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Transition To Home After A Rehab Stay Podcast

Transition To Home After A Rehab Stay Podcast
Krista Covell-Pierson, OTR/L, BCB-PMD, Dennis Cleary, MS, OTD, OTR/L, FAOTA
March 6, 2023

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Editor's note: This text-based course is a transcript of the Transition To Home After A Rehab Stay Podcast, presented by Krista Covell-Pierson, OTR/L, BCB-PMD; Dennis Cleary, MS, OTD, OTR/L, FAOTA.

**Please use the handout to complete the exam.

Learning Outcomes

  • After this course, participants will be able to:
    • examine community-based occupational therapy.
    • examine ways to articulate options for patients in a way that is relatable and meaningful to the patient.
    • evaluate the importance of providing ongoing, supportive services.

Podcast Discussion

Dennis: Thanks, everyone, for being here. My name's Dr. Dennis Cleary, and I'm joined today by Krista Covell-Pierson. She is going to talk to us again about transitioning home after a rehabilitation stay. Thanks for joining us. Could you tell us a little bit about your background and your interest in this topic of having a positive discharge home?

Krista: I have been an OT for about 22 years. I started in skilled nursing facilities, home care, and hospitals; all in traditional settings. When I was first starting in occupational therapy, I thought that when I discharged patients home, home care would take over and care for them. Once I got a little bit more experience under my belt, I realized this is not always the case. There are many things that patients still need help with and a lot of details that get missed even in a good discharge. I started working with a neuropsychologist that valued occupational therapy in the home. This collaboration grew into a private practice that I did on the side where I followed many of my patients home. This allowed me to see what we can do better on the inpatient and home care sides for a better transition and experiences for the patient. 

Dennis: Great. You have your own company now, and we will talk about that a little bit later in the podcast. I talk to my OT friend, one of my former OT classmates, on most days. He is doing home health now, and occasionally between visits, he will give me a call. He will tell me about some interesting situations he finds himself in, of course, not disclosing any HIPAA information. Do you think that occupational therapy practitioners might have some misunderstanding, especially those from skilled nursing or rehab-based background, about the reality for many of our homebound patients?

Krista:  I do not think it is necessarily a misperception. I think there is so much that happens when a patient goes home, and many things we cannot anticipate. We can open up our landscape a little bit when looking at discharge. We do not want to only look at showering, dressing, hygiene, and grooming. We want to look beyond these because most people are motivated to go beyond that. We need to plan for that, even if they are not ready. There are many details and IADL areas to address with patients that I think we miss. Some of this has to do with time, too. We only get so much time with our patients. 

Dennis: Absolutely. In your company, how are you doing things differently than a traditional home health company?

Krista: We call it outpatient services or community-based treatments. It is now a bit more commonplace, but it is certainly not mainstream yet. It was very new when I first started the company. I only knew a small handful of therapists in this practice area, and now I know much more.

As OTs, we value the environment that patients are moving around in so much. Environment influences our treatment, so it is important that we are in people's homes, at their jobs, and in the community, like on the city bus. We can problem-solve and do context-based treatment, which impacts the patient.

We do physical, occupational, and speech therapy. We also have fitness trainers. For anybody that has ever worked in skilled nursing, you know how important restorative nursing is. This is why we brought in the fitness training piece to help support patients after they come off of therapy services. It is a little bit a la carte for patients. They can pick and choose what services they want. We can also do maintenance therapy, which is a little bit different. We can come in and out as patients need or want us to. We are more flexible to meet the client's needs.

Dennis: How do you offer those a la carte services? Is there a menu of options, or do you propose services based on an occupational profile? Are they your clients or patients?

Krista: We call them patients. We tried for a long time to transition it to "client," but as the medical world refers to them as patients, we went back to calling them patients to make it easier, mostly for doctors and other colleagues.

As far as figuring out what a patient needs, we usually get a referral, phone call, or inquiry about a patient and a specific service. Let's say they want physical therapy. When the PT goes in, they might screen for other issues. If they are having problems with ADLs, they may recommend an OT. Other times, physicians will send over orders for everything. We then sit down with the patients once we do the evaluation and run through all the issues we are seeing. We then talk about what a good treatment plan would look like and set it up from there.

