If you’ve been lurking in OT or rehab-based Facebook groups (with a large U.S. audience) you will read many complaints regarding productivity and questions stating “Is this realistic? My director of rehab expects me to be 90% productive!”

When I graduated, my first job was based in Canada and I was lurking on these threads ALL THE TIME as a new grad. Not necessarily because I was ready to move to the states, but because imposter syndrome was kicking in and I had lost the sense of community I had during OT school. These productivity questions confused me so much. I had no idea what they meant. When I heard the word productivity, I immediately thought of the words leisure and self-care and treated it as a framework I could use to frame my OT interventions. 

...Cut to my first U.S. OT (skype) interview. The director of rehab mentioned that expected productivity is 85%. Of course, wanting to move to California as soon as possible, I stated: “that’s no problem at all.” Spoiler alert: I got the job!

So what does productivity mean when working in the U.S. as an Occupational Therapist? Essentially, it is the amount of billable time you spend with your patients. It doesn’t include time documenting, finding (or creating) relevant handouts, or time researching evidence-based practice for your OT interventions. Think of it as the 1:1 time you spend with your patients.

Why does productivity matter?

The U.S. healthcare system is very profit-driven. Employers are constantly looking to see how much money therapists are bringing into their company. Because of this, your caseload can be quite heavy at times as 1:1 time is highly encouraged vs time working on projects, etc. It is very typical to have two main focuses when working in the U.S. - 1:1 treatment time and documentation time. I always recommend asking “how much time will I have to document?” when preparing for any interview. While it took me a while to adjust to this model, I’m also hyper-aware that this profit-driven model allows me to make a comfortable wage in the U.S. 

Canada vs USA productivity standards

In Canada, you may be asked to record your statistics either monthly or weekly. While working at a rural Canadian hospital, I was told to manually keep track of how much time I was spending on patient care. This actually included things like phone calls, funding applications, discussion with vendors, and creating handouts AS WELL AS 1:1 time with patients. I would then enter my numbers in a document and submit it to corporate. There was never any set standard for how many patients I should be working with as my 1:1 time with patients never created any financial gain for the hospital. In fact, I had such a low caseload at times that I was often worried the hospital would view my services as unnecessary.

Long Term Acute Care Facilities

The productivity standards for long term acute care facilities/hospitals are dependent on the facility but since the company is usually for-profit, the company would like the employees to see the patient and bill for the time they see them. Generally, the company wants the therapists to achieve 80%+ productivity when treating patients. There is a difference in how funding is for therapy in this setting. The facility is given a certain amount of funding for the patient’s care, which incorporates products, equipment, the cost for the bed per day, and services provided by nursing and therapists. Therapy in this setting is considered a luxury for patients as the focus is to help patients be medically stable (e.g. wean off the ventilator). The billing that healthcare providers note down each day is not to get reimbursement from the insurance as the insurance already gave a pot of money to care for this patient, but the billing is to show the government/insurance company how much it actually costs to care for the patient and hopefully it will maintain or increase the pot of money for next year. In general, this setting requires us to cut down on the cost/visits of therapy to usually 3 times a week to maximize the gains from therapy and the profits from the expenses related to therapy. 

Ethical billing

Many new grads will encounter facilities with unsustainable productivity standards. Many therapists feel pressure to bill more than actual time spent with their patients. Fortunately, this has improved somewhat since the billing model for skilled nursing facilities has changed since October 2019 and standards are a little less crazy. However, it is important to be aware of how you're spending your time at work so that you have a defense if you are ever questioned about your productivity. I’ve worked in many places where myself and my coworkers productivity has been lower than the “expected” amount and yet we still continued to work. If you have an understanding boss, they will realize that much of your time is spent doing valuable tasks even if they aren’t billable. Have confidence in the value of what you provide, and be wary of facilities that ask you to bill an unethical amount.

For more information on what it’s like working as an OT in the U.S., follow us on Instagram @two.canadian.ots :)

One of the biggest differences that we found working as an OT in the two countries is that the US has many skilled nursing facilities (SNF) for which Canada does not have an equivalent. Canada has inpatient rehabilitation in hospitals, where clients receive intensive therapies to regain function to return home with community health services, as needed. The US has inpatient rehabilitation and home health (aka community health) rehab services but they also have SNFs that allow patients more time to regain their abilities through therapies, before safely returning home. 

