP goals
    • Defined Period: it has a beginning and a conclusion
    • Beginning: when the team decides the specific need for a related service 
    • Conclusion: usually, when the meaningful outcome (i.e., IEP goal) has been met. Read about other reasons for conclusion of services in this article.

(Adapted from: Palisano & Murr, 2009)

 

 

3 Types of Service Delivery

 

 

We can represent 3 common types of episodes of care along a student’s school years as follows:

 

 

 

Option 1: Throughout the School Years 

Continuous provision of services from the start to the end of a student’s schooling. This can happen when services are determined: 

1. 1. 1. Based on the Student’s Disability
         • For instance, there’s a common assumption that a student with complex disabilities will constantly require services.
      2. Via “Qualification” for Services
         • For example, when a student who continually falls 1.5 standard deviations below the mean on a standardized test always “qualifies” for services. Read “Why We Should Not Say ‘Qualifying for a School-based Related Service’” 
         • We know that many students with lifelong disabilities will increasingly fall behind their peers in norm-referenced tests. For this reason, we do not recommend norm-referenced tests as outcome measures.
      3. Prior to Establishing IEP Goals
         • This happens a lot! For example, when an IEP coordinator routinely asks the therapist, “Do you recommend services? If yes, please send your goals.” In this situation, a therapist may feel the pressure to continually provide services.

 

Option 2: During the Early School Years

Higher amount of service when a student is young, gradually tapering off and concluding in a few years (hence, the line going down to the right and stopping in our illustration). 

 

 

This approach is often employed under the assumption that younger students have greater potential for skill acquisition. While this assumption holds some validity, particularly when thinking merely about typical developmental contexts, it often proves erroneous for students with lifelong disabilities. Why? Because skill development is dependent on the “critical period of acquisition”,  the period when an individual is more receptive to skill development. 

 

The critical period of acquisition is highly individualized and influenced by various factors beyond mere age. Consider the following examples: 

1. 1. 1. Motivation: A middle school student expresses a newfound desire to enhance their handwriting skills, indicating a heightened receptiveness to learning despite their age.
      2. Behavior: A student demonstrates improved safety awareness, facilitating independent navigation of the school environment.
      3. Life Stage: A high school student engaging in vocational training makes the acquisition of job-specific skills important.
      4. Medical Condition: A medical regression prompts the adoption of a new assistive technology to promote participation. 
      5. Development of a Precursor Skill: Mastering wheelchair use for getting on/off a school bus, pave the way for independent commuting via public transportation for work participation.

These examples underscore the multifaceted nature of skill acquisition and the need to tailor support services to individualized developmental trajectories.

 

 

Option 3: Multiple Episodes of Care (The Goldilocks’ “Just Right” Approach)

Multiple episodes of care take into account different critical periods of acquisition for skills across the lifespan. In simpler terms, it’s an approach like visiting the dentist every six months. Sometimes you need a procedure, like a filling, and sometimes you don’t!

 

In simple terms: a related service provider initiates a new “episode of care” whenever it is the “critical period of acquisition” for a student to achieve an IEP goal. These episodes end once the goal is met (click here to read about other reasons to end services). In between, there are breaks from services.

 

As an example, let’s describe the multiple episodes of care for Johnny’s school journey as shown in the illustration:

 

 

• • • • Episode of Care 1: Pre-K to 1st Grade 
        • Johnny starts OT in pre-k to address IEP goals for classroom participation. 
        • At the IEP meeting before kindergarten, his IEP goals were partly met, and the team decided that continued OT was needed to fully meet the goals. 
        • At the IEP meeting before 1st grade, his previous IEP goals were met. The team upgraded his IEP goals, requiring continued OT services. 
        • At the end of 1st grade, Johnny met his goals, and there were no new goals requiring continued OT. Thus, he graduated from OT services.
      • No services needed in 2nd Grade 
      • Episode of Care 2: 3rd Grade
        • A new IEP goal was established around classroom productivity requiring OT services; a new episode of care is started. 
        • Johnny met this goal within 1 year, and graduated from OT.
      • No services needed in 4th-5th Grade
      • Episode of Care 3: 6th to 7th Grade
        • Johnny had new IEP goals around life skills; the team determined a new OT episode of care.
        • By the end of 7th grade, Johnny met his goals and graduated from OT.
      • No services in 8th-10th Grade
      • Episode of Care 4: 11th Grade
        • Johnny’s IEP now includes on vocational and independent living goals, initiating another episode of OT services.
        • Johnny successfully met goals and graduated from OT at the end of 11th grade. 

It’s important to note that breaks from services don’t mean nothing is happening. During these times, Johnny is practicing and applying his skills independently, with classroom support, and with family, preparing him for his next critical period of skill acquisition.

 

 

Benefits of Multiple Episodes of Care

 

 

This 3rd approach offers advantages for all involved:

• • • For Students:
      • Enhanced Motivation: They work on goals when they’re ready. 
      • Promoting Self-sufficiency: Breaks in services empower students to independently practice skills alongside classroom peers and family, nurturing their self-determination and autonomy.
      • Post-School Outcomes: Providing services when they are older is in line with IDEA’s charge that special education and related services prepare students “for further education, employment, and independent living” (IDEA §300.1).  
    • For Families:
      • Peace of Mind: Knowing that support is available when needed reassures families that therapy is not one-and-done.
    • For the School Team:
      • Meaningful Support: They receive assistance when critical for the student’s learning, which can also mean they will actively carry over practice everyday.
      • Least Restrictive Environment (LRE): This adheres to the concept of LRE, which means the student is in class with their peers as much as possible.
    • For You, as the Related Service Provider:
      • Job Satisfaction: Collaborating with students on attainable goals fuels a sense of accomplishment and purpose. You don’t need to provide services when you can’t even come up with meaningful goals.
      • Balanced Workload: Services are tailored to meet the immediate needs of students, ensuring efficient allocation of resources.
      • Reduced Conflicts: Getting buy-in for graduation from services becomes smoother when stakeholders recognize availability of support as needed.
      • Diverse Caseload: Working with students across various age groups adds variety and depth to the role. You will also see students progress throughout their schooling. What can be more fulfilling?! 

 

 

Final Tips: Action Plan

 

 

Ready to implement multiple episodes of care? Start the conversation early. Talk about episodes of care from your first encounter with families and educators, and at every IEP meeting. When the time comes that you have to recommend graduation from services, reinforce that you can start a new episode of care in the future when the team determines you are needed.

 

 

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References:

APTA (2020). Standards of PT Practice. American Physical Therapy Association. Alexandria, VA

 

Individuals with Disabilities Education Act (IDEA): Sec. 300.1 Purposes

 

Palisano, R. J., & Murr, S. (2009). Intensity of therapy services: what are the considerations?. Physical & occupational therapy in pediatrics, 29(2), 107-112.