Strategies for Creative Fieldwork Opportunities

There have been many recent discussions among AOTA members regarding the shortage of traditional fieldwork sites. This general decrease in available sites was exacerbated by the recent Medicare regulation that precludes students from providing hands-on reimbursable services to patients under Medicare Part B.

In an ongoing effort to assist our members, the National Office staff have compiled the following suggestions.

Considerations for Clinical Fieldwork Coordinators at Fieldwork sites With a Medicare Part B Population

Occupational therapy students in fieldwork internships can engage in many activities in addition to hands-on patient care that provide rich learning opportunities and that meet the Accreditation Council for Occupational Therapy Education Standards. One of the first rules of thumb for fieldwork site coordinators is to think creatively about the experiences and opportunities available at your site before agreeing to take a student.

Specific suggestions include:

  • Identify appropriate screening and assessment tools for specific patients.
  • Review evaluations performed by the therapists and make recommendations for initial treatment interventions and changes in treatment goals and activities as a patient's status changes.
  • Develop patient/client intervention plans for review by, and discussion with, the clinical supervisor.
  • Make recommendations for discharge summary.
  • Practice clinical interviewing skills.
  • Accompany therapists on home assessment visits, make recommendations, and write up reports for review by therapists.
  • Select and use correct billing procedures and codes (e.g., helping therapists research CCI edits, other payer requirements).
  • Provide discharge-planning assistance to the therapists to include
    • providing family education,
    • researching and determining available community resources,
    • determining accessibility issues and problems and developing solutions, and
    • recommending possible adaptive devices and advantages and disadvantages of prescribing a specific device.
  • Use videotapes of treatment sessions as a means of developing clinical reasoning skills and critical observation skills.
  • Design a beginning clinical research project involving direct interaction with patients. Students would be
    • gathering data,
    • assessing results of study,
    • writing results, and
    • presenting results to staff.
  • Prepare presentations for staff (including other non-OT staff when appropriate). In case study presentations, progress from simple to complex cases and analyze applicability of case results to develop practice parameters or protocols.
  • Use role playing with other students and with the clinical supervisor to improve clinical decision making and appropriate therapeutic interpersonal skills.
  • Evaluate the department's operations using a systems analysis and prepare recommendations that address
    • operational improvements,
    • operational effectiveness,
    • work flow,
    • productivity,
    • billing accuracy,
    • time management, and
    • documentation timelines.
  • Develop quality assurance activities and measures in implementing a client-care program.
  • Provide opportunities for the student to meet with local support groups:
    • Evaluate his or her needs and develop a plan of action (use knowledge of groups, condition-specific information, and observations and interactions from the meeting).
    • Develop patient education materials for support groups and families of group members.
  • Provide opportunities for the student to explore community groups, city planners, agencies (e.g., Office on Aging, etc.) for a broad perspective of the occupational therapy "fit" and needs that may exist.
  • Provide extra supervised hands-on treatment time for Medicare Part B patients, if appropriate and amenable to the facility and management staff.
  • Provide the student with opportunities to assist in the treatment of Medicare Part B patients, as long as the supervisor provides the hands-on treatment at all times.
  • Rotate students between inpatient and outpatient units whenever possible in facilities with both types of programs because the inpatient and outpatient payment rules differ.
  • Consider how to enrich the clinical learning experience by including observation of clinicians performing components of the patient management model at varied levels of clinical experience and expertise.
  • Develop critical skills that students usually associate with nonpatient care, such as peer review, quality assurance, administrative management, billing procedures, education, and documentation.
  • Provide opportunities for students to strengthen their clinical reasoning abilities by seeking evidence to justify care delivered (compare observational learning experience of similar patient diagnoses) and developing a systematic approach to patient examination, including histories and assessments.
  • Provide opportunities for students to make initial and/or follow-up calls to physicians' offices to clarify orders, obtain records, report progress, and obtain information (e.g., ICD 9 CM codes).
  • Assign students to develop a resource center of community contacts (e.g., volunteer organizations, sample equipment, pro bono support services for families).

Considerations for Fieldwork Coordinators at Universities/Colleges

  • Look for sites that have a diverse case mix, including some Medicare Part B but not exclusively Medicare Part B patients.
  • Look for sites providing more traditional occupational therapy services that do not rely on Medicare Part B reimbursement, such as Workers' Compensation and community programs with non-insurance funding.
  • Consider community-based practice areas that do not rely on Medicare or other health insurance for funding, such as
    • senior centers,
    • congregate meals,
    • assisted living centers,
    • clubhouses/community mental health centers,
    • supported employment,
    • homeless shelters,
    • wellness centers,
    • continence clinics,
    • public service screenings,
    • prisons/correctional facilities,
    • area agencies on aging,
    • Building Together With Christmas in April,
    • Headstart and other early intervention programs,
    • school-based programs,
    • Lifestyle Redesign programs,
    • home builders,
    • the Salvation Army,
    • life coaching programs,
    • adult day care centers,
    • the YMCA or YWCA,
    • Safe houses for abused women, and
    • health promotion programs.
  • Consider alternative funding to subsidize students and supervisors in areas of practice where occupational therapy services are appropriate but are not provided.
    • Consider having faculty members supervise students if the fieldwork site requires supervision.
    • Contract with adjunct faculty to serve as fieldwork educators and supervise students at several sites.
    • Provide opportunities for independent thinking, decision making, and critical reasoning.

General Comments

  • To be considered viable as a fieldwork option, facilities that treat a high volume of patients covered by Medicare Part B must
  1. be part of a larger system that allows for rotation through the non-Medicare Part B parts of the system that do not rely on Part B reimbursement, or
  2. be willing to design a creative fieldwork experience for students.
  • In fieldwork sites where there is no occupational therapist and the question of students writing progress notes arises, be cognizant of the following:
    • All student documentation must be cosigned by a qualified occupational therapist.
    • Discussions should be pursued between the program and the site to see whether a statement could be included in the Memorandum of Understanding (Educational Standard, A.1.4) allowing the off site qualified occupational therapy supervisor to cosign documentation (in effect "credentialing" the off-site supervisor).

We would love to hear about other innovative ways you are solving the Fieldwork dilemma. Please send your own tried-and-true solutions to