Over the last few years, the Utah Occupational Therapy Association (UOTA) Government Affairs Committee has received multiple inquiries regarding the use of school support staff as a means to deliver occupational therapy services in Utah’s public schools. Motor aides, motor paraeducators, and motor paraprofessionals (hereafter motor aides) are general titles given to school support staff who are supervised and directed by licensed occupational and/or physical therapy professionals. Motor aides are being used in a similar role to that of reading aides and math aides who are supervised under an educator’s license. Teachers frequently use aides as an extension of their efforts to meet their students’ educational needs. The UOTA acknowledges the efforts of paraprofessionals across Utah’s schools.

How are Motor Aides Being Used by Occupational Therapy Practitioners?

The title “motor aide” is absent in the occupational therapy literature, and their role has been unique to a few school districts and charter schools in Utah. To the best of our knowledge, it appears that some of Utah’s earliest school-based occupational and physical therapists decided to utilize teacher’s aides in the therapy process by delegating motor development interventions to improve students’ fine and gross motor skills. Although the majority of school-based occupational therapists do not appear to be currently using motor aides to deliver occupational therapy services, motor aides are being used in some schools.

The UOTA Government Affairs Committee is aware that there are occupational therapists who participate in the hiring process of motor aides and then provide training in their day-to-day duties. These occupational therapists delegate specific activities to motor aides to engage students in their motor development. During these structured student encounters, motor aides challenge students' fine motor, dexterity, visuomotor, balance, coordination, strength, sensory processing, and other physical and self-care skills. While motor aides work directly with students, the supervising occupational therapist visits other schools on a rotational basis. In the absence of direct supervision, motor aides report back to the occupational therapist and describe how students are progressing in their motor development programs. With motor aides at different school locations, occupational therapists rotate through multiple schools and provide supervision as needed, but generally on a monthly or quarterly consultation basis. During these supervised visits, an occupational therapist observes a motor aide working with their students and provides feedback on the activities so that the students can be challenged according to their needs. The occupational therapist can then update the motor development plan, give specific feedback and training, and demonstrate how to make the intervention activities more or less challenging for the students. Finally, the motor aide demonstrates these motor-based interventions so that they can challenge the students accordingly until the subsequent occupational therapy supervised visit. The broad use of motor aides as a service delivery option for occupational therapy can be summarized accordingly.

• The occupational therapist interviews or contributes to the interview process of the motor aide.
• The school district assigns supervision of motor aides to the occupational therapist.
• The occupational therapist provides specific on-the-job training to the motor aide.
• The occupational therapist delegates specific motor-based or occupational therapy-based interventions to the motor aide and specifies the students and frequency of instruction.
• The occupational therapist is physically present to supervise the motor aide’s actions during rotational school visits (generally monthly or quarterly) and updates the students’ interventions based on their individual needs.
• Motor aides work directly with students (generally weekly or a few times a week) while the supervising occupational therapist is at other school locations.
• In the absence of a physically present occupational therapist, the motor aide provides feedback regarding student performance and/or progress to the supervising occupational therapist through a variety of means including, but not limited to, phone calls, text messaging, emails, checklists, and observation notes.
• Many school districts throughout Utah seek reimbursement from Medicaid for the “medical services” that are provided by motor aides with the assumption that motor aides are an extension of the occupational therapy or occupational therapy assistant licensure.

Licensure Regulations for Occupational Therapy Practice

The UOTA Government Affairs Committee has many concerns with the use of motor aides as a service delivery method. Occupational therapy is a licensed profession through the Occupational Therapy Practice Act (2015, hereafter Practice Act) and the Occupational Therapy Practice Act Rule (2018, hereafter Rules). The Practice Act and Rules specifically define and distinguish between occupational therapy, occupational therapist, occupational therapy assistant, and occupational therapy aide. The terms motor aide, motor para educator, fine motor assistant, etc. are not recognized in the Practice Act or Rules.

In brief, an occupational therapy assistant is a licensed professional supervised under the direction of the occupational therapist and has graduated from an accredited occupational therapy assistant program with an associate or bachelor’s degree. An occupational therapy assistant requires monthly in-person supervision but may work out-of-sight of the occupational therapist. An occupational therapist may supervise up to two full-time occupational therapy assistants or four part-time occupational therapy assistants whose combined weekly hours do not exceed 80 hours per week.