If a patient feels overwhelmed because they have PT, OT, and speech coming in and are going to an outpatient service for something, we may have the PT hang back for a while. They may come in when OT is done, and we can be a little bit more creative. I let the patients call the shots as long as they are safe and still making progress.

Dennis: What can inpatient therapists do to make the transition home a little bit more seamless?

Krista: It starts with a conversation asking many more questions or hypothetical situations. For example, I had a patient who, by the time he would get out of his car in the garage and go to the door, the garage door light would go out, and he would lose his balance.

I use examples such as these to ask patients what they would do. This helps you to get a better idea of how prepared your patient is in emergencies. Another example might be the question, "Where do you keep your holiday decorations?" And, "How are you going to get them down?" You can have these conversations while you are walking down the hall to the rehab gym or while they are taking a shower. These casual conversations are helpful and give you some good talking points.

I also like to use simulations; however, our treatment places are typically accessible with bright lights and clear hallways. You can make a mess in your therapy kitchen, and then have them clean it up or talk about what their kitchen looks like. You want to make it as close to the home environment as possible. This is going to increase the patient's confidence and get them back to their normal environment.

I also like to share things about people that my patients can relate to, like new amputations. I can talk about a patient without giving private information away. I want to help that patient not feel so alone.

We can also get them plugged into organizations. For example, in northern Colorado, we have a strong Parkinson's support group. On the inpatient side, you can help them call or open the website on your device while taking a rest break. You can start to link them back to the outside world.

You also want to set up things as close to real life as possible. If they take their showers in the evening, that might be hard because you do not work in the evening, but you can make them the last visit of the day to see how tired they are. When I worked in skilled nursing, we used to do a lot of meal prep for safety training and invite a couple of other residents or their families. We also had them make a double batch so that they could freeze half so they would have a meal when they get home.

It is trying to think practically and long term. It makes it more fun, and it gets that patient to start thinking a little bit more analytically about going home. I always tell my patients that there is no magic threshold. They are not going to be better when they go home. They will have some of the same issues and need to be prepared. Your patients trust you more when you are being as realistic as possible about home.

Dennis: An inpatient hospital where I worked had an apartment. They would have patients stay in there the day before their discharge. However, there were issues during the last night, so they moved it earlier in the stay. The closer we can get to being authentic with the interventions that we are providing, the more successful the therapy can be. I also think you get better buy-in from the patients you work with because they cannot say, "I will do differently at home."

Krista: It helps to run a little interference with the nursing staff. Often, they have many things they need to get done, and due to time, they do things for the patients. We may say that the patient needs to ask for their meds when they are due. They still need to disseminate the pills if they do not ask, but we want to start to give the patient more autonomy. It is about educating the nursing staff about the importance of backing off a little bit and letting the patients have more independence. You want the team to work together to get the patient home as independently as possible.

Dennis: As occupational therapists, we understand this, but I do not think every profession does. Getting everybody on the same page improves outcomes. What are some other areas that you think inpatient occupational therapy practitioners miss during this transition of care to home?

Krista: There are many examples, especially IADLs. How are they getting their mail or groceries? Who puts the groceries away?  It is important for inpatient therapists to take a dive deep into those IADL needs.

They also need to consider lighting. If someone has low vision, they need to make sure to address that in addition to their primary diagnosis, like a hip replacement. Are lighting and the home set-up being addressed?

Emergency planning is another big one. Do they need a Life Alert type system? Who are they contacting in case of an emergency? If it is a family member, do they realize they are on call all the time? If, for instance, the patient identifies his son, but the son travels a lot. What then? We need to cover the little details using our activity analysis skills.

In an inpatient setting, it is sometimes hard to dot all the i's and cross all the t's because everybody is different. Running through the patient's daily routine hour by hour can be helpful. What is the client doing and where is important to know. If they need to get the mail, simulate that. Are they going to use a walker and have trouble negotiating the keys to open it? Or, do they have to walk down a long driveway?

These are examples of the many details that we do not often address on the inpatient side.

