The Role of Physical and
Occupational Therapists in the
School Setting Working
Collaboratively with
School Nurses
Dr. Rachel W. Alachnowicz, PT

Graduated from The College of William and Mary in
1996 with a BS in Chemistry

Masters of Science from the Medical College of Virginia
in 1999

Doctorate of Physical Therapy from Virginia
Commonwealth University in 2006

Why I became a Physical Therapist

Been a school system physical therapist for the past 16
years for a large school system in Virginia.
Linda Carson, O.T.R.

Received a Bachelor’s of Science in
Occupational Therapy from Virginia
Commonwealth University in 1994.

Is currently working on a Doctorate in
Occupational Therapy through Rocky
Mountain University of Health Professions.

Have been working for the past 12 years in a
large school system in Virginia as an
occupational therapist.
Objectives

At the conclusion of this session participants should be able to:

1. Explain the difference between the medical model and the educational
model for purposes of therapy in the school setting.

2. Give three reasons why an interdisciplinary approach to patient care is
beneficial.

3. Discuss the ways school nurses can work collaboratively with school
physical therapist and occupational therapist to insure each medically fragile
student is following the plan set by the physician.
Educational Model vs. Medical Model

Occupational and physical therapy as an educational support services can be
quite different from therapy in a hospital or clinic. School-based therapists
focus on assisting students to acquire the functional abilities necessary to
access educational materials and adapt to their educational environment. We
may help students with daily activities related to educational participation,
adapt the performance context, teach alternative methods, or facilitate the
use of assistive devices. Occupational and physical therapists in schools work
with other educational professionals, members of the community and families
to help all students engage in their educational activities. This collaboration
is also the foundation for promoting the participation of students with
disabilities in the general educational environment.
Educational Model vs. Medical Model
Educational Model
Accessing the Curriculum
within the least restrictive
environment
O.T. & P.T.
Medical Model
Physician Driven
Focus on: Perfecting
Movement and ADLs
Educational Model vs. Medical Model

There are primarily four ways a child can receive occupational and physical
therapy once a need has been identified.
1.
a hospital or an outpatient clinic; served by medical model
2.
outpatient clinic; served by medical model
3.
home-based services; served by medical model
4.
school-based services; served by educational model only when physical
therapy is required to meet educational needs

The factors determining need for intervention may be very different in these
two models. This can sometimes be very confusing.
Educational Model vs. Medical Model

In the medical model:

• Referral is initiated by the physician based on a particular diagnosis or observed
delay in one or more areas of development

• The parent is then referred to a hospital or clinic for an evaluation and/or
treatment by the appropriate professional.

• Need for service is primarily based on testing and clinical observations. The
assessment would take all settings into consideration.

• Children with mild, moderate and severe deficits may qualify for services.

• Therapy can address movement quality as well as function.

• The parent is responsible for obtaining the needed services as well as payment
for those services.

• Health insurance may frequently assist with payment, but not always.
Educational Model vs. Medical Model

In the educational model:

• Occupational and physical therapy is provided by schools as service only
when it is related to special educational needs.

• Related services are possible only when they are “required to assist a child
with a disability to benefit from special education".

• Need for service is primarily based on testing, classroom observations and
input from the student’s IEP team. However, the child is only assessed for
needs associated with his or her educational program.

• The school district must establish whether the service is needed for the
child to benefit from his or her education. There are many "related services"
that might benefit a child with a disability, just as there are many services
that might benefit a child without a disability.
Educational Model vs. Medical Model

In the education model (Continued):

In general, students with significant need qualify for as these services in order
to benefit from their special education.

• Related services, like occupational and physical therapy, are only provided
when the student's educational program would become less than appropriate
without the service.

• A child who does not perform to what may be his/her full potential but does
function adequately, would not qualify for school based services.