A SNF is a multidisciplinary setting, where patients receive short term skilled services from occupational therapy, physical therapy, speech therapy, and nursing. The patients have a variety of conditions, illnesses, disabilities, but are stable enough to be discharged from the hospital; however, they are still debilitated that returning home is not a safe option. The various skilled services are to help the patients regain their abilities and function required to return home, or if that is not possible, to find alternative options for safe discharge (e.g. assisted living facilities, group homes, etc.). Often SNFs have a section of the facility where they attend to long-term care residents, who are usually covered by Medicaid, and require significant care, and do not receive skilled therapy. SNFs are commonly called nursing homes for that reason. 

If you are curious about how and why the US decided to establish SNFs, the difference between the two country’s reimbursement systems played an important factor- which you can read more about in this journal article

What is occupational therapy like in a SNF?

Patients typically receive OT services for 5-6 times per week for days to weeks, up to 100 days, depending on the patient's insurance and the patient's progress with skilled services. OT sessions can range from 20 minutes to over an hour-long depending on the patient's insurance and activity tolerance with therapy. 

What is OT’s role?

Occupational therapists complete an assessment of the patient's baseline abilities and impairments affecting ADLs, and then create and implement a plan of care to help the patient achieve their goals that are required to be discharged from the facility (with exceptions for patients who leave against medical advice). Interventions can focus on educating patients and their caregivers, exercises, equipment or assistive device recommendations, orthotic recommendations, use of physical agent modalities, and re-training of ADLs, transfers, and mobility. Insurances reimburse for OT services and therefore therapists have to complete detailed documentation to justify the services provided and any continuation for them. 

SNFs continue to change as funding models change. Adapting to the pandemic and covid regulations set in place by each state has also changed how SNFs operate. Email us at support@two-canadian-ots.com if you want us to share our experience with working in SNFs!

(The above table is a summary of the characteristics of the NOTCE and NBCOT)

Whether or not you want to work in Canada or the US as an occupational therapist, you will first need to pass a unique national OT certification exam. I know! Do we have to? 

Most Canadian OTs will be familiar with the National Occupational Therapy Certification Examination (NOTCE) and the requirements to pass the exam. To summarize, the NOTCE is a 200 question, case study-based, multiple-choice exam, completed by an answer sheet filled-in by pencil. For examples of the exam practice questions, please refer to CAOT’s NOTCE Study Guide and Practice Exam. The exam is completed at specific times of the year and at specific exam sites. Examinees will need 70% to pass the exam. (NOTCE, 2015)

In order to work in the US, any OT will need to pass the National Board for Certification in Occupational Therapy (NBCOT) exam. The NBCOT exam is completed at an exam center, on the computer and under strict supervision. The exam is 4 hours long with the exam appointment allotted for 5 hours and 15 minutes and consists of 3 clinical simulation test items and 170 four- and three-option single response multiple-choice items (NBCOT, 2020). 

References:

National Occupational Therapy Certification Examination (NOTCE)  (2015). Resource Manual. Retrieved from http://caot.in1touch.org/uploaded/web/exam/Resource%20Manual%20NOTCE%20May%202017.pdf

NBCOT (2020). Certification Exam Handbook. Retrieved from https://www.nbcot.org/-/media/NBCOT/PDFs/Cert_Exam_Handbook.ashx?la=en

Karen’s experience: 

I wrote the NOTCE in November 2015. From what I remembered, the NOTCE was difficult to study for, mainly because I didn’t know exactly what to study. All the practice guides and exams were case study or scenario-based and we had to choose the best answer out of the ones provided. I am sure we can argue our clinical reasoning for some of our choices. I did come out of that exam thinking, “I don’t know if I passed,” but I did! Yay!! After writing and passing the NOTCE, I knew I wanted to work in the US, so I did not register for any Canadian OT regulatory body and/or CAOT memberships or apply for any jobs in any of the provinces in Canada. Though I knew I did not want to work as an OT in Canada at the time, I might want to eventually when I return to Canada, so it was best to write the NOTCE, while what I learned from OT school was still fresh in my mind. It was also better for me to take on the NBCOT while I was still in my studying mode. I chose to spend one month focusing on studying for the NBCOT, while doing more volunteer work and spending time with family and friends, before writing the NBCOT exam in early 2016. The NBCOT was more difficult to study for and to write but in the process of studying, I felt I learned more technical/medical OT knowledge that was not always covered in the OT program I was educated in. It definitely helped prepare me better to work in the US, where they are more medically-based, and to be a better occupational therapist! 