Dennis: One of my former coworkers is an OT and has two sisters that are OTs. I also think there are a psychologist and a nurse in the family. When their mom went in for an inpatient stay, she said that there were three steps into the house. She is from Pittsburgh, which is hilly. While there were three steps to get into the house, there were like 20 steps to get to those three steps. The family said, "We're not discharging." This is another example of what occupational therapy practitioners need to consider when prepping a patient for discharge.

Krista: I think you bring up a great point. We do not always get the correct information. I had a similar incident with a patient. I asked about his entrance, and he said that there were four to five steps. We found out later that the stairs were rotten and not safe. He was actually using the back door with a completely different setup, but he did not share that with me. Sometimes things get lost in translation.

I like to have families bring in photographs and videos, being mindful of HIPAA rules. We can even FaceTime. Often, we cannot get to patients that live in the mountains, so pictures and videos are crucial for discharge planning.

Another area that we tend to gloss over is driving. If a patient has been driving, we need to address that. Driving is one of the most meaningful activities of daily living for most people. People want to drive, and we must have those conversations with patients.

Dennis: It is sometimes hard to get physicians on board, as they want high ratings. One of my first patients had some driving issues. My rehab manager saw it as a learning opportunity. I had to negotiate with him, his family, and the Department of Transportation to determine the best solution. I was unprepared for this, but it is an important part of our role, as it is a huge loss when people stop driving.

My dad went through a driver rehab program, and they were the ones that made the decision that he should not drive anymore. In his last few weeks, he still said that my mom should not be driving either as she could not have passed the driver's test that he was put through. It impacted him so much. When driving is not an option, what resources do you use for patients?

Krista: Giving up driving is very emotional. People can feel very vulnerable and attacked. They also do not want to burden their family. It is important to have those conversations and validate their emotions. You may want to start before they have to give up driving. "If you have to stop driving, what are your options? They need to have a good overview of what is available in their community

We have some driving resources here, but they are not great. As such, it is tough to confidently recommend them sometimes because I know how frustrating it will be for the patient. I brainstorm with them about door-to-door transit, Uber, the bus, community volunteers, hiring a driver, et cetera. Sometimes, there is no great option, but it is important to process that with your patient.

Dennis: Absolutely. My dad was a carpet salesman. He would go around to different carpet stores throughout the state and loved doing that. Even in retirement, he appreciated driving. One activity he enjoyed was working at a soup kitchen. My mom would drop him off, and then he would go out to lunch with his co-volunteers, and they would drop him. It was a way to negotiate his transportation that worked, but I still think not driving took a toll on his mental health. He was still an optimistic guy, but I think he lost a sense of himself. Driving was a meaningful occupation to him, as it is to me. Hopefully, when I get to that point, I will be less dramatic for my child than my father was for me.

Krista: The research says that most people will outlive their ability to drive for the first time in history. It will become more of a problem as people live longer. I challenge you to think about what you would do if you could not drive for 30 days. What resources come into play? It is hard to live in the United States and not drive unless you are somewhere urban, like New York City.

Dennis: The federal law says that paratransit services should be at the same level as public transportation services. However, if you are in an area that does not have great public transportation, then paratransit services are not going to be great either.

Krista: That is true.

Dennis: Hopefully, we will continue to make some progress with public transportation to make it more accessible for everybody.

Krista: We need some OTs advocating in that space.

Dennis: We do! I was part of a group at the Ohio State University where we worked with the local transportation agency to start to put forth resources to do that. We had our students go down and look at their mobility center to see and support the work they were doing. We wanted them to have a good understanding of the role that public transportation plays for so many people, especially folks with disabilities.

From personal experience, my mom, when discharged from an inpatient rehab stay, had orders for both OT and PT. However, the home health company changed OT to a nursing assistant twice weekly to help with showers. I called and said we already had a nursing assistant that could help with the showers and that we needed the OT to be there. Can you talk about why that sometimes happens and how we can ensure that folks get the services that they need?

Krista: When you become an OT, you sign up for a lifetime of educating people about what occupational therapy is. It is a big question mark for a lot of people. We need to start on the inpatient side to educate people about the role of OT. It is not just, "I had an OT, and she made me make a scrambled egg." I hear that all the time. We must advocate for what OT does with patients, social workers, nursing staff, administrators, care teams, and agencies. We need to educate why someone needs OT, and that is where our skill level comes in. When working in an agency, it is our professional responsibility to ensure we show our value because we can do many great things, especially in home care. However, if nobody sees us, they do not understand what we are doing.