• Related services are provided only when they support an educational need.
They are not provided when there is a transportation problem or other
obstacle in getting outpatient or home based occupational and physical
therapy.
EDUCATIONAL MODEL
MEDICAL MODEL
Who Decides? Educational team, including parents,
student (if appropriate), educators,
administrators and school based therapists
determine the student’s educational needs
and what support is required by related
services.
Medical team determines
focus, frequency and
duration of therapy.
Insurance coverage may be
determining factor.
What?
Therapy focuses on adaptation and
intervention to allow the student to
participate, access their special education
and school environment.
Therapy addresses medical
conditions; works to get full
potential realized.
Where?
On school grounds, bus, halls, playground,
classroom, lunchroom, …
In the clinic, hospital or
home.
How
The student’s educational needs are met
Direct one on one treatment
individually. Services may include direct
to accomplish set goals.
one on one treatments, staff training,
program development, collaboration with
staff, integrated therapy, inclusive therapy
(with peers) or by consultation for the
student’s daily program.
EDUCATIONAL MODEL
MEDICAL MODEL
ELIGIBILITY
Educational need as
determined by the IEP
team.
Medical need as
determined by medical
professionals.
COST
No cost to student or
family.
Fee for service payment
by family, insurance or
governmental assistance.
DOCUMENTATION
Related to IEP with
accessible,
readable language guided
by
the setting and best
practice.
Dictated by insurance
requirements and
guidelines of the setting.
Emphasis on medical
terminology
EDUCATIONAL MODEL
MEDICAL MODEL
Gait training
To improve efficiency,
speed to safely move
between classes.
To improve heel strike or
attain normal gait
pattern,
not required for daily
function.
Range of motion
Positioning program to
address range of motion
daily during class
activities. Goal to
attain what range is
needed for
daily living.
Program to gain full
physiological joint range,
beyond what is required
for daily living.
THERAPY EXAMPLES:
Changes in physical status Adapting equipment,
schedule
or environment to
provide
access to special
education/meet IEP
goals.
Rehabilitate for strength,
range of motion to attain
full potential post
surgery.
EDUCATIONAL MODEL
MEDICAL MODEL
Oral Motor Skills and
Feeding
To improve responsiveness
to sensory input such as
food texture and
temperature. To work on
motor performance such as
chewing, lip closure,
swallowing and selffeeding.
Program to develop a
feeding schedule, amounts,
methods of intake in
addition to sensory
responsiveness and
improving oral motor
performance.
Visual Motor Activities
Interventions that involve
movement activities and
also collaboration with
others to modify the
environment or the
student’s routines.
Programs that involve
improving eye movement
and muscle control/
postural control
Fine Motor Skills
To improve efficiency,
speed to be able to cut with
scissors, write letters within
the lines, and put puzzle
pieces together.
Program to gain full
physiological muscle
strength and normal
movement for what is
required for daily living.
THERAPY EXAMPLES:
Educational Model vs. Medical Model

Some children will receive services through both models.

For some children the frequency or intensity of occupational and physical
therapy they receive at school through the educational model will not meet
all of the child's needs for OT and PT.

There may be goals that are not addressed by school-based therapy and would
require home or community based services from the medical model.

In each setting, the child should be assessed individually to determine the
best way to meet his or her needs.
Historical Perspective Of OT & PT in
the School Setting

Occupational and physical therapy and the therapist’s role in educational
settings have evolved along with educational reforms.

Traditional school-based therapy often isolated students with disabilities from
their peers. Therapists identified “problems” among students and treated
them in a special therapy room.

The need for more appropriate education of students, including those with
disabilities, spurred legislative changes in the mid 1970s.

Professional research in physical therapy suggests that a collaborative service
model works best.
Occupational and Physical Therapy As An Educational
Support Service Historical Continuum
Formerly
Focus on Disabilities and Problems
Pullout Isolated Service
Families Given Information, Little
Involvement
Students’ Segregated from other
Students
Therapy-specific Student Goals
Therapist Provides Service
Independently
Standardized Tests Used
Clinic-Based Assistance
Currently
Focus on Student Learning Outcomes
and Abilities
Support to Student from all School
Personnel
Families Team with School Personnel
as Partners
Students Included with other Students
Curriculum-based Educational Student
Goals
Many Types of School Personnel
Involved
Also Observe and Assess Student Level
of Functioning
School- and Community-Based
Assistance
“Ten Principles of Good Interdisciplinary
Team Work”

Background: Interdisciplinary team work is increasingly prevalent, supported by policies and
practices that bring care closer to the patient and challenge traditional professional boundaries.
To date, there has been a great deal of emphasis on the processes of team work, and in some
cases, outcomes.

Method: This study draws on two sources of knowledge to identify the attributes of a good
interdisciplinary team; a published systematic review of the literature on interdisciplinary team
work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate
care teams in the UK. These data sources were merged using qualitative content analysis to arrive
at a framework that identifies characteristics and proposes ten competencies that support
effective interdisciplinary team work.

Results: Ten characteristics underpinning effective interdisciplinary team work were identified:
positive leadership and management attributes; communication strategies and structures;
personal rewards, training and development; appropriate resources and procedures; appropriate
skill mix; supportive team climate; individual characteristics that support interdisciplinary team
work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.