Kristina’s experience: 

I felt it was very challenging to study for the NOTCE. I had a study group of 2 friends and we purchased study material from COTO. We spent many hours at the library discussing clinical scenarios and how to properly answer a question. After writing it, I had NO IDEA if I passed. This is very common. But I did! I worked in Canada as an OT for 7 months before taking the NBCOT. I really wanted to move to the states so I put a lot of pressure on myself to study for 3 consecutive months. I used the resources we list in our study guide. I felt more at ease taking the NBCOT because I knew it was offered several times throughout the year. I thought the answers for the NBCOT were more clear and exact vs the NOTCE. The clinical simulation questions were kind of odd to answer and I was trying to answer questions as quickly as possible so I wouldn’t run out of time. I also think I may have felt the NBCOT was easier because I had been practicing for a few months prior to taking the exam. Looking back I feel the NOTCE was easier to study for (remember...they always want the most client centered answer unless it causes harm) but harder to write. The NBCOT was easier to write but harder to study for- probably because I didn’t have a study group!

For more details the resources we used to pass the NBCOT exam, please go to the “resource” link at the top of the website or this link for our free NEW GRAD SURVIVAL KIT. 

YOU CAN DO THIS!!

Karen and Kristina

Are you wondering how much you can ACTUALLY make as a traveling therapist? Do your eyes light up with images of FREE HOUSING, LOW TAXES, LICENSE REIMBURSEMENTS and getting paid to move around the US and travel?

If the above interests you, check out our other blog posts addressing the travel therapy world and learn how you can experience working in the U.S. as an Occupational Therapist. 

If it seems too good to be true, it is. Our plan is to take you on a deep dive of what you can expect to ACTUALLY make (i.e., take home money in your pocket) and things to negotiate for!

Why we should talk about our pay with other therapists

You’ve worked hard, graduated from OT school, and are now ready to begin your mission of helping people lead better lives!! We all have our own reasons for becoming OTs, but it is important to remember that we deserve to be fairly financially compensated for our time and the unique skills we have developed. Don’t be afraid to ask around and know what others in your field are making so that you can feel confident when you discuss pay with potential employers. 

What does a travel pay packet look like? 

You can make up to $1600-2000 USD/week take home pay (depending on the setting and location you work in). Feel free to contact us at support@two-canadian-ots.com if you would like to see a sample contract. 

Other things to negotiate for in your contract

Do you have any upcoming trips? Any days you need off? Be sure to specify them when you talk to your recruiter!

Have you been asked to extend your contract? Great! Time to think about other things you can negotiate for. Some therapists ask for an extension bonus, a higher pay rate, or my personal favourite for Canadians: “please reimburse my trip home so I can renew my TN visa.”

Things to look out for

$1600-2000 USD/week TAKE HOME sounds amazing! Especially when you compare this to the standard rate for O.T.s in Canada. 

It is, but when you’re a travel therapist that qualifies for tax-free stipends, you should be

-paying duplicate rent (e.g. in Canada and in the US state you are working in)

-visiting your tax home every so often/defined number of days

-considering $ required in between contracts/time off

And consider the following questions:

-What are you doing for U.S. health insurance in between contracts?

-What state are you licensed in/planning to be licensed in (waiting period, upfront fees, etc.)

-What does the housing market look like where you plan to work/are offered a job in

-What are you going to do for U.S. healthcare coverage in between contracts? Similarly, if you visit Canada during your time off, do you have travel medical insurance?

There are definite financial benefits to pursuing travel therapy, but remember to look at the full picture and not just the shiny “make 1600-2000/week take-home” phrase. We want you to find a situation that works best for you!

Questions? Email us: support@two-canadian-ots.com

If you want some guidance and advice, consider our online course OT Passport to USA.

Disclaimer: WE ARE NOT TAX SPECIALISTS. Talk to an accountant about this as many therapists have accidentally broken the rules. Please contact the members of Travel Tax if you have tax-specific questions.

Travel therapy sounds interesting but what should you consider when deciding to embark on this adventure? We’ve figured out some pros and cons of travel therapy based on our experience.

Pros: 

• The personal and professional growth from living and working in different settings, and interacting with a variety of traveling or non-traveling healthcare professionals. 

• Travel and live in a state/city/location that you want to

• Pay/benefit packages for travelers are better than full-time permanent positions as you can be given meal, mileage and accommodation stipends that are non-taxable; reimbursement for state licenses, some reimbursement for the flight to the state you’ll be working in, and occasionally reimbursement for continued education depending on your contract. 

• A portion of income through travel therapy is tax-free (*as long as you meet certain criteria. Please contact us at support@two-canadian-ots.com for further questions regarding the criteria!)

• The flexibility of when you want to take a vacation or when you want to stop working in the US- Once your 13-week contract is over, you have no more obligations to that recruiting company. You can go back to Canada to work or choose another recruiting company to work for. 