Another thing that comes into play is staffing, especially right now. If they do not have an OT, then maybe they think they need to farm it out to something else that they think is going to foot the bill. A CNA certainly is not going to do what an OT will do. Sometimes insurance restrictions come into play, or the patient refuses because they do not value what OT does. People want to "walk" and "get stronger." 

Figure out what your elevator speech will be so that people realize the necessity of your services. Once we have that conversation and it clicks, they get it and start to refer to OT all the time. It takes work to keep OT kind of front and center sometimes.

Dennis: Our physical therapy, nursing, and SLP friends can become gatekeepers. Is there language that you like to use so that the patient has access to occupational therapy services?

Krista: It is all about the relationship you have with individuals and nurturing that relationship. Let them get to know you, as that is important. We also need to provide education that has some legs, so to speak. For instance, I read a great article in OT Practice about wheelchairs and working with an Assistive Technology Professional (ATP) that I will share with some of my colleagues. It describes the role that we have. We need to stay on top of the research and share information. I give many presentations to home care agencies and discuss our role with low vision, incontinence, et cetera.  It is also important to share our success stories as that goes a long way with other professionals.

Dennis: Even having the patient share with the PT or the nurse what types of things they are doing in OT may be helpful.

The business of community-based occupational therapy has always been fascinating to me. I have been fortunate enough to be able to do it myself. Do you feel like community OT makes a difference in terms of the types of services that you provide and in the type of relationships that you have with the patients?

Krista: I do. When you are invited into somebody's home, it changes things. There is a little bit more intimacy because you are entering their home and seeing where their bedrooms and bathrooms are. You do not even do that with your neighbors. It changes the relationship and almost gives the patient a little bit more power or agency. 

In their home, you can be client-centered. For example, you can see how often their daughter comes in and out during your visit, or you can see that the cat is all over the place when they are trying to take a shower. In this environment, you can create beautiful dynamic treatment plans.

My favorite thing about being in the home is getting to know their life on a personal level. Let's say someone has ALS or Parkinson's, they may need different supportive services at different times. When you have already been in their home, they can call you, and you can come back. Then, they do not have to explain their whole story again. I love that. In fact, I have patients I have seen for years off and on, and then see them when they are in hospice at the end of their life. It is a really beautiful thing.

I learn just as much from my patients as they learn from me by being part of their lives.

Dennis: We have a number of international occupational therapists and non-occupational therapists who listen to the podcast. For those OTs from other countries, in the US, occupational therapists typically deliver care within institutions, like hospitals, clinics, schools, and skilled nursing facilities. I believe international occupational therapy is more community based, and occurs much more frequently. Have you modeled any of your approaches on any international models or what folks are doing in other countries?

Krista: I have not. I did have a few students who were from out of the country, but I have not used a specific model or organization. I, too, love some of the things I have read about other countries and how they are providing occupational therapy. I think there is so much that we can learn from them.

With Covell Care, it has been more about what the different communities have needed and responding to those needs. It has been more responsive, and we figure it out from there. I wish more communities had mobile outpatient services available because it is so good.

Dennis: In the United Kingdom, Canada, and Ireland, the OT rides along in the ambulance and does a home evaluation right there to make some recommendations to avoid an expensive emergency department trip if possible. It is expensive and stressful for the patient to go to the ED and possibly spend a few nights there. Some cool models are out there, including where the occupational therapist or physical therapist is in the emergency department. The international model, as mentioned above, takes that one step further. Maybe that could be your next move; a Covell Care car with an emergency siren.

Krista: I like where you are going with this. Sounds like a good plan.

Dennis: Absolutely. When in the community, are you doing things like bus training? Are there any special considerations that you need to think about if you are an occupational therapist interested in following your model?

