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TxSpot | School-Based Therapy > Blog > Posts > To Consult or Not to Consult: That is the Question.
November 10
To Consult or Not to Consult: That is the Question.

Direct vs Indirect services.jpg

 ​To Consult or Not to Consult: That is the Question.

Direct versus indirect services. Which should I do?

 by Janine Calmes, PT, MS

TxSpot has received many questions about direct services versus consultation services. First, it may be helpful to understand that neither the state of Texas nor the Individuals with Disabilities Act (IDEA) use the term, “consultation.”
IDEA regulations state that a student’s IEP must contain a statement of “special education and related services and supplementary aids and services…to be provided to the child, on behalf of the child, and…(through) program modifications and supports” (IDEA Regulations, Part B, Section 300.230, italics added).
The Texas Education Agency (TEA) uses the terms, “direct” and “indirect” to describe services. The TEA describes these two terms as follows:
Direct services usually refer to hands-on, face-to-face interactions between the related services professional and the student. These interactions can take place in a variety of settings, such as the classroom, gym, health office, resource room, counseling office, or playground. Typically, the related service professional analyzes student responses and uses specific techniques to develop or improve particular skills.
Indirect services may involve teaching, consulting with, and/or directly supervising other personnel (including paraprofessionals and parents) so that they can carry out therapeutically-appropriate activities. …. (For example), a physical therapist may serve as a consultant to a teacher and provide expertise to solve problems regarding a student's access to instruction.
Although the TEA defined direct and indirect services in their 2009 FAQ, the terms were not meant to be mutually exclusive since they describe methodologies that may both be needed to best meet the student’s ongoing needs. Defining and limiting the methodologic approach can result in unnecessary inflexibility that is unresponsive to student needs.
Instead of defining the treatment approach as either direct or indirect, the evidence supports a blended approach, sometimes called an integrated service model. This model stresses the importance of working in context: interventions are applied in the environment and to the task or activity where the student’s needs occur. Integrated services include both direct and indirect services embedded into the natural environment where the participation or performance issue occurs.
 Unfortunately, some IEP management software is designed using a drop-down menu that requires a forced choice of direct OR indirect. If so, there is sometimes a “work around” that will allow designation of a blended approach.
Further complicating the matter is Medicaid reimbursement for services. Medicaid only reimburses for direct service, that is, for service when the student is directly involved. For example, time spent consulting or training staff or developing or modifying the adaptive equipment is billable ONLY when the student actively takes part in the activity.
There are times when the therapist may be pressured to provide only direct services. However, IDEA indicates that the treatment approach is to be determined by the IEP committee based on individual student needs. It should not be influenced by software limitations, the student location (e.g. - school vs. homebound) or reimbursement rules (Medicaid). It must be recognized that both direct and indirect services are important in contributing to successful student outcomes and should be included as part of integrated IEP service time. 
Some school districts support the concept of “classroom support” in which generalized support or consultation is offered to the teacher and other classroom personnel to provide non-individualized strategies that apply to any student in the class. An example would be an occupational therapist who describes the strategy of using a short pencil or broken crayon to help students develop a tripod grasp for handwriting. This is a general strategy that would be applicable to any or all students in the class.  This type of generalized support does not need to be included as part of IEP service time.
So, to the question, “Direct versus indirect services: Which should I do?” the answer is…Both!