Expanding the role of school-based OT practitioners

The start of a new academic year offers students and staff a prime opportunity to not only look forward to new school experiences, but to also take a moment to reflect on the progress of the previous few years and what the future may hold. The start of the 2024–2025 school year also provides the American Occupational Therapy Association (AOTA) with the same opportunity to reflect on how far national school-based occupational therapy policy has progressed and what challenges remain.

The unique nature of education policy makes capitalizing on these opportunities a vital part of any advocacy effort. The federal government’s role in other domains—health care as an example—is traditionally more centralized and direct. Education policy in the United States is characterized by a delicate balance between federal and state authority.

Although the federal government plays a crucial role in shaping the overarching framework of education through legislation and funding, states retain considerable autonomy in implementing and funding educational initiatives tailored to their specific needs. No place is this autonomy clearer than in how public schools are funded. In 2020, total funding for schools totaled roughly $800 billion, but only about 10% came from the federal government. The remaining $720 billion came from the budgets of state or local governments.

This policy creates a system where the federal government’s control over public education comes more from its ability to share best practices than to dictate specific requirements to schools. Moreover, the two federal laws with the most control over education, the Individuals with Disabilities Education Act (IDEA; Pub. L. 108-446) and the Elementary and Secondary Education Act (Pub. L. 89-313), have not been changed by Congress in a decade.

In the last few years, AOTA has had success leveraging relationships with federal, state, and local education policymakers to increase their understanding of the role of occupational therapy in general education, student mental health, and special education.

Occupational Therapy in General Education

SISP Guidance

In 2015, Congress passed the Every Student Succeeds Act (ESSA; Pub. L. 114-95). This legislation, reauthorizing the Elementary and Secondary Education Act (Pub. L. 89-313), updated a number of federal funding sources and policies. It also included perhaps the largest expansion to occupational therapy’s role in general education. AOTA led the National Alliance of Specialized Instructional Support Personnel’s (NASISP’s) effort to create a new term, Specialized Instructional Support Personnel (SISP) to reflect professionals explicitly intended to support all students, regardless of disability status (identical to the list of related services professionals).

However, the Department of Education never provided state and local education agencies with guidance defining who SISP are and their role, leading to the differing use of these professionals from district to district. To address this ambiguity, NASISP released an SISP guidance document to provide schools with an overview of how SISP can be utilized (https://bit.ly/4cGAqch).

Additionally, AOTA produced a fact sheet to debunk eight myths of SISP in schools to help provide occupational therapy practitioners (OTPs) with a resource to practice in accordance with ESSA and the occupational therapy scope of practice (https://bit.ly/3W11Q5Z).

Workload Versus Caseload

AOTA joined the American Speech-Language-Hearing Association (ASHA) and the American Physical Therapy Association (APTA) in 2014 to release a joint document on shifting school-based practice to a workload model (https://bit.ly/4eCjCEZ). In recent years, the AOTA Representative Assembly (RA) voted to approve the creation of a set of recommendations on what a school workload model would look like (https://bit.ly/3zgdTnX).

As the RA workgroup developed those recommendations, Oregon and Indiana’s legislatures considered bills to task their state Departments of Education with studying different workload models. Although the bill was not successful in its first year in Indiana, it was passed into law in Oregon. The Oregon Department of Education released the first report on using a workload approach in schools for occupational therapy, physical therapy, and speech- language pathology (https://bit.ly/3VEXG3s).

Medicaid in Schools

AOTA, along with a broad coalition of education policy organizations, has been advocating for more than a decade for changes in guidance about how schools can seek Medicaid reimbursement. Federal guidelines on the reimbursement process had not been updated since 2003 and did not include information related to a new interpretation of law that allows schools to seek Medicaid reimbursement for eligible services provided to students without an individualized education program (IEP).

Medicaid accounts for between $4 billion and $5 billion in school funding every year, making it the third-largest single source of public-school funding in the nation. However, if states were to seek reimbursement for all eligible services provided in a school, that amount is estimated to increase to between $15 billion and $18 billion every year.

When Congress passed the Bipartisan Safer Communities Act (Pub. L. 117-159) in 2022 (https://bit.ly/3VyjmOA), AOTA was thrilled to see that this legislation not only required the changes we had been seeking, but included additional financial and technical supports. After working with policymakers at the Centers for Medicare & Medicaid Services (CMS) and the Department of Education for a year, the updated guidance was released in the middle of 2023 (https://bit.ly/3RJ55xi).

