School-based OT practitioners are well-acquainted with the challenges of balancing direct student support (like 1-on-1 services) and indirect responsibilities (like showing the teacher how to use an accommodation).
Over the past decade or so, as caseloads have grown and administrative duties expanded, the 3:1 model has gained traction as an effective way to manage both.
In this article, I’ll share insights on what the 3:1 model entails, the research supporting it, and why it’s worth considering in your practice.
What is the 3:1 Model in school-based OT?
The 3:1 service delivery model structures school-based OT work (or any related service provider's work, really) into four-week cycles, designating three weeks for direct intervention with students and one week for indirect tasks.
This “indirect” week allows practitioners to handle essential responsibilities like teacher consultations, classroom observations to monitor goal progress, IEP meetings, and material preparation, all of which contribute to student success. The 3:1 model emphasizes a workload approach over a caseload focus, acknowledging the full scope of tasks that OTs manage in school settings (Seruya & Garfinkel, 2020).
Evidence and Support for the 3:1 Model
While there is research on practitioner and teacher beliefs regarding using a 3:1 model, there is no research (that I could find) on the student impact of using a 3:1 model.
As Seruya and Garfinkel (2020) analyze, practitioners strongly desire to transition from a caseload approach, which prioritizes direct service minutes, to a workload approach that recognizes indirect services’ critical value. While caseloads typically count the number of students treated directly, the workload approach encompasses all activities necessary for effective school-based practice, such as documentation, teacher collaboration, and program planning.
In the study, many school-based OTPs reported being overextended due to large caseloads (Average = 41-50), high direct service demands, and insufficient time for non-direct service tasks.
Practitioners also noted that balancing direct intervention with indirect responsibilities was crucial for providing quality support but cited barriers like limited administrative support, procedural knowledge, and time constraints in implementing workload-based models (Seruya & Garfinkel, 2020). Additionally, a 2019 survey indicated that OT practitioners' ability to collaborate with teachers and provide services in the natural environment is impeded by high caseloads and inadequate support (Schraeder, 2019).
The 3:1 model directly addresses these issues by dedicating structured time to indirect tasks, potentially reducing workload-related stress and enhancing practitioner job satisfaction.
Practical Benefits of the 3:1 Model for OT Practice
As you might imagine, having a week dedicated once a month to non-direct treatment may provide you time to:
Screen incoming kindergartners
Support teachers
Ensure the progress students are making in direct therapy is generalizing into the natural setting.
And more
However, I want to discuss three key ways the 3:1 model can impact OT practitioners and school communities.
Enhanced Collaboration and Integration:
With a designated indirect week, the 3:1 model could facilitate deeper collaboration with teachers and school staff. Teacher perspectives reveal a strong appreciation for OT collaboration in developing classroom strategies and enhancing student success when OT practitioners have time to consult and integrate their expertise into the classroom environment (Bradley, Hassett, Mazza, & Abraham, 2020). Practitioners can use this time for proactive consultation on goals and whole-classroom support, aligning with the model’s aim to support not just students on our caseload but EVERY student on campus.
Balanced Workload and Reduced Burnout:
High caseload numbers and intensive direct service schedules often lead to practitioner burnout. The 3:1 model’s indirect week allows OTs to manage administrative tasks within regular work hours, aligning with best practices that advocate for sustainable workload management.
This structure can alleviate the “always-on” demand of direct service and enhance job satisfaction among school-based practitioners (Seruya & Garfinkel, 2020). When an entire School uses a 3:1 model, IEPs and other meetings can be scheduled during the "Flex week" (as some call it) to avoid missed services.
Improved Service Delivery Quality:
Research indicates that when practitioners have time for indirect tasks, the quality of direct interventions improves. During the indirect week, OTs can fine-tune therapy plans, observe classroom environments, and refine strategies with educators, ultimately creating more cohesive and impactful support for students across their school day (Seruya & Garfinkel, 2020). This time away from direct therapy allows therapists to make data-driven decisions.
Looking to ditch the Caseload Model and move to a Workload Approach?
While at a rural school district with a caseload of over 100 kids, I knew something had to change. That's when I began to study where my time went and create a plan to get support.
After changing how our program operated and convincing my boss to hire another OT, I created this course to help OT practitioners and other providers do the same.
Current Research and Limitations
While the 3:1 model holds promise, research specific to its implementation in OT remains limited. Studies in related fields, like speech-language pathology, have shown positive effects, but OT-focused research is still emerging. Seruya and Garfinkel’s survey underscored the need for further exploration into how workload models impact student outcomes. This research gap suggests a strong need for advocacy, both for adopting the model and for studies to validate its effectiveness in diverse school environments.