Krista: From a logistics point of view, you need to ensure that you have liability insurance when you are out and about. If anything, it changes your perspective sometimes when you are working with patients in a real environment. I had a patient with a neck fusion, who had decided not to drive, spoke English as a second language, and was very short. When the transit system came, the way the bus could pull up to the house made the steps a little lopsided, and they were steep. She lost her balance and fell backward. Luckily, I was behind her and caught her. The bus driver was a big and loud guy that talked fast. She had no idea what he was saying, and I could tell she was nervous. The trip cost her $3 to the drugstore to pick up her prescription.  He went a different way than she was used to, and she panicked, as she thought he was kidnapping us. If I had not been there, she would have been out of her mind. Although I was there to reassure her, it took her a long time to be willing to do it again. This is all part of the therapeutic process. Had I just coached her and not done it with her, I would not have anticipated any of that happening. Things happen out in the community that you do not expect, and it is so imperative that we are there to help them problem-solve. And, it keeps us on our toes as OTs.

I was with an OT assistant once, and we had a group of patients at Walmart. One of the women was in her power chair, and she had connected to a clothing rack that began to travel with her throughout Walmart. When I brought it to her attention, she said, "I didn't do that." Things like this definitely keep us on our toes.

Dennis: Absolutely. Do you bring tools with you in the community or when doing home health visits, or do you rely on the natural environment and the things that people have access to?

Krista: Both. I usually go on my visits without much equipment. I have a few bags of tricks that I keep in the back of my car if needed, like duct tape, puff paint, bump dots, paper, markers, et cetera. There is a great organization here where we can get adaptive equipment. Sometimes it is used, but it is pretty cheap, so we can use it to trial things. I keep a few of these items in the car.

Dennis: Nice. I like to have duct tape on non-stick baking paper, so you do not need the whole roll.

Krista: Hmm. I did not know that.

Dennis: It is my little duct tape trick for you. You can also use it for Velcro.

Krista: That is an awesome idea. Thank you.

Dennis: I have some in my bag with a couple of other weird things. It is fun to go through TSA sometimes because they wonder what you are doing.

Krista: My aunt is an OT, and she always had so much stuff in the back of her car. I always said, "I am never going to be like that." These are famous last words.

Dennis: Primarily, I am a researcher, but I have about five or six giant tubs of OT things in our basement, in addition to the tubs I have at my office. Occasionally, my wife wonders about these things, but it has been a lifetime of getting those things together, and I am sure it will continue. She has three sets of china that she has inherited, so that is the trade-off. 

What are some real-life examples of people with whom you have made a difference?

Krista: One of my all-time favorite patients I saw for many years because he had a progressive neurological disorder. He was a "man's man." He was tough and had a lot of pride. He was a well-respected physician in the community, and everything he touched turned to gold all his life. He was devastated when diagnosed with this vulnerable disease. He also lost a son very tragically, and as a result, he was very stoic.

I began to see him, and eventually, I stopped billing his insurance. However, his wife asked if I would come and visit him occasionally. I would bring my dog and sit with him. Finally, one day, he talked about his son and sobbed. If I had not had that relationship with him, I do not know if he would have confided in someone. Our relationship went way beyond OT for us.

We eventually remodeled his bathroom and installed a lift system. He also used to like to go in his backyard, where he had a golf cart. Before he got too bad, we problems solved how to get him on the back of the golf cart safely. It was not pretty, but we did it. He has been gone a long time, but I have great memories of him and still talk to his wife.

I had another patient with quickly progressing ALS. Her dream was to go to Alaska on a cruise, and she was just losing skills every few weeks. She inherited some money, and I told her I would help her. I researched different cruise ships that could accommodate all her equipment, and she hired two caregivers to go with her. One thing I learned is that certain airlines will not let you bring certain types of oxygen tanks or power wheelchair batteries. We figured all that out, and she got to go. She actually broke her ankle on the ship during a transfer. While the caregivers were transferring her, the ship listed one direction, and she went the other way. They took her to the ship's doctor, who said, "You have to get off at the next port and go to the hospital." She responded, "I do not walk, and I have ALS. I'm not going anywhere." She stayed on the ship with her broken ankle. Despite this, she completed her goal. Helping somebody get out in the world is so meaningful. You never forget those patients, either, even after they have passed.

