Occupational Therapy and Care Coordination: The Challenges Faced by Occupational Therapists in Community Mental Health Settings
Culverhouse, Jane, Bibby, Paul F., British Journal of Occupational Therapy
There is continuing debate concerning the role of occupational therapists within community mental health practice. This opinion piece advocates the need for occupational therapists to undertake more profession-specific work. Its argument draws upon real life case studies as well as the service users' views expressed in the recent College of Occupational Therapists' 10-year strategy for occupational therapy mental health services.
Key words: Mental health, care coordination, generic working.
In 1991, the Department of Health (DH 1990) introduced the Care Programme Approach as a means of providing a framework for effective mental health care in the United Kingdom (UK). The Government confirmed its commitment to this framework in Effective Care Co-ordination in Mental Health Services (DH 1999) and, with it, the preservation of the requirement for a named care coordinator for each person falling under the Effective Care Co-ordination (ECC) framework. Anecdotal evidence indicates that occupational therapists within community mental health teams (CMHTs) and other specialist mental health services operate in a variety of ways within the ECC framework. Principally, this tends to be in one of three ways: occupational therapists acting as the care coordinator for all clients on their caseloads; occupational therapists undertaking solely occupational therapy interventions (with a separate health professional acting as the care coordinator); and occupational therapists operating 'split' caseloads in a way that combines both these approaches (Harries and Gilhooly 2003). The authors of this paper, who previously worked in an assertive outreach team (AOT), carried split caseloads, and it was the management of these caseloads that stimulated the discussion of care coordination versus profession-specific roles.
The difficulties facing occupational therapists as care coordinators
A service user (College of Occupational Therapists [COT] 2006, p11) stated:
It could be easier if they [occupational therapists] didn't know what our mental illness was in the first place. It might make it easier for us to feel that we are being treated as a person distinct from the illness. They did that with me, not me the patient, but me that I am.
This statement addresses the principal issue of the conflicting roles of care coordinator and occupational therapist. Care coordination compels a health professional to consider particular aspects of an individual's circumstances; for example, symptomatology, medication, criminal and legal issues, and illicit substance misuse. From merely a therapeutic relationship perspective, this can often have negative connotations. Occupational therapy philosophy, on the other hand, focuses on a client's strengths and potential for optimum functioning and independence. Frequently, occupational rehabilitation can be successful in spite of the existence of such problems. Occupational therapists, through their profession-specific approach, can establish effective therapeutic relationships with their clients through the introduction of activity, affording a unique 'triadic' relationship, that is, therapist /client /occupation (Hagedorn 2001), with the emphasis on occupation rather than other generic duties, such as care coordination:
We thought that many professionals concentrate on the problems and conditions that we face but that occupational therapy can and should help us achieve a balance in our lives by treating us holistically and addressing mind, body and spirit (Service User, COT 2006, p8).
Care coordination plays an important role in mental health, as does occupational therapy. Even where occupational therapy needs exist, when an occupational therapist attempts to undertake both roles, a service user's rehabilitation can be delayed or even omitted due to the therapist becoming involved in care coordination duties. …