Another consideration is that successful implementation may depend on administrative support and understanding the workload model's benefits. As a profession, we need to work toward sharing the 3:1 model's benefits in a way that administrators can relate to. We can also partner with our related service provider counterparts to do this together.
Please note that the 3:1 model is not a quick fix for larger staffing issues! It is not designed to help you “see more students in less time.”
Rather, it is a program to help you provide more comprehensive services to the students you already serve.
Implementing the 3:1 Model: Considerations and Best Practices
Implementing the 3:1 model effectively requires careful planning and advocacy. Here are key recommendations based on the research:
IEP Documentation Adjustments:
Adjusting IEPs to reflect both direct and indirect service needs helps parents and administrators understand that the indirect week is integral to quality service. By clearly outlining both components in IEP documentation, practitioners can facilitate broader acceptance of the 3:1 model (Seruya & Garfinkel, 2020).
I would typically do this by listing OT on the IEP service 3x a month or 30x a year. I would then add OT support to the IEP as a consult 1x a month. That consult would allow me to be flexible in supporting the student during the 4th week of each month.
Advocacy and Education:
Advocacy is crucial to gaining administrative buy-in. Many practitioners in Garfinkel and Seruya’s study highlighted a need for better advocacy resources, such as data on workload distribution and outcome tracking. Providing clear, evidence-based insights on the model’s benefits can build support among stakeholders, increasing the likelihood of successful implementation (Seruya & Garfinkel, 2020).
One tool you may consider using is the OT Schoolhouse Workload Calculator, which helps you identify your workload based on your current caseload.
Feedback and Adaptation:
Regular feedback from teachers, parents, and administrators is essential for ensuring that the model is meeting the community’s needs. Adaptations based on feedback can enhance the model’s effectiveness and foster a collaborative school culture where OT support is fully integrated.
Debra B., a colleague inside the OT Schoolhouse Collaborative, recently shared how she adapted the 3:1 model. Rather than reserve an entire week for indirect services, she would block off a particular day each week for flex services.
For example, each Friday would be reserved for evals, consults, and other tasks. This allowed her to still have five days a month for non-direct services without completely changing her routine for one week every month.
The Wrap-up
If you are considering using the 3:1 model in your practice, I say go for it!
The model offers a structured, balanced approach to school-based OT that supports practitioners, teachers, and students. Although additional research is needed to validate its impact, the evidence and practitioner feedback underscores the model’s potential to enhance service quality, reduce burnout, and foster effective collaboration. Plus, I also don't think I could show you research that says a 4x month direct service frequency is any better.
By addressing both direct and indirect needs, the 3:1 model can make school-based OT more impactful for both the students we serve directly and the students who don't need direct OT services.
Keep the conversation going!
Have you incorporated the 3:1 model into your practice? Are you considering it? Share your thoughts in the comments below.
References
American Occupational Therapy Association, American Physical Therapy Association, American Speech-Language-Hearing Association . (2014). Workload Approach: A Paradigm Shift for Positive Impact on Student Outcomes. Retrieved from https://pediatricapta.org/special-interest-groups/SB/pdfs/APTA-ASHA-AOTA-Joint-Doc-Workload-Approach-.pdf
Bradley, E., Hassett, E., Mazza, A., & Abraham, G. (2020). General Education Teachers’ Perspectives on Collaboration With OTs in the School Setting. The American Journal of Occupational Therapy, 74(4_Supplement_1), 7411505163p1-7411505163p1. https://doi.org/10.5014/ajot.2020.74s1-po5124
Garfinkel, M., & Seruya, F. (2019). Therapists’ perceptions of the 3:1 Service Delivery Model: A workload approach to school-based practice. Journal of Occupational Therapy, Schools, & Early Intervention, 11(3). https://doi.org/10.1080//19411243.2018.1455551
Gjellstad, M. (2023). Impact on Teacher Ratings & Perceptions of Efficacy of a 3:1 Model of OT Service Delivery. The American Journal of Occupational Therapy, 77(Supplement_2), 7711505150p1-7711505150p1. https://doi.org/10.5014/ajot.2023.77s2-po150
Hubert, W. (2011). A Survey Of Speech-Language Pathologists’ Attitudes Toward The 3:1 Service Delivery Model. https://doi.org/10.58809/jfiu5737
Schraeder, T. (2019). The 3:1 Model—One of Many Workload Solutions to Improve Students’ Success. ASHA Leader, 24(5), 36–37. https://doi.org/10.1044/leader.scm.24052019.36
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(5), 7405205090p1-7405205090p8. https://doi.org/10.5014/ajot.2020.039818