An occupational therapy aide is not a licensed professional. Their role is defined in the Practice Act and Rules, and they have the following limitations (Occupational Therapy Practice Act, 2015, 58-42a-305):

(2) An occupational therapy aide:

(a) may only perform occupational therapy services under the direct supervision of an occupational therapist or an occupational therapy assistant;

(b) may not write, modify, contribute, or maintain an individual treatment plan; and

(c) may only perform tasks that are repetitive and routine for which the aide has been trained and has demonstrated competence.

As described earlier, some school districts and charter schools in Utah have been using motor aides since the late 1980s and early 1990s, and these schools likely anticipate the same pattern to continue; however, current school administrators and therapy practitioners may not realize that motor aides are acting as occupational therapy aides per the Practice Act and Rules, placing the occupational therapy service delivery model in violation to state law.

Some occupational therapy practitioners and administrators may justify the use of motor aides by taking the position that the aides are not providing occupational therapy; therefore, the Practice Act and Rules would not apply in the school setting. However, the use of a different title (motor aide vs occupational therapy aide) does not change the occupational therapy service process as described in the Practice Act and Rules. The Practice Act and Rules do not apply to one practice setting and not another practice setting. The Practice Act and Rules apply in all settings throughout the state where occupational therapy practitioners provide services. When occupational therapists hire aides, train aides, delegate tasks to aides, receive feedback on student performance, and supervise aides, their actions fall under the Utah Occupational Therapy Practice Act and Rules.

  

Historical Use of Motor Aides

It is unclear when Utah’s earliest school-based occupational therapy practitioners began using classroom aides to deliver services or when the title of motor aides started. Many believe it evolved with the Education for All Handicapped Children Act of 1975 (Pub. L. 94-142) and the Individuals with Disabilities Education Act of 1990 (Pub. L. 101-476) which defined occupational therapy as a special education service and mandated that occupational therapy be available in public schools. At that time, there were no university programs in Utah to produce occupational therapists or occupational therapy assistants. School districts had to recruit occupational therapy practitioners from other states. With few licensed practitioners available, some of Utah’s earliest occupational therapists began using school support staff for day-to-day therapy interventions. We suppose that some of these early practitioners had worked in medical settings and provided home exercise programs for their patients when they were discharged from the hospital or clinic. The idea of providing routine and non-skilled activities to students through a program akin to a home exercise program was born. With so few practitioners available for hire, both occupational therapists and school administrators found this service delivery model advantageous. First, the occupational therapists were able to help their students progress through their therapy and they avoided burnout by serving so many students. Second, schools found the service delivery model financially advantageous to have one occupational therapist consulting on 200-300 students while a handful of motor aides worked with students on a more frequent basis. These mutual benefits continue today and perpetuate the use of motor aides as a service delivery model.

Utah’s Ability to Produce Occupational Therapy Practitioners

Historically, the demand for occupational therapy practitioners has been high, and the profession can expect better-than-average growth (O*Net Online, 2024). Fortunately, the availability of licensed occupational therapy practitioners has changed since motor aides were first introduced. The following table lists university programs throughout Utah that offer entry-level occupational therapy education programs and the cumulative number of therapy graduates to date.

Table 1

Approximate Number of Occupational Therapy Professionals Prepared at Academic Institutions in Utah.

Academic Institution	First Graduating Class	Approximate Number of Entry-level Graduates to Date (3/1/2024)
Ameritech College / Joyce University (Draper)	2018	103 Occupational Therapy Assistants
Rocky Mountain University (Provo)	2026	Up to 40 students beginning 2026
Salt Lake Community College (Salt Lake City)	1994	516 Occupational Therapy Assistants
Utah Tech University (St. George)	2026	Up to 25 students beginning 2026
Utah Valley University (Orem)	TBD- Developing OTA Program
University of Utah (Salt Lake City)	2002	607 Occupational Therapists
Weber State University (Ogden)	TBD- Developing OTA Program

Utah’s ability to educate occupational therapy practitioners has improved significantly with the efforts of the University of Utah and Salt Lake Community College, and it will continue to improve with additional university programs in the future. Currently, there are nearly 1,400 licensed occupational therapists and 500 occupational therapy assistants in Utah (Utah Department of Commerce: Division of Professional Licensing, 2024).

UOTA’s Stance on the Use of Motor Aides

Over the last few years, UOTA has received multiple inquiries from occupational therapy practitioners asking about the use of motor aides for occupational therapy service delivery. Many of these practitioners are uncomfortable supervising motor aides as part of their work responsibilities. As motor aides are not occupational therapy assistants, many practitioners are asking themselves and UOTA if the use of motor aides is appropriate and even legal. Some practitioners report feeling pressured to maintain the status quo as their employment setting has used motor aides for many years (Chamberlain, 2021).