AOTA continues to advocate for every state’s Medicaid Agency to seek the most reimbursement allowable by law. This additional funding will help support efforts to hire additional OTPs, allowing schools to switch to a workload model and providing access to occupational therapy services and its benefits to more students.

The Role of Occupational Therapy in School Mental health

Mental Health Service Professionals

Much like any successful advocacy campaign, AOTA continues to build on the victories of the past to expand access for students in the future. In 2016, Congress passed the 21st Century Cures Act (Pub. L. 114-255), which added occupational therapy to the Behavioral Health Workforce Education Training (BHWET) program (https://bit.ly/45IoVi7). This was one of the very first inclusions of occupational therapy in federal mental health law. Since then, AOTA has worked to educate lawmakers and school administrators on the role of occupational therapy in school mental health.

This effort led to a series of large, recent victories. In late 2022 and early 2023, it was announced that two occupational therapy doctoral education programs received awards from the Department of Education’s Office of Elementary and Secondary Education (OESE) Mental Health Service Professionals (MHSP) Demonstration Grant Program (https://bit.ly/4czSlkI). This grant is designed to bolster the school-based mental health workforce, and the awards to the University of Incarnate Word (UIW) in Texas and the College of St. Scholastic (CSS) in Minnesota mark the first time that general education mental health funding has been awarded to any occupational therapy higher education programs.

Later in 2023, the Deputy Assistant Secretary overseeing OESE spoke at AOTA’s Education Summit in Denver (https://bit.ly/3xKaNYZ). Prior to speaking, she met with several students who are beneficiaries of the grant. When staff from UIW invited Deputy Assistant Secretary Ryder to tour their program the following March, she gladly accepted (https://bit.ly/3L1s0Aj).

These victories culminated in OESE releasing a new FAQ resource for future applicants to the MHSP program. The FAQ explicitly states that occupational therapy programs are eligible for both the MHSP program and the School-Based Mental Health (SBMH) Services Grant Program. The SBMH program is intended to address current shortages in the school-based mental health workforce.

Practicing the Full Scope of the Profession

Educating School Administrators

Although AOTA continues to advocate for broader access to occupational therapy services for general education students, the majority of these services continue to be provided to students with IEPs or 504 plans. These services, however, often do not reflect the entirety of the profession’s scope. School-based OTPs are frequently seen as only capable of working on student handwriting. Frustratingly, most of these limitations are not due to federal or state law, but to a misunderstanding of the profession or the allowable uses of education funding.

AOTA has worked to directly educate administrators on what occupational therapy can do, and how it can be funded. AOTA was invited to present at the annual conference for the Council of Administrators of Special Education (CASE), the association of local special education directors, on the role of occupational therapy and how to pay for it. AOTA also partnered with national organizations in the education policy and advocacy space.

The Council of Exceptional Children, the largest international professional organization dedicated to improving the success of children and youth with disabilities and gifts and talents, produced a free webinar on the role of occupational therapy assisting students with self-regulation (https://bit.ly/3zh1Y9J). AOTA also participated in the Council of Chief State School Officers’ (CCSSO’s) Inclusive Leadership Webisode Series (https://bit.ly/3L2Gno6). CCSSO is a nonpartisan, nationwide, nonprofit organization of public officials who head departments of elementary and secondary education.

There is Still Work to Do

Advocacy efforts create a snowball effect. Although they may start off small, they can grow too large to be ignored. There is still so much to do to expand the ability of school-based OTPs to support students, while ensuring schools have the tools needed to support the school-based OTP workforce. Join AOTA’s efforts today by visiting https://www.votervoice.net/AOTA/Home or emailing FAD@AOTA.org.

References

21st Century Cures Act of 2016, Pub. L. 114-255.

Bipartisan Safer Communities Act of 2022, Pub. L. 117-159.

Elementary and Secondary Education Act of 1965, Pub. L. 89-313, 20 U.S.C. §§ 2701–3386.

Every Student Succeeds Act of 2015, Pub. L. 114-95, 20 U.S.C. 6301

Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108-446, 20 U.S.C. §§ 1400–1482.

Abe Saffer, MPM, is AOTA’s Senior Legislative Representative in Federal Affairs.