School-Based OT vs. Outpatient Peds: Pros and Cons

If you’re a pediatric OT, you may be wondering which setting is a better fit for you: school-based OT vs outpatient peds. While these settings are similar, they’re also different enough that most therapists who’ve done both have a clear preference. Curious which one is right for you? Consider the following positives and negatives of various aspects for each setting. 

School-Based OT vs. Outpatient Peds Schedule

It’s hard to beat a job where you can realistically be off work by 4 pm every day! And this is exactly what you’ll find with school-based OT. Plus, having weekends, holiday breaks, and summers off doesn’t hurt either. This is pretty much the best OT setting you can work in if you have kids of your own. But even if you don’t, the consistency and extensive time off is really nice for planning vacations. Though, one thing that you should note is that there is often pressure to take work home and do it in the evenings/weekends as a school-based OT. Not every district will be like this, and you don’t have to succumb to this pressure, but it can be a challenge. 

Outpatient peds, on the other hand, has more variety in schedules. When I worked in this setting I was eventually able to work 8:30 – 5ish hours. However, I worked til 6 or 7 pm for a long time before I was able to build a daytime schedule. Depending on the needs of the specific clinic you’re working at, it may not be possible to refrain from working in the late afternoons and evenings. Some outpatient clinics are even open on weekends. For some people, this increased flexibility may be nice, but for many, the hours you end up working aren’t ideal.

For me, school-based OT wins in this category. Even with the pressure to work off the clock, I still think the schedule is unbeatable. 

School-Based OT vs. Outpatient Peds Pay

While pay for both settings will vary wildly based on location, there are some things you can count on. School pay tends to be very transparent because public schools are required to post salaries by law. This makes it much easier to figure out if you’re getting paid fairly. Some school districts also pay really well. On the west coast, it’s not abnormal for school-based OTs to be making $100,000+ a year. But on the contrary, some schools in more rural areas don’t even pay half of that. 

One other nice thing about public school district pay is that you will move up on the salary schedule every year of experience you gain – meaning your pay is guaranteed to increase regularly. This often comes with regular cost-of-living raises as well. Also, school districts are one of the only settings where having a doctorate degree can actually net you more pay as an OT. Not every district will offer this, but it’s worth checking into.

Something else to consider with school pay is that most schools only pay for the 9-10 months of the year. This is important to keep in mind when comparing offers. For example, you’d be getting paid more per hour at a school district offering $75,000 for 10 months of work vs an outpatient peds clinic offering $84,000. But it’s also important to keep in mind when planning and budgeting – many school-based OTs don’t receive a paycheck over the summer at all.

Outpatient peds salaries can be all over the board as well. It’s definitely possible to make similar amounts as to schools, and potentially more given your area. However, the pay is typically much less transparent, and raises aren’t usually guaranteed. Another rather insidious style of pay that you’ll find in outpatient peds is being paid by the “billable hour.” This means that you only get paid while treating, and not while documenting, calling doctors, getting no-showed, etc. In theory, billable hour pay should be much higher than a typical hourly rate to offset this. In practice, it often means you are underpaid and can’t rely on a consistent amount of income. You will find some school-based OT contract positions that are set up this way as well, but it’s much more common in outpatient peds. 

Since pay is so dependent on your region, this is one where you’ll have to compare specific salaries to see which setting comes out ahead. But for me, school-based OT wins based on the transparency and guaranteed raises alone.

Union Membership

A union can be a great thing, and schools are one of the only OT settings where we can easily join one. In states where unions are empowered to serve their members, school district unions have protected the rights and benefits of employees over and over again. Unions fight for things like increased pay, better contracts, and work/life balance of their members. They also provide mediation and support to you if you ever find yourself in a sticky situation at work, such as being targeted by admin or being put in an unethical situation. When they work well, they are a blessing to have.

Unfortunately, some states and areas heavily restrict the power of unions, so your school district’s union may not be able to offer you the same level of support as others. Also, sometimes OTs aren’t allowed to join the union, or they find themselves in a union that doesn’t fