Integrated Services

Integrated services help ensure that therapists become a part of the school's culture, that personnel and students understand therapists' distinct knowledge and scope of practice, and that therapists can positively impact students at the universal, targeted, and individualized levels.

Suggested Strategies for Moving Toward an Inclusive Classroom Integrated Service Model:
1. Educate administrators and school personnel on why integrated services is best practice – refer to the section above on ‘Why’. Share the AOTA information sheet on Inclusion of Students with Disabilities.

2. Obtain school administrative support to free teachers and related service providers from their teaching/therapy schedules. Bazyk and colleagues¹ found that when providing integrated services, time spent collaborating with the teacher and other personnel outweighed time spent in direct intervention by a 2 : 1 ratio.

3. Identify a time for planning and commit to collaboration over time. Strive to develop positive relationships with teachers, paraeducators, and other relevant stakeholders (e.g. SLP, school psychologist, PT, cafeteria supervisor, etc.). Commit to a collaborative style of interaction built on mutual trust, respect, and effective communication characterized by the equal status of all parties involved. Consider developing a community of practice (CoP) to enhance collective work and impact. A CoP is a group of people who are committed to a common cause, interact regularly, and share leadership and work for collective competence and impact.²

4. Learn about the unique classroom culture, the curriculum, and performance expectations. Therapists need to understand school district policies, curriculum, and the classroom practices of teachers to develop educationally relevant approaches to providing services in an inclusive classroom. Informally observe the physical, social, and emotional aspects of the environment (e.g., classroom layout, teacher-student interactions). Talk with the teacher about challenges and needs specific to your scope of practice. When working with students in a classroom, related service providers need to have a clear understanding of classroom expectations. This includes knowledge of classroom rules, routines, and dynamics and of the general education curriculum and special education adaptations. Each classroom teacher has unique teaching and classroom management styles. Intervention strategies conducted in the classroom that may be acceptable to one teacher may not be acceptable to another teacher; they may even be considered intrusive.

5. Offer inclusive classroom intervention strategies that fit the existing classroom structure and culture. For example, a teacher who values child-directed learning and hands-on learning centers may respond well to a therapist's suggestions for activities to be included in the learning centers. Another teacher who uses a strong teacher-directed classroom may prefer to engage in team-teaching activities with the therapist.

6. Provide information about your professional and full scope of practice using informal opportunities to share information (e.g., conversations in the hallway, one-page information briefs) and formal in-service education. Occupational therapists, for example, can describe the areas of function they can address beyond handwriting and sensorimotor processing, such as social participation, mental health, play, leisure, sleep/rest, and work.

7. Explore teacher preferences for integrated services. Be sensitive to the general education classroom routines and avoid disrupting the student's and the classroom schedule, if possible. Teachers may prefer to have therapist in the classroom at certain times or on certain days. These preferences should be negotiated with the teacher before intervention, and attempts should be made to schedule times for providing services to the student that coincide with targeted goal areas. For example, mental health literacy might be integrated into the student's language arts time.³

8. Consider integrating services during non-academic times of the school day, especially lunch and recess. Also, don't forget to integrate services in art, music, PE, and health education. These are critical times of the day for students to enjoy time with friends, eat lunch, engage in conversations, and have fun playing. These are also times when therapists can offer small group interventions (Tier 2) for students who struggle socially and/or who have difficulty participating due to functional limitations. Group participants can include students with and without disabilities and/or mental health challenges in order to foster inclusion. Lunch and recess periods also offer opportunities for therapists to provide universal services, such as the Refreshing Recess and Comfortable Cafeteria programs.

References:

1Bazyk, S., Goodman, G., Michaud, P., Papp, P., & Hawkins, E. (2009). Integration of occupational therapy services in a kindergarten curriculum: A look at the outcomes. The American Journal of Occupational Therapy, 63, 160-171.

2Wenger, E., McDermott, R., & Snyder, W. (2002). Cultivating communities of practice: A guide to managing knowledge. Cambridge, MA: Harvard Business School Press.

3Cahill, S., & Bazyk, S. (2019). School-Based Occupational Therapy. In Jane Clifford O’Brien & Health Kuhaneck (eds.). Case-Smith’s Occupational Therapy for Children & Adolescents (8th edition). Mosby

Success Story: From pull-out to integrated service provision. How one school district made the transition
Occupational therapist: Carol Conway, MS, OTR/L
Hudson City Schools, Ohio

About the school district: The top ranked, high performing Midwestern suburban school district where I work has a reputation for academic excellence with 97% of our graduates attending four year colleges. Students receiving special education services make up 16% of the student population. Despite the fact that integrated services is considered best practice in schools, related services in this district reflected an outdated pull-out therapy model. Factors that may have prevented the transition to integrated services and a more inclusive classroom include: 1) lack of knowledge about how to provide integrated therapy services; 2) a belief by some school staff and parents that pull-out therapy is most effective; and 3) a lack of planning time to change practice. Although some therapists made attempts to shift to an integrated service model, without the ability to meet and develop a unified plan, it was difficult to make significant changes.

In the fall of 2011, with the assistance of an outside OT consultant from a local university, the district OTs (6) and PTs (2) made a commitment to working together to shift services to an integrated model. Before making changes, we met with the Director of Pupil Personnel to communicate the need for this work and to obtain buy-in. This was a critical first step, because her support throughout the change process was essential (e.g. to obtain permission to meet during school hours).

Here is a summary of what we did and the outcomes of our work:

Step 1: Getting Started
Become knowledgeable about integrated services: what, why, how, and where. The OTs, PTs, and Director of Pupil Personnel met for an initial 2-hour meeting during which we reviewed the requirements of the law and evidence supporting integrated services. Time was spent discussing the need to shift services as well as barriers and supports. We decided to complete a time study of our services in order to obtain a baseline and to meet afterward to begin strategic planning.¹

Complete a time study of therapy services. Two pieces of data were collected from the OTs and PTs: type of direct service (individual or group) and location of service (pull-out in therapy room or embedded in resource room, general education classroom, or ‘other’). ‘Other’ included any natural setting in the school including: playground, cafeteria, hallway, locker, restroom or the bus. Results of our initial time study indicated that the majority of our services were being delivered using pull-out therapy in isolated settings (75.5%). Therapy was integrated in the resource (special education) room 10.1% of the time, in the general education classroom 9.7% of the time, and ‘other’ 4.7% of the time. Direct services were provided individually 75.3% of the time and in groups 24.7% of the time. It was clear that our initial data supported the need for change in how related services were being delivered in our district.

Step 2: Warming up for change
Therapists began to explore opportunities for integrating services and brainstorm how to implement change. They also began to talk with relevant stakeholders (administrators, teachers, staff and parents) who were likely to support and pilot a more collaborative integrated model. The seeds of change where planted, mini trials of “push in” services where implemented and success stories where shared. The results of brainstorming, planning and mini-trials from the spring of 2012 led the district committing shifting to an integrated service model during the upcoming school year.

Step 3: Mobilize supports for action using a Community of Practice (CoP)
Because changing service provision to an integrated model affects all school personnel and parents, we decided to develop a Community of Practice (CoP) of relevant stakeholders to be a part of and assist in the change process. A CoP is a group of people who are committed to a common cause and interact regularly for collective competence and impact.² A diverse group of stakeholders representing all district school buildings were invited to be a part of the CoP including: Director of Pupil Personnel (our direct supervisor), two district principals, two general education teachers, several special education teachers, a school psychologist, two parents of children with disabilities, the district parent mentor, a speech pathologist, and three paraprofessionals. During our first meeting (August), an overview of legislation requiring integrated services (i.e. LRE) and supporting research evidence was presented followed by open discussion. The group’s support of an integrated model was overwhelming positive. Ideas of how to generate change were discussed and the role of the CoP members was defined.

Shared leadership and collaborative work. During the first year of implementation four CoP meetings were held. One concern about shifting services was that parents and some school personnel might perceive integrated therapy as inferior to and ‘less than’ individual pull-out therapy and question administration about this change. Subsequently, it was decided that the first priority was to educate and communicate our message within the district and to the community in order to obtain ‘buy in’. Collectively, the CoP also decided to strategically communicate success stories of integrated services.

Step 4: Implementing change
District therapists began discussing and implementing changes in service delivery within their individual educational teams at the start of the school year in 2012. By starting at the beginning of the year, therapists were able to schedule integrated programing more effectively. Therapists chose teams where they had established strong relationships and who they believed would be open to a more collaborative, integrated approach. Strategies to initiate change varied from building to building and were influenced by the age of the student as well as individual student needs. The district goal was to shift from 24.5% to at least 40% integrated services and inclusive classrooms during the 2012-2013 school year.

The most significant challenge for most therapists was establishing time to collaborate with teachers and other relevant school staff. Therapists often worked on multiple teams and needed multiple planning times. Finally, therapists needed to develop a new skill set which involved a role release from a traditional clinical model to a more collaborative, inclusive classroom co-teaching model.

Within individual buildings therapists embedded services at the Tier 1, 2 and 3 levels in collaboration with educational colleagues. The net results were overwhelmingly positive as therapists were increasingly welcomed into classrooms and other natural settings (e.g. art, music, PE). Word of success and student growth using integrated collaborative approaches spread among the faculty, administration, and parents resulting in expanding interest to replicate such strategies in more settings throughout the district.

Step 5: Celebrating outcomes
The original time study was repeated at the end of the school year (June 2013). Changes in place of service delivery were impressive. Integrated services shifted from 24.5% (2011) to 60.2% (2013) with 17.2% of services occurring in the general education classroom, 31.6% in the resource room, and 11.6% in other natural settings. Pull-out services in the therapy room decreased significantly from 75% down to 40%. The type of direct services also shifted to more time providing group services (44%, up from the original 24.7%) and less time providing individual services (55.8%, down from the original 75%). The success of the first year bolstered the interest and continued work toward integrated therapy. One year later (June 2014), integrated services grew to 70.3% with a steady decline in pull-out therapy.

We believe the following factors contributed to overall success: therapists' ability to reflect on practice and to be open to change; administrative buy in and support; development of a Community of Practice to foster collective learning and impact; and initiating change with educational team members where we had existing strong relationships.

Step 5: Commit to sustainability
What we have learned over the past 10 years, is that change takes time and a commitment from the whole team to shift to an integrated model. To sustain the provision of integrated services, it is helpful to have a handful of related service providers serve as champions to intentionally re-educate therapists and orient new personnel to integrating therapy in natural settings. This can be done by formal and informal professional development, modeling integrated services, and sharing success stories in school newsletters.

References:

1Cahill, S., & Bazyk, S. (2019). School-Based Occupational Therapy. In Jane Clifford O’Brien & Health Kuhaneck (eds.). Case-Smith’s Occupational Therapy for Children & Adolescents (8th edition). Mosby.
2Wenger, E., McDermott, R., & Snyder, W. (2002). Cultivating communities of practice: A guide to managing knowledge. Cambridge, MA: Harvard Business School Press.

Rebecca Mohler, MS, OTR/L
President, Sendero Therapies, Inc.

Becky’s vision: “At the initial development of the company, I wanted to address the need for school-based occupational therapy to enhance proper delivery of the educational model. It was also important to me that occupational therapy practitioners working in the schools felt supported and had a network and resource through Sendero Therapies, Inc.”

Celebrating over 20 years, Sendero Therapies, Inc. is a pediatric practice that employs over 40 occupational therapists (OTs), certified occupational therapy assistants (OTAs), speech-language pathologists (SLPs), physical therapists (PTs) and physical therapy assistants (PTAs). Sendero Therapies, Inc. serves school districts, charter schools, and private schools in Northeast Ohio.

Guiding framework: Integrating services within a multi-tiered framework guides therapists in order to address the academic and non-academic (e.g. lunch, recess) participation needs of students with and without disabilities and/or mental health challenges. Direct and indirect services are provided reflecting:
Tier 3: Individual therapy for student receiving special education
Tier 2: Targeted services for students at-risk of academic and participation challenges (small group prevention interventions)
Tier 1: Universal, whole classroom and school services focusing on participation and mental health promotion (e.g. Comfortable Cafeteria, Refreshing Recess)

How does Becky shape practice to reflect integrated services emphasizing academic success and health?

A critical part of Becky’s role is education and advocacy for ‘best practice’ in schools. This is an ongoing process. Education and advocacy of best practice must be done with:

• School district administrators
• Sendero-employed therapists

Initial and ongoing communication with school district administrators and potential employees is provided to educate them on Sendero’s mission and values. New school contracts are established and therapists hired based on a shared understanding of Sendero’s commitment to:

1) Therapists working as a team with all school personnel at their assigned schools. Therapists work to develop relationships and become a part of the school’s culture.

2) Services that reflect therapists’ full scope of practice. School administrators and personnel learn about OT, PT, and SLP’s scope of practice within an educational model. E.g. OTs address student’s participation in academics (e.g. handwriting, self-regulation) as well as daily living skills (e.g. eating lunch), social participation (e.g. friendships), play during recess, extracurricular leisure, and health maintenance.

3) The integration of services in the natural school context versus isolated therapy rooms. Educating employed therapists on how to integrate services throughout the school day (versus pull-out therapy) and ongoing coaching to ensure implementation is essential. This is done with ongoing continuing education and supervision.

4) A workload versus caseload model that supports universal and targeted services (e.g. implementing the Comfortable Cafeteria and Refreshing Recess programs) in addition to 1:1 interventions. Therapists are encouraged to provide services in non-academic settings (e.g. lunch, recess) in addition to the classroom and are paid for their planning and implementation of universal programs such as the Comfortable Cafeteria.

5) Evidence-based practice. Ongoing strategies to build capacity of therapists to develop new knowledge and skills are offered (e.g. continuing education courses, mentoring, and shared resources).

6) Innovation. Sendero therapists have been involved with the Every Moment Counts’ initiative since its inception in 2011. Becky has been a committed OT Change Leader in program development and research (co-developed the Refreshing Recess program), building capacity of Ohio OT/OTAs, and presenting nationally. She provides ongoing education and coaching to help therapists implement Every Moment Counts initiatives.

7) Clinical education of entry-level OT/OTA and PT/PTA students and volunteers planning to pursue OT or PT education. Sendero Therapies, Inc. has a long history of providing Practicum and Level 2 fieldwork/clinical experiences for students. More recently, OTD capstone students have also been accepted. Even during the pandemic with many schools providing virtual education, Becky has encouraged student education. Twelve students were supervised during the Fall and Spring school year (2020-2021). In order to ensure that therapists and students would have positive learning experiences, Becky developed a Pandemic FW Education Exploration & Innovation initiative. This demonstrates Sendero’s commitment to clinical education, service, and therapists’ professional growth and innovation.

Success Stories:
Cheri Harney, COTA, has contributed to the Making Leisure Matters initiative. In this capacity, she led an occupation-based breakfast leisure group with a group of siblings at-risk of mental health challenges whose mother was incarcerated. Cheri was also involved in the initial implementation of the Refreshing Recess program and provides mentoring and coaching to Sendero therapists planning to implement Tier 1 and 2 services.

Ashleigh Spires, MOT, OTR/L, Jen McCallen, MOT, OTR/L, and Casey Kingsley, COTA/L have implemented the Comfortable Cafeteria program several times in their district. Most recently, they have implemented the program as a Tier 2 service with students who struggle with social challenges. General education peer helpers also participate in order to foster inclusion.

Making Connections and Learning Together (MCaLT)
Developed by: Robin Kirschenbaum, OTD, OTR/L (2016)¹

MCaLT is an occupational therapy (OT) developed program focusing on the development of social and emotional learning (SEL) and inclusion. It is designed to be embedded in integrated primary level classrooms (students with and without disabilities), especially in classrooms with students who have challenges in social participation and/or self-regulation. Specifically, students with autism spectrum disorders (ASD) or attention deficit hyperactivity disorder (ADHD) may benefit from this program when in inclusive settings. MCaLT is a peer-mediated intervention program in which all students engage in learning activities to create and support a positive, caring, and respectful social emotional classroom environment. The interventions utilize selected children's literature, cooperative learning activities and lessons from The Zones of Regulation® curriculum.² Key elements of the MCaLT program are the use of children's literature, visual supports such as posters, a classroom binder with child-friendly hand-outs and student generated work and collaborative efforts of the occupational therapist and general educator to support generalization of learned skills to everyday activities and routines.

The MCaLT e-Manual provides occupational therapy practitioners (OTPs) and other school personnel with guidelines, specific lessons, and resources to implement the program in elementary school classrooms. Teachers can use the materials to support carry over into daily class activities and routines. All the necessary materials are free and downloadable.

Download the full MCaLT manual here

A key aspect of the MCaLT program is teaching all children about the importance of peace, love, and respect for everyone. Robin developed an activity to have children say the MCaLT affirmation along with physical gestures. In this way, children are an active participant in learning 'Peace, love, and respect for everyone'. Click on this link to view a 9 second video of Robin demonstrating the MCaLT affirmation.

Watch the video of Robin Kirschenbaum discussing MCaLT.

MCaLT Toolkit Materials:
Video of the MCaLT affirmation – peace, love, and respect for everyone
Orientation Power Point to introduce MCaLT to school personnel
Visual Task Schedule with icons
Think, Feel, Do Person Poster
Module 1, Lesson 4, DJLM posters
Module 1, Lesson 5, Taylor poster
Module 3, Lesson 1, Diagram of lungs
Module 4, Lesson 3, Assertiveness Bill of Rights
Module 4, Lesson 3, Passive-assertive-aggressive continuum
Suggested Children's Literature for MCaLT

References
1Kirschenbaum, R. (2016). Making Connections and Learning Together (MCaLT) e-Manual. Every Moment Counts. 
2Kuypers, L.M. (2011). The Zones of Regulation: A curriculum designed to foster self-regulation and emotional control. San Jose, CA: Social Thinking Publishing.

“Brownie Busters”: An Occupation-Based Group for Children with Multiple Disabilities
Occupational therapist: Eileen Dixon, MS, OTR/L
Cleveland Municipal School District, Cleveland, Ohio

What? The Brownie Busters program was developed to integrate occupational therapy (OT) services within a special education classroom. Using a co-teaching model, the OT planned and led the program with the teacher and para-educators serving as helpers. The program consisted of six 1.5 hour groups that occurred over a 6-week period.

The Brownie Busters program was developed to: 1) provide a community-based functional curriculum for elementary students with multiple disabilities; 2) provide meaningful activities that would teach skills needed for future independent living and employment; and 3) encourage collaboration among school team members, including the teacher, teacher's assistant, occupational therapist, and parents.^1,2,3

The Brownie Busters group involved having the students make and sell brownie-making kits to teachers, students, and staff at their school. Emphasis was on the development of independent living and work skills, such as:
1. planning a work task
2. functional reading (reading labels and recipes)
3. safe community mobility (e.g. walking to the grocery shopping)
4. simple cooking and baking (measuring, pouring, and mixing ingredients)
5. using an oven
6. sanitary food handling (e.g. washing hands, wearing hairnets)
7. making and selling a product

Participants
Eight elementary students ages 9 to 12 years with multiple disabilities, including mild to moderate intellectual impairment and language delays.

Group Sessions
The group sessions involved weekly discussions of basic work skills, a trip to the grocery store, making the brownie mixes, putting them in jars, decorating the jars, and selling them. Each session also involved clean up.

One must crack an egg in order to learn how to crack an egg!

Qualitative Research Findings
Qualitative research methods were used to explore the meaning of group participation from the children's perspective. Each of the eight group members were interviewed during weeks 2 and 6 of the program by the occupational therapist to explore the personal meaning of the group experience. Participant observations served as the second form of data and consisted of weekly observations of the group.

Based on a qualitative analysis of the interviews and participant observations, three themes unfolded: shopping, special ingredients, and doing everything. When asked what comes to mind or what they liked the most when they think of the groups, all the participants talked about walking to and shopping at the neighborhood grocery store, ingredients needed for the project, and doing the tasks necessary for making the brownie jars. By being actively involved in the shopping process, students learned first-hand about how to locate the baking ingredients needed for the brownies. The students began to take on the role of shoppers by looking for items needed for baking and using a shopping list. Students also learned about each special ingredient's unique properties by handling, measuring, and tasting it.

Finally, students expressed joy in doing everything and began to function like workers—doing the task, sharing, demonstrating care with the ingredients, using sanitary food handling, and preparing the jars to sell. Findings support the importance of occupation-based practice in fostering the link between doing and becoming.

1Dixon, E. (2006). The Meaning of an Occupational Therapy Work Group for Children with Multiple Disabilities: A Phenomenological Study. [Unpublished master’s project]. Cleveland State University.
2Kardos, M., & White, B. (2006). Evaluation options for secondary transition planning. American Journal of Occupational Therapy, 60, 333–339. doi:10.5014/ajot.60.3.333
3Mankey, T. (2012). Educator's perceived role of occupational therapy in secondary transitions. Journal of Occupational Therapy in Schools and Early Intervention, 5, 105–113. doi.org/10.1080/19411243.2012.701974