At this time, the UOTA Government Affairs Committee is publicly commenting on the use of motor aides in Utah’s public schools. The Committee feels that motor aides are being used as occupational therapy aides but under a different title; that despite the title difference, occupational therapists are using motor aides as an extension of their licenses to provide interventions to improve student’s occupational performance. In short, occupational therapists and schools are using motor aides to provide occupational therapy. We feel that the process of hiring, training, delegating, reporting, and supervising denotes a clear connection between an occupational therapist and an occupational therapy aide despite a title change.

The Government Affairs Committee is concerned that non-licensed paraprofessionals, under the title of motor aides, are being supervised out-of-sight by occupational therapists. Under the Practice Act and Rules, occupational therapy aides must be directly supervised. An occupational therapist may only delegate treatment to an occupational therapy assistant in an indirect supervision scenario. Furthermore, the Practice Act and Rules specify the maximum number of assistants that can be supervised by an occupational therapist and the maximum number of therapy hours that can be delegated to an occupational therapy assistant. An occupational therapist may only supervise the equivalent of two full-time occupational therapy assistants. Based on recent survey and interview data (Chamberlain, 2021), some occupational therapy practitioners in Utah are delegating treatment interventions for up to 200 students across as many as fifteen different schools. This supervision relationship clearly exceeds the supervision requirements for even a licensed occupational therapy assistant.

The Committee is also concerned with the practice of occupational therapy becoming diluted or diminished to the point that any individual employed by a school could offer “tasks that are repetitive and routine,” and that this service could be construed as occupational therapy or similar to occupational therapy based on the supervision relationship. Hence, a need for licensure- to protect the health and safety of Utah’s school children from impotent routine and non-skilled interventions. Parents, educators, and other stakeholders have the right to expect that occupational therapy practitioners use standard and accepted therapy practices when working with Utah’s children. The use of motor aides disguised as unsupervised occupational therapy aides directly challenges many principles of the American Occupational Therapy Association’s Code of Ethics (AOTA, 2020a).

Solutions to Align Occupational Therapy Practice with State Law

The UOTA Government Affairs Committee recognizes that an abrupt change to service delivery is extremely challenging, and it will take time and funding to rectify the OT service delivery model to its intended pattern per the Practice Act and Rules. We urge occupational therapy practitioners working in school-based practice settings to educate their administrators on the historical use of motor aides and the legal requirements for providing occupational therapy and supervising occupational therapy personnel. Administrators are likely following the status quo of prior administrators and therapists who initially developed paraprofessionals into motor aides. We feel that current administrators and some practitioners are simply unaware of the occupational therapy domain and process as described in the Practice Act and Rules (AOTA, 2020b). We further recognize that schools will need time and funding to transition their workforce accordingly.

School administrators and educators may want to consider how an educator’s license may allow teachers to supervise their classroom staff in typical motor development instruction. For example, preschool teachers are trained to help young children with various types of developmental skills, including communication, motor, cognition, social-emotional, and adaptive skills. The UOTA Government Affairs Committee believes that educators could provide classwide and small group instruction for typical running, throwing, catching, grasping, pinching, and pencil use through their educator’s license and then delegate educational instruction accordingly to classroom aides as appropriate. This type of service delivery should not require an occupational therapy practitioner to hire, train, delegate, receive reports, or supervise any classroom aides in an ongoing or perpetual service-delivery relationship. This does not mean that an occupational therapy practitioner could not collaborate with educators or facilitate interdisciplinary collaboration or training. We fully support collaboration and training between professions. To be clear, we feel that educators may provide motor-development activities with their students, and when an educator delegates this task to a classroom aide, that aide is then working under the educator’s teaching license.

The UOTA Government Affairs Committee encourages practitioners to exercise their clinical judgment when deciding how to best meet their students’ occupational therapy needs (Chamberlain, 2021). Practitioners should be able to provide a combination of direct and indirect services across their caseloads (AOTA, 2017; Watt et al., 2021). For example, it would be inappropriate for an occupational therapist to only provide consultation for all students based on the school’s expectation that no direct services be provided.

