Occupational Therapy Clinical Practice Settings

By Caitlin Dobson

Occupational therapists assist people across a wide range of ages and functional abilities and are trained to have broad, versatile skill sets; it should come as no surprise that OTs can work in many different places. OTs may work in clinical practice settings, or pursue opportunities in areas like education, writing, research, and consulting. However, this article will mainly describe the trends in the more prevalent, traditional clinical practice settings where most OT students will do fieldwork placements, and where most new OTs will find their first jobs. (Where relevant, I will mention where I have seen OTs practicing in less traditional or specialized ways.)

Statistics & Job Offerings

In 2017, the American Occupational Therapy Association (AOTA) reported the following distribution across 10 clinical and non-clinical practice settings from a survey of practitioners:

  1. Hospital (27%)
  2. Schools (20%)
  3. Long-term care/Skilled nursing facility (19%)
  4. Freestanding outpatient (11%)
  5. Home health (7%)
  6. Academia (6%)
  7. Early intervention (5%)
  8. Mental health (2%)
  9. Community (2%)
  10. Other (1%)

Similarly, the Bureau of Labor Statistics reported the following organizations as employing 77% of occupational therapists:

  1. State, local, and private hospitals (26%)
  2. Offices of rehabilitation professionals (24%)
  3. State, local, and private elementary and secondary schools (10%)
  4. Nursing facilities (9%)
  5. Home healthcare services (8%)

There are some notable differences in the two reports—but we can easily see that the most common places for OTs to work are hospitals, specialty clinics, nursing homes, and schools. (From personal experience, these four settings are the most typical for me to see in a job search, with skilled nursing jobs being slightly more represented in my search results. I also see home health job advertisements with increasing frequency.)

Hospitals

The range of medical conditions seen at a hospital can be very broad—alternatively, hospitals may focus on a specific patient population, such as children, adults, veterans, or psychiatric patients. Hospital-based OTs work alongside many different health professionals, most likely in acute care or an inpatient setting. In acute care, the OT’s role is often to focus on evaluations, and the pacing is fast. Interventions are regularly carried out by the occupational therapy assistant (OTA), though the actual amount of intervention done by the OT varies based on the specific facility and the demands of the day. Ordinarily, patients only stay for a few days before being discharged to settings appropriate for their levels of function, which can include home with home health services, skilled nursing facilities, or inpatient units. Interventions revolve around basic activities of daily living (ADLs).

Inpatient settings involve fewer evaluations and allow the therapist more intervention time with the patient. The patient’s stay is usually longer. Interventions should include ADLs, but may also emphasize basic skills related to independent living, like problem-solving or cooking.

Hospitals may also see patients on an outpatient basis if the patient is relatively independent but requires periodic follow-ups. Rather than seeing patients for a few days in a row like in acute settings, or daily like in inpatient settings, an outpatient OT might see an outpatient weekly or monthly.

OTs may work in specialized areas within a hospital. As a pre-OT student, I shadowed at a burn center that was part of a large hospital campus. The OT I shadowed worked with many patients whose participation was very limited due to being unconscious; in these instances, interventions might center around carving foam blocks to position patients, making splints to prevent deformity, wound care, and passive range of motion as appropriate. The setting required a high tolerance for working with blood, recognizing psychosocial factors in burn treatment, and a large amount of independence—the OT I followed mentioned being one of only two OTs in the state who had that sort of job.

During my Level 1 fieldwork at the VA hospital, I was able to observe mental health treatment in both an inpatient and outpatient capacity. My fieldwork supervisor used half of her time treating patients with substance use disorders who lived in a residential unit on the hospital campus during their time in treatment. Many interventions centered around social participation, leisure, and rest—arts-based therapy, yoga, meditation, and discussing healthy relationships are examples of activities in that setting. My supervisor also provided outpatient biofeedback therapy for relaxation and self-regulation, typically for patients experiencing problems related to sleep and anxiety. Patients were given instruction in breathing and visualization techniques to practice at home. Several times per month, they would come to the VA for outpatient treatment and meet my supervisor in her office. Using biofeedback devices, she monitored their breathing and heart rate to measure the effectiveness of their use of relaxation techniques.

Long-Term Care & Skilled Nursing

Long-term care (LTC) and skilled nursing facilities (SNF) are inpatient settings where patients may stay for weeks, months, or sometimes even longer than a year. These patients are not able to live independently in their homes without on-site rehabilitation first. Some patients eventually achieve a level of function that allows them to be discharged to their homes (with or without services).

Therapists in these settings can get to know their patients over a longer period of time. Patients live on-site, and generally the productivity expectation in these settings is higher. As in inpatient and acute settings, patients in LTC and SNF may have a wide range of diagnoses, from orthopedic injuries to severe mental health diagnoses. Some facilities may specialize in certain types of patients. One of my Level 2 fieldwork placements was in long-term acute care, where patients needed intensive care followed by a less intensive, extended period of care. The setting specialized in neurorehabilitation and ventilation-dependent patients. Common diagnoses in this setting were traumatic brain injuries, stroke, and respiratory failure.