• Typically I would take a 2-3 week vacation in between travel assignments or extension of contracts. Of course, these vacations are generally unpaid, but depending on the recruiter company, they might have it that you can accumulate Paid Time Off (PTOs) (e.g. Delta Healthcare Providers’ Rewards Day). Also, depending on your company or recruiter, they might reimburse your flights as a reward for loyalty or hard work that was done. Some recruiter companies even have an annual vacation for all their employees (if they have worked for the company for at least a year).

• I have heard of therapists that work back to back assignments for 10 months and then take a 2-month vacation since the higher income earned during the 10 months can cover the 2 months off. 

• There are more work opportunities as there are higher demands for therapists than in Canada

• Work in an OT setting you are interested in but might be harder to experience in Canada (e.g., acute care or rehab hospitals, outpatient clinics, etc.). Ever curious about which OT setting in the USA you would be most suitable to work in? Download our quiz along with other resources that will be helpful in starting your journey to working in the US as an OT! 

• Challenge yourself in being more independent, adaptable and getting out of your comfort zone.

• Meeting new people and building good work relationships and/or friendships

• Better pay working in the US! As of 2023, on average, new grads in Canada earned $80,895 CAD per year vs. an average of $77,115 USD per year for new grads in the US (take into conversion rate of $1 USD to $1.34 CAD = $103,529.20 CAD/year). Those stats are more for permanent OT jobs. The pay packages for travel therapy can be even more lucrative. 

Cons:

• Applying for state licenses: Each state has its own specific requirements (e.g., transcripts, fingerprints, letters of endorsements from other states you have licenses with, continued education units (CEU) requirements). The process of applying for the state license(s) can be complex and have long wait times, particularly with California which can take up to 6 months for the OT board to approve the license. 

• The intensity of travel assignments: The facility hires travelers because they can not hire a full-time therapist at that time and so they often expect the traveler to come-in and do everything a full-time employee can do within the first few days of the assignment. 

• The steep learning curve with learning the American Healthcare System, documentation systems and the facility’s procedures and policies. 

• Emphasis on productivity and “meeting the minutes” with face-to-face patient care in SNFs and inpatient rehab.

• Early cancellations of travel contract- I was fortunate enough not to have experienced this, but supposedly 75% of traveling therapists have or will experience an early cancellation of their typical 13-week job assignment. This is due to the facility having a low census or the facility has found a full-time permanent OT to fill the position.

• Adapting to a new living and working environment after the end of a travel assignment/extension

• Depending on the location you want to work in, the cost of living might equal to income (e.g. Hawaii) while you can earn more money in certain states and have a lower cost of living (e.g. Nevada) 

If you have questions about travel therapy or working in the US, consider our online course (OT Passport to USA) that will provide step-by-step guidance on how to transition to working in the US as a Canadian OT. 

Check out our resource page and grab some OT freebies of your choice! 

Visit our www.two-canadian-OTs.com website and subscribe for notifications and freebies on how to work in the US as a Canadian occupational therapist

Do you love traveling and exploring different locations? Do you love working as an occupational therapist that you worked so hard to become? Travel therapy fuses those two passions together allowing you to grow as a clinician and enjoy the pleasures of traveling!

Travel therapy has been popularized in the United States to help supply the demands of facilities in different states that are in need of occupational, physical and speech therapists. There is international travel therapy (although more geared to physical therapy- please see this blog for details); however, we will focus on travel therapy in the US as it appeals to Occupational Therapists from and/or educated from the Great White North. 

Travel therapy assignments are short term contracts commonly mediated through a travel therapy recruiting agency to work at facilities/organizations in different occupational therapy settings such as skilled nursing facilities, acute rehab or long term care hospitals, home health, outpatient rehab clinics for adults or pediatrics, schools (pediatrics), palliative and hospice care, etc. The contracts are typically 13 weeks long but it depends on the assignment and can be extended depending on the need of the facility. 

There are hundreds of travel therapy recruiting agencies due to the high needs of therapists in the US. Many of these agencies have started recruiting Canadian therapists to help supply demands. There are few agencies that have experience with helping Canadians transition to working in the US due to laws, policies, and requirements. There are also therapists that overcome the need to use a third-party recruiting agency and instead were employed by US facilities directly. It is important to find a company that is FAMILIAR with the hiring process for Canadians as it will make your transition to the U.S. a lot smoother. We both have experience with Delta Healthcare Providers, Jackson Therapy Partners, and Core Medical Group (travel staffing agencies) that are familiar with the visa required for Canadians- and we are happy to provide you with a recruiter referral if you reach out to us at support@two-canadian-ots.com.

