Home Health Therapy in 1990s Contra Costa County

When looking for online guidance about how to explore the field of Occupational Therapy, I found 2 book recommendations. The first is the Ora Ruggles book [Healing Heart], which I am using to get a sense of what OT was like in the early 20th century. The second is 'Tree Barking' by Nesta Rovina, which details what it was like to do Occupational Therapy as a home health therapist in the East Bay Area in the mid 1990s.

The rest of this post is about ‘Tree Barking.’


First of all, this title, 'Tree barking.' It's mysterious. Is barking a verb? Like a dog barks? 'Barking up the wrong tree?' I wondered what, if anything, 'tree barking' had to do with Occupational Therapy.

In the first chapter Ms. Rovina explains that 'tree barking' is chronic stasis dermatitis, a condition where swelling of the legs makes them look like tree trunks covered in bark. This is the medical condition suffered by Mae, the first patient of many that Ms. Rovina portrays in her book.

But 'tree-barking' is also the metaphor Ms. Rovina deploys to convey something about the larger story arc of her own life. In short, she found herself, after being set somewhat adrift in her early life, becoming rooted like a tree [and hardened, like bark] in a specific time and place through a specific kind of work [occupational therapy].

At the same time, the title 'tree barking' doesn't even hint at some of the more fierce and acerbic observations and perspectives that Ms. Rovina has as a ground-level witness to the functionality [and dysfunctionality] of health care systems in 1990s America.

I was hired in 1992 into a place of work declared by my supervisor to be as secure as that of a chrysalis in the dark comfort of its self-made cocoon.

Within the next few months, my position as a therapist in home health for the county became extremely insecure. When I first began, the county was flush with money and was, apparently, absolutely dedicated to the health, safety, and well-being of its citizens. When the county, along with the rest of California and, indeed, America, began its plummet deep down the tunnel of not-enough-money and slid into a recession, budget cuts began. Essential services were cut or downsized, along with mental health facilities, libraries, drug and alcohol rehabilitation programs, fire departments, and after-school activities--in short, the services which hold together the fragile veneer of civilization."

“The fragile veneer of civilization.” That would have been quite a different title for a book about OT.

As someone looking into the pros and cons of acquiring the professional identity of 'Occupational Therapist,' I learned a lot from Ms. Rovina about the inner workings of the system.


Some of my key takes:

  1. Upon starting her job in 1992: "I spent a week learning the most important aspect of home health in america: paperwork... Completing paperwork, it seemed, was far more important than time spent with patients. All of this was to satisfy the insurance companies whom we billed for our services."

  2. "Working in home health is not the same as working in a rehabilitation center or in a hospital with say, stroke patients, or people suffering from traumatic brain injury. In these settings the treatment is routine and predictable. In the home environment every situation is new and challenging, and there were many times I felt I was simply incapable of doing good work."

  3. "Everyone has a story. No one is just a string of illnesses. I do my best to listen to them and to put myself in their place so that I can better understand what they must be feeling and what they truly need. So many just need someone to listen to them."


"The first changes in the health-care system began in the early 1990s, in hospitals. Health insurance companies pay a certain amount per patient, based on "diagnostic related groups." For example, the total amount allotted to a hospital for the care of a woman diagnosed with breast cancer might be forty thousand dollars, irrespective of her age, other related health problems, type of cancer, and so on. Therefore the hospital, in order to make a profit, is inclined not to order too many tests, and only to provide the minimum amount of care: if they exceed the limit, they lose money. By not making use of all available treatments and therapies, the hospital profits.

Because hospital stays became shorter, people were sent home who still needed skilled care, and so home health agencies began seeing a great number of people who were still very ill. It can be beneficial for patients to be in their home environments, but patients now needed more skilled nursing and therapist visits than before. It was the insurance companies who dictated the amount of care patients received--not doctors or nurses, who understood the patients and the nature of their diseases, but cost-saving accountants. Apparently, insurance companies do not understand the laws of cause and effect. Their next step was to investigate the possibilities of defraying Medicare and MediCal costs for home health.


AND, on the other hand, she still finds meaning through the work she does:

Despite all I have seen, and the manner in which I have been treated, it still seems to me that anything I can do to alleviate suffering, either my own or that of others, is the only thing worth living for."

"To contribute to others is my reason for being here. Because of this work, I no longer feel like a stranger in a strange land, separate from all that surrounds me."

Sounds like a grounded take. After reading her book, I admire her travails as an Occupational Therapist and I can see myself in a similar role.