By removing motor aides as an extension of occupational therapy services and allowing occupational therapy practitioners to exercise their clinical judgment, the Government Affairs Committee believes that occupational therapy practitioners will be better positioned to focus their time and efforts on students with more significant limitations that necessitate the unique skills of a licensed practitioner over that of a licensed educator (Anaby et al., 2019; Bonnard & Anaby, 2016). Occupational therapists may then legally delegate occupational therapy services to an occupational therapy assistant under the State Practice Act and Rules. This supervisory change would also assist practitioners in achieving reasonable caseloads that mirror national trends of no more than 50 students per full-time occupational therapist and 75 students per full-time occupational therapist and full-time occupational therapy assistant team (Chamberlain, 2021; Seruya & Garfinkel, 2018, 2020; Spencer et al., 2006).

At this time, the UOTA Government Affairs Committee does not intend to single-out practitioners who use motor aides and submit formal complaints to the Utah Department of Professional Licensing, the American Occupational Therapy Association, or the National Board for Certification in Occupational Therapy. We realize that practitioners are providing for their families and many are trying to move away from supervising motor aides entirely but are unable to do so despite their best efforts. We call upon school administrators and occupational therapy practitioners to work together to align their occupational therapy service delivery models with the Occupational Therapy Practice Act and Rules.

Sincerely,

The UOTA Government Affairs Committee

Approved by the UOTA Government Affairs Committee on February 6, 2024, and the UOTA Executive Board on February 13, 2024. Copyright 2024 by The Utah Occupational Therapy Association. All rights reserved.

References

American Occupational Therapy Association. (2017). Guidelines for occupational therapy services in early intervention and schools. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410010. https://doi.org/10.5014/ajot.2017.716S01

American Occupational Therapy Association. (2020a). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, Vol. 74(Supplement_3), 7413410005p1–7413410005p13. https://doi.org/10.5014/ajot.2020.74S3006

American Occupational Therapy Association. (2020b). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Anaby, D. R., Campbell, W. N., Missiuna, C., Shaw, S. R., Bennett, S., Khan, S., Tremblay, S., Kalubi-Lukusa, J., Camden, C., & GOLDs (Group for Optimizing Leadership and Delivering Services). (2019). Recommended practices to organize and deliver school-based services for children with disabilities: A scoping review. Child: Care, Health, and Development, 45(1), 15-27. https://doi.org/10.1111/cch.12621

Bonnard, M., & Anaby, D. (2016). Enabling participation of students through school-based occupational therapy services: Towards a broader scope of practice. British Journal of Occupational Therapy, 79(3), 188-192. https://doi.org/10.1177/0308022615612807

Chamberlain, T. (2021). The areas of occupation addressed by Utah’s school-based occupational therapy practitioners and the factors that influence school-based practice [Unpublished Capstone Project]. The University of Utah, Salt Lake City. https://utahotassociation.org/wp-content/uploads/2023/06/The-Areas-of-Occupation-Addressed-by-Utahs-OT-Practitioners.pdf

Education of the Handicapped Act of 1975, Pub. L. 94-142

Individuals With Disabilities Education Act of 1990, Pub. L. 101-476

Occupational Therapy Practice Act (2015). 58-42a, Utah Code. https://le.utah.gov/xcode/Title58/Chapter42a/58-42a.html

Occupational Therapy Practice Act Rule (2018). R156-42a, Utah Code. https://adminrules.utah.gov/public/rule/R156-42a/Current%20Rules

O*Net Online. (2024, January 2). Occupational therapists.        https://www.onetonline.org/link/summary/29-1122.00

Seruya, F. M., & Garfinkel, M. (2018). What is a reasonable caseload? Current trends in school-based practice. Poster Session, AOTA Conference, Salt Lake City, UT

Seruya, F. M., & Garfinkel, M. (2020). Caseload and workload: Current trends in school-based practice across the United States. American Journal of Occupational Therapy, 74, 7405205090. https://doi.org/10.5014/ajot.2020.039818

Spencer, K. C., Turkett, A., Vaughan, R., & Koenig, S. (2006). School-based practice patterns: A survey of occupational therapists in Colorado. American Journal of Occupational Therapy, 60, 81–91. https://doi.org/10.5014/ajot.60.1.81

Utah Department of Commerce: Division of Professional Licensing. (2024, January 2). Active licensee count. https://db.dopl.utah.gov/licensee_count.html

Watt, H., Richards, L. G., Woolley, H., Price, P., & Gray, S. (2021). Integrated services or pullout? Factors influencing school-based occupational therapy service delivery models. Journal of Occupational Therapy, Schools, & Early Intervention. https://doi.org/10.1080/19411243.2021.1934226