I just saw a patient recently via telehealth because she lives about 2 1/2 hours away. She needs a power wheelchair. She got one from a thrift store, which looked like it had been run over. I worked with a wheelchair vendor who went to her house via video. Now, she is working with a PT via telehealth. Eventually, she will work with a personal trainer via telehealth. She is excited about her progress and wants to cook and garden. Telehealth has been crucial as there are not many services in her area.

The most rewarding part of the job is helping people live their life the way that they want to.

Dennis: Absolutely. I did recreational stuff with people with disabilities before becoming an OT. I worked with a gentleman with CP who had a trust fund. I provided many recreational experiences, like attending football and basketball games and going out to dinner. It is the meaningful occupations of life that make life worth living. Some of the choices that you have made give you a little bit more freedom to be able to do that.

Historically, occupational therapists have been a little bit reluctant to start their own businesses, but this seems to be changing a little bit. Do you have any tips on how someone could start a business like yours? 

Krista: I always start with personal development. Wherever you are, you need to figure out a little bit more about yourself first, because we can get in our own way. Sometimes, our thoughts or insecurities keep us from doing certain things. For many different practitioners, like chiropractors and physical therapists, there is almost an expectation that a percentage will go out on their own. Still, it is not expected of OTs, which is interesting. When there is nothing out there that looks like our type of practice, we may opt to shy away from that. I think it is getting comfortable with following the breadcrumbs or having a curiosity. You can find other small business owners, or most communities have a small business development center, which is government funded. I learned so much from them, and many courses are free or affordable. You can also get a business coach to help.

It is also important to be open-minded so that if you have a roadblock that comes up, you can move around it. OTs are good problem solvers. I think this skill bodes well for being in business because there are always things that come up.

It is going to be more challenging than you ever thought, but you can do it despite the challenges. Trust yourself. I encourage OTs all the time if they are interested in starting a business because we need OTs out there to change the playing field for our patients.

Dennis: Many Facebook pages showcase OTs using alternative ways to practice. I was fortunate or silly enough that I started my own company about nine months into practice.

Krista: Oh wow.

Dennis: I am kidding a little bit. I was 27, so a little older and seasoned. When I talk to former students interested in starting their own practice, one of the big hangups is taxes. I started with a CPA to help with that process, as there are many deductions when you have your own business. I also worked with a physician who was working as a private contractor, and he said he used TurboTax. I have been using TurboTax now for the last 10 years or so, and it is pretty easy. The IRS has not shut me down yet. What are the pros and cons of accepting insurance?

Krista: There are a lot of pros and cons. We will start with the cons. The cons are that it is challenging and has gotten more challenging in the last several years, mostly thanks to different types of plans, like Medicare Advantage. Depending on your state, becoming a Medicare or Medicaid contractor is not a difficult process. I always tell therapists, if they want to accept insurance, to start with these two plans. The good thing is that a lot of patients, especially older adults, have insurance and want to use it. It opens up the door for lots of patients to come to you and receive services.

We also have a handful of therapists that come to us that are private insurance and need somebody to help them with that, so we process their insurance for them. If you are going to bill insurance, remember that you are a therapist and not a medical biller. Many therapists start out trying to do their own, but it takes so much time. It is important to hire a biller, in my opinion, so you can focus on therapy and your business. The big pro is that you will probably have an easier time getting clients, and then the big con is that you're going to have an expense to pay for the biller, but they usually pay for themselves with the collections that you get.

We also see pediatric clients. Sometimes their insurance plans have such high deductibles that parents will pay privately instead of going through their insurance. There are those options, too.

Also, remember, if you are seeing a patient with Medicare, OTs are not allowed to opt-out, meaning that they should be getting their services from an OT that is contracted with Medicare. There are ways around that, but you must do it legally with the right paperwork. Sometimes I think therapists, naively think, "I'll just do cash payment for all my older adults," but professionally, we cannot.

Dennis: How do you drum up business? Are you cold-calling physicians or skilled nursing facilities?

Krista: It has depended upon the phases of the business. In the beginning, it was beating the streets, making calls, going to coffee, joining groups, and giving presentations. You name it, we did it. It is about getting to know your community and asking many questions. "What do you do because I might need you for my patients?" It was years of this resource building. We have been around for a while, so hospitals, physicians, home care agencies, social workers, and county caseworkers refer to us consistently. Sometimes, people find us on the internet and send us an email, but usually, somebody in their medical team makes the referral.