Conclusions: Purposed competency statements that an effective interdisciplinary team
functioning at a high level should demonstrate.
Ten principles of good interdisciplinary team work Susan A Nancarrow, Andrew Booth, Steven Ariss, Tony Smith, Pam Enderby, Alison Roots Hum
Resour Health. 2013; 11: 19. Published online 2013 May 10. doi: 10.1186/1478-4491-11-19
“Ten Principles of Good Interdisciplinary
Team Work” Cont.

Competencies of an interdisciplinary team:

1. Identifies a leader who establishes a clear direction and vision for the team, while listening and providing
support and supervision to the team members.

2. Incorporates a set of values that clearly provide direction for the team’s service provision; these values
should be visible and consistently portrayed.

3. Demonstrates a team culture and interdisciplinary atmosphere of trust where contributions are valued and
consensus is fostered.

4. Ensures appropriate processes and infrastructures are in place to uphold the vision of the service (for
example, referral criteria, communications infrastructure).

5. Provides quality patient-focused services with documented outcomes; utilizes feedback to improve the
quality of care.

6. Utilizes communication strategies that promote intra-team communication, collaborative decision-making
and effective team processes.

7. Provides sufficient team staffing to integrate an appropriate mix of skills, competencies, and personalities to
meet the needs of patients and enhance smooth functioning.

8. Facilitates recruitment of staff who demonstrate interdisciplinary competencies including team functioning,
collaborative leadership, communication, and sufficient professional knowledge and experience.

9. Promotes role interdependence while respecting individual roles and autonomy.

10. Facilitates personal development through appropriate training, rewards, recognition, and opportunities for
career development.
Ten principles of good interdisciplinary team work Susan A Nancarrow, Andrew Booth, Steven Ariss, Tony Smith, Pam
Enderby, Alison Roots Hum Resour Health. 2013; 11: 19. Published online 2013 May 10. doi: 10.1186/1478-4491-11-19
Interdisciplinary Approach in the School
Setting

Role of the School System Occupational Therapist:

Conducting activity and environmental analysis and making recommendations to
improve the fit for greater access, progress, and participation

Reducing barriers that limit student participation within the school environment

Providing assistive technology to support student success

Supporting the needs of students with significant challenges, such as by helping to
determine methods for alternate educational assessment and learning

Helping to identify long-term goals for appropriate post-school outcomes

Helping to plan relevant instructional activities for ongoing implementation in the
classroom

Preparing students for successfully transitioning into appropriate post–high school
employment, independent living, and/or further education

To help students develop self-advocacy and self-determination skills in order to plan for
their future and transition to college, career/employment, and community living;
improve their performance in learning environments throughout the school (e.g.,
playgrounds, classrooms, lunchrooms, bathrooms); and optimize their performance
through specific adaptations and accommodations
Interdisciplinary Approach in the School
Setting

Role of the School System Physical Therapist:

• document impairments and their severity;

• document students’ functional performance level at school;

• modify students’ positioning, methods of functional performance, and
mobility;

• modify the environment to compensate for or accommodate existing
impairments;

• instruct parents, students, and teachers about precautions students with
disabilities should take at school;

• advise teachers on how they can incorporate equipment, positioning and
exercise to promote students’ educational performance;

• advise parents how (at home) they can use equipment, positioning and
exercise to maintain or promote their students’ educational performance; and

• establish lines of communication with physicians and therapists who are
treating students in the wider health care arena where students receive
health and medical services.
Interdisciplinary Approach in the School
Setting

The Role of School Nurses:

Providing preventive services

Identifying problems in the earliest stages

Overseeing interventions and referrals as a way to foster health and ensure
educational success

Promote a healthy school environment

Encourage students to maintain healthy habits and behaviors when they are
not in school

Identifying both actual and potential health problems, providing case
management services, and collaborating with educators, school officials,
students, and families to ensure students respond positively to their
environment and develop normally.
Interdisciplinary Approach in the School
Setting

Reasons why we need to collaborate:

Medical Professionals need to stick together.

Two heads are better than one.

Dealing with medically fragile students and parents have a tendency to
compartmentalize information.

Screenings/Consultation

Communication between the medical world and the schools.
Case Examples of Therapist/Nurse
Collaboration
Questions????
Disclosure

Rachel Alachnowicz, DPT and Linda Carson, OTR

We disclose the absence of personal financial relationships with commercial
interests relevant to this educational activity within the past 12 months.