Therapy Assistants vs Support Workers: Delegation Done Right

In the middle of most OT caseloads lies an arrangement in a definitional fog. One person is a support worker doing the therapy program with a participant, and it's impossible to say exactly what it is that they are doing.

It could be a therapy assistant arrangement, delegated clinical work supervised by a therapist, or a support worker implementing strategies appropriate to the person's everyday life, or an unsupervised person delivering therapy without anyone being responsible for the supervision. The first two are good and worthwhile. The third is a danger to the participant, the worker and the OT whose name is on the plan; it is not necessarily a result of any bad intent, but rather fog. The OT is the only person in the arrangement who is in a position to know the lines' locations, and it is the OT's job to clear it.

The two roles, drawn properly

The therapy assistant implements part of the therapy programme which has been prescribed by the therapist: structured practice, activity programmes and certain protocols. The direction and the accountability: the OT decides what is delegated, is satisfied that the assistant is competent for it, and supervises to a level commensurate with the risk, while maintaining professional responsibility for the delegation. Within the NDIS, therapy assistant work is a component of the therapy service and is funded as such, and the professional standards that cover delegation are applicable to it.

The support worker provides day to day living supports and, within these, reinforces the techniques established by the OT in real day to day routines, sets up the environment designed by the OT, prompts, practises with and reports what they observe. The most distinguishing aspect is that the clinical material is not presented in the form of a program, but rather the person is being helped to live the way the therapy is teaching them to live. This is briefing (as explained in this series) and not delegation, and it is funded as a form of support.

The distinction isn't the activity, it's the structure that surrounds it. If the OT has delegated the session to a therapy assistant as part of the program, with supervision added, it is therapy assistant work. If a support worker is running the exercises without the OT's supervision because a printed sheet exists and everybody assumed it was appropriate, it is not. Who decided this would happen? Who looks after it being done right? Who is accountable for it?

Choosing the structure for the situation

Both structures are instruments, and it's a clinical decision. Delegation to a therapy assistant is appropriate where fidelity, progression, and clinical oversight is required: specific protocols, higher-risk activity, a dosage and technique sensitive phase of the program. Support worker reinforcement is best used when the goal is generalisation, taking what therapy has achieved and incorporating it into meals, mornings and community life, the home base of most OT goals. Some people are perfectly ok with having both hats on at various times in a plan, and others need both across a plan; a worker who holds delegated assistant and daily support roles at the same time must know which hat is on, and so do you.

The delegation disciplines, briefly

The disciplines are the ones you would normally apply to delegation, but done without shortcuts: what is delegated is documented, along with its limits; the supervision is real and actually takes place; and there is a list of triggers to stop and call you. If you brief rather than delegate, the equivalent discipline is the mirror image: the brief is the explicit statement of what the worker is not supposed to be doing, so that reinforcement doesn't quietly self-promote.

How this plays out in practice

Imagine that a participant with an acquired brain injury has funding for OT and daily support in his plan and his program encompasses a structured upper limb protocol and a general goal of kitchen independence. The cleared-fog version is a clear division of labour: the OT's protocol is delivered twice a week, delegated to and monitored by the therapy assistant, and the support team, after being briefed on one page, documents what they observe and reports it to the OT. There is no undesignated therapy, both funding streams are utilised as prescribed, and if there is a plateau in week 5, the program adjusts accordingly. This configuration is present on a thousand caseloads in fog mode. It's just one afternoon of structure.

Next steps

Review your supported participants and, for each therapy-adjacent activity occurring between sessions, ask one question of the arrangement: who made the decision, who checks, who answers? If there are not three answers to the activity, then it is the fog, and it is yours to clear.