Dennis: What are the risks and rewards of doing your own thing and starting your own business? It seems like you are happy with what you are doing.

Krista: I would do it all over again because I love what I do. It is a big part of who I am, and feel lucky to feel that way. The hard part is that when you are the owner, the buck stops with you. If something happens, you are on the line. When we went through the pandemic and everything was shutting down, it was a challenging time as a small business owner in healthcare. There was a lot of anxiety. Another time, Medicare incorrectly classified us as cardiologists, and all our claims got denied. We had nothing to do with that, but that error dried up our cash flow for a while. These things happen and can be very stressful. Employees are depending on you for their livelihood, so there is pressure to produce.

In a regular setting, you may not be responsible for these administrative duties, but you do not get to be as creative with your interventions. That is a huge pro for business owners. The saying goes, "Entrepreneurs work 80 hours a week, so they do not have to work 40 hours a week for somebody else." However, you get to pick and choose what you want to do, and I really enjoy that.

I also love working with other therapists because there is so much creativity. I get to mentor them, and I love that. 

Dennis: Other than reaching out to you directly, are there things people interested in starting their own business can do? Are there websites or organizations they can contact?

Krista: If you want to bill Medicare, I would definitely suggest going to the CMS website to learn more. As I said, a small business development center in your community is another great asset. The Better Business Bureau or local Chamber of Commerce may also be able to help. There are some business coaches and mentorship programs to support you. One of the mentors I had was a physician that I worked with here in town. It does not have to be another OT in business.

Get on those Facebook groups and start learning what is going on in the industry. You can also find networking groups online or locally. You can go to the library and pick up some books to start educating yourself. Even with a master's or a PhD in occupational therapy, you may not know how a business works. We need to educate ourselves.

There are some good webinars out there, and I would start chipping away or have some goals of what you want to get done or what you want to learn.

Dennis: There you go. That was the occupational therapist in you speaking at the end about being goal-directed.

Krista: Right. Get your goals in there and ensure they are measurable.

Dennis: Thanks so much. I enjoyed our conversation, and I appreciate your time today.

Krista: Thanks! There is one other organization, if you are interested, called ADED (The Association for Driver Rehabilitation Specialists). We definitely need some OTs in that space. 

Dennis: Thanks so much. Have a great day.


Available in the handout.


Covell-Pierson, K., & Cleary, D. (2023). Transition to home after a rehab stay podcast. OccupationalTherapy.com, Article 5582. Available at www.occupationaltherapy.com

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krista covell pierson

Krista Covell-Pierson, OTR/L, BCB-PMD

Occupational therapist and entrepreneur, Krista Covell-Pierson is the founder and owner of Covell Care and Rehabilitation, LLC. Krista created Covell Care and Rehabilitation to improve the quality of services available for clients of all ages living in the community through a one-of-a-kind mobile outpatient practice which aims to improve the lives of clients and clinicians alike. Krista attended Colorado State University receiving degrees in social work and occupational therapy. She has worked in various settings including hospitals, home health, rehabilitation centers and skilled nursing. Through her private practice, Krista created a model that she teaches other therapists looking to start their own business. She has extensive experience as a fieldwork educator and received the Fieldwork Educator of the Year Award from Colorado State University. Krista served as the President of the Occupational Therapy Association of Colorado for two years. She presents to groups of professionals and community members on a regular basis and has a heart to help others become the best version of themselves. 

dennis cleary

Dennis Cleary, MS, OTD, OTR/L, FAOTA

Dr. Dennis Cleary has over 25 years of experience as an occupational therapist.  Dennis’ clinical practice has been primarily with children and adults with intellectual disabilities to encourage their full participation in all aspects of life at home, work, and in the community. He has had faculty positions at The Ohio State University and Indiana University. As a researcher, he has been on teams that have received over seven million dollars in grants from state and federal agencies, including a National Institutes of Health multisite trial of the Vocational Fit Assessment, an age-appropriate transition assessment, which he co-created. He has numerous publications and national and international presentations. Dennis is passionate about increasing the role of Occupational Therapy in transition-age service with the goal of improving outcomes and quality of life for all. 


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