For more information on travel therapy, please visit this article by Core Medical Group, a travel healthcare agency that Kristina has secured travel contracts with in the past!

Remember to save this page as our next piece will be focused on the pros and cons of travel therapy! 

If you would like to learn more about how to be a travel therapist or work in the US as an OT, please check out our comprehensive online course: OT Passport to USA.

Coming to the US to work as an OT can stir up all sorts of questions…

Will I be safe there? How does health insurance work? Can I use my Canadian drivers license? Is OT reflected the same way as it is in Canada? Will I know what I’m doing? Will I have a higher chance of getting sued?

Disclaimer: most of the above questions are NOT answered in this post.

Honestly, I knew my plan was to move to California no matter what, so I didn’t spend too much time pondering over these questions BEFORE my move. However, once I FINALLY received my California OT license (yay!!)- the same day I went to go look at some VERY tall trees in Muir Woods National Monument, I had to actually face the music. Here are some observations I’ve collected during my time here.

Safety: I’ve been working in California since 2016 and overall, I have felt quite safe. This is a good thing, considering some of the towns I completed travel contracts in had a reputation for being very unsafe (Bakersfield, Inglewood, Lancaster...you name it) but I fortunately have not experienced any crime within my travels. HOWEVER, one clear difference can be demonstrated by this example: my facility recently had an “active shooter drill” so we could prepare for what to do in such a horrific event. In my manager’s words: “it’s not a matter of if, it’s unfortunately a matter of when, and we need to be prepared.” It’s not a fun thought, and it was never on my mind when working in a rural Canadian Hospital.

Pay: OTs are unionized in British Columbia, and for this reason, everyone gets the same pay (unless you work in private practice) depending on their amount of experience and there is little room for growth. In the U.S., the pay is MUCH higher since healthcare is privatized and operates as a business. To give you an idea, I transitioned from my B.C. based rural hospital job to a permanent job in Northern California within 7 months of graduating and received the equivalent of a $10.60 cad/ hour pay raise. Say what? Take that student loans!!

Billing for Services: Unless you are in private practice in Canada, you just record your lovely OT S.O.A.P notes and continue on with your merry day. In the U.S., you write your notes, and THEN you decide what billing code to place them under. I know, I was confused too, but it really is just a matter of placing “15”(min) under words like ther act, ther ex, neuro-re-ed, and ADL training. Some facilities may pressure you into billing more than necessary, especially if you are a new grad, so it is important to stand your ground and have confidence in billing the APPROPRIATE amount of time. For more information of how billing for services are conducted in the US, please read this blog post

A Higher Caseload: This may be biased, considering I worked in a VERY rural Canadian hospital, but when I moved to the states, my caseload increased DRASTICALLY. You will gain more experience with hands on treatment sessions, but the high caseload (and the documentation that comes along with it) can take some getting used to.

Opportunity for career growth: Since the patient population is simply much larger, that comes with more options of settings to work in (e.g., outpatient rehab). If you have a dream setting, chances are you can find it in the states whereas in Canada those positions may be highly competitive. Hi y’all, Karen here! A few years ago, I had never experienced working in the acute care setting and had very minimal experience in an acute rehab unit setting from my OT program, but I was still hired for a travel assignment in a hospital in Texas. At that hospital, I received very good training and mentorship to work mainly in the long term acute care unit, but I often helped out in Intensive Care Units (ICU), Progressive Care Units (PCU), and in the acute rehab unit. What a deal! One assignment but experiences in 3-4 OT settings!! Because of that travel assignment and the one prior, I am now able to work in different OT settings in Viva Las Vegas!

More treatment focused (hands on-yay!) vs resources/community-focused: In Canada, I did spend time treating patients, but I also spent a LOT of time talking about patients, writing about patients, developing community resources, tracking down vendors, etc.  Since the U.S. Healthcare System is profit-driven, you will be spending a lot of billable (i.e. 1:1 time) hours WITH your patients. This allows for more time dedicated to actual treatment time! Roles such as discharge planning and writing funding applications for durable medical equipment are usually taken on by the case manager or social worker. 

Less emphasis on mental health: This is my LEAST favourite difference when it comes to working in U.S. Mental Health Therapist positions DO exist for OTs in the states but they are few and far between. If you are a student or a recent grad from a university in Ontario, Canada, you may be familiar with OTs who also practice psychotherapy (more info here), which is not currently an option for OTs in the USA.


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