Interventions are similar to what one would see in a hospital inpatient setting, primarily centering upon ADLs and IADLs (independent activities of daily living). However, patients tend to need more care and stay for longer periods of time than in other inpatient settings, allowing the therapist and patient more opportunity to work on strengthening, range of motion, problem-solving, and skills related to completing ADLs and IADLs.

Outpatient Specialty Clinics

Outpatient clinics tend to specialize in specific areas of rehabilitation. They can be independently owned, or part of a healthcare system. There are several nationwide physical rehabilitation outpatient clinic chains that frequently advertise OT positions. As with hospital-based outpatient OTs, clinic-based outpatient OTs will see their patients with less frequency, so their weekly caseloads will involve many different patients. Cancellations tend to be higher in outpatient settings than in inpatient settings, since patients do not live on-site. Health professionals such as physical therapists, physiatrists, psychiatrists, psychologists, and speech language pathologists commonly work in clinics with OTs.

Hand therapy is regularly seen in outpatient clinics. A hand therapist may see patients due to a disorder like arthritis, after surgery or an injury, or to address other dysfunctions of the upper extremity. Forming custom splints, testing grip strength, developing and demonstrating home exercise programs, and recommending specific assistive technology devices are all ordinary parts of a hand therapist’s job.

Pediatric outpatient clinics are also very popular. These clinics will often concentrate on autism, sensory integration, and behavioral conditions. They may also address physical disabilities. Interventions in pediatric outpatient settings will typically address ADLs, play, and social participation.

The options for outpatient services are extremely broad. Less familiar services provided by outpatient clinics include driver rehabilitation, work hardening, low-vision, hippotherapy, and more.

Community & Home Health

OTs also treat patients in their natural environments. Community and home health services can take place in patients’ houses, community-based residential facilities, community centers, and other settings. Part of an OT’s day includes traveling to meet the patient, and documentation is often done in the car on a device provided by the OT’s employer. Sometimes OTs work alongside other professionals, but oftentimes the OT is alone during treatment sessions. This type of practice requires an individual who can independently structure their time use, and act in a culturally sensitive manner no matter whose home they are in. Flexibility is also key—as with outpatient settings, a therapist must be ready for last-minute cancellations.

Most home health agencies will employ OTs to work with older adults who are often homebound and need therapy for a defined period of time. They may have just been discharged from an inpatient setting. ADLs, independent living skills, use of assistive technology, and caregiver training are typical parts of home health.

Assertive community treatment involves seeing patients in the community and their homes, and is commonly used with patients who have severe mental illnesses. Interventions may include ADLs, navigating the public transportation system, shopping in a grocery store, and social skills training.

Early intervention is a service for infants and toddlers with developmental delays or who are at risk for developing them. Services are frequently provided in-home, but can occur in a different natural environment like a daycare center. It is important to include parents in the intervention process so that they can carry over therapeutic techniques in the child’s everyday life. I had a Level 2 in early intervention, and we were expected to be able to provide the basics of OT, PT, and SLP interventions. Treatment sessions would often incorporate elements of play, language, social skills, and mobility while still being based around OT goals.

Opportunities in these settings are scarce compared to others, as indicated by the statistics mentioned earlier. Companies may be hesitant to hire new graduates in these settings, due to the demands for independence and comfort with entering others’ homes.

School

OTs may also work in school-based settings. An OT may work in one school, or travel between different schools. Sometimes the OT will have an office, and sometimes the OT will need to make use of other areas in the school. The OT may work with children who have physical or behavioral dysfunctions or delays. IEPs (individualized education programs) and care coordination with the family are important parts of school-based OT.

School-based OT is similar to community and home health in that it is centered around helping patients in their natural environments. However, in school-based OT, interventions must only address things that the child does in school. Handwriting, typing, bilateral coordination, and other fine motor skills are typical skills to address. Behavior management, sensory processing, self-regulation, and social skills are also popular focuses of school OT. In fact, there is a fairly significant mental health component in many pediatric treatment settings, where it is usual for OTs to address the occupations of play, leisure, and social participation. Intervention can include ADLs—for example, if the child needs to zip a jacket at school, the OT can help the child work on that component of dressing. ADLs unrelated to function in school should be addressed by an OT outside of the school setting.

Treatment can be individual or group-based. Some children require one-on-one attention for interventions. However, during my Level 1 fieldwork, I observed an OT who liked to treat in small groups or in the classroom. For small groups, children of similar abilities worked on the same project, and the OT often facilitated social interaction among the children. In classroom-based activities, the OT and the teachers involved the entire class—for example, only a few children received OT services, but the OT read a book to the entire class about the Zones of Regulation.

I shadowed a school-based OT who had a large role as a consultant and who had her own consulting practice as a second job. As a consultant, she was less involved in the intervention process, and more involved with coaching other health professionals.

In Closing

This article should give you a good point for understanding conventional OT practice settings, but it is not comprehensive. There are many settings that do not fit the mold and may contradict the explanations above. Shadow, volunteer, research, and explore—there are many opportunities for OTs!

About the Author

Caitlin Dobson, BA, MS, OTR/L is an occupational therapist and qualitative researcher with interests in mental health and sociocultural factors in client-centered practice. She is a graduate of UW-Milwaukee. She likes dogs, vegetarian cooking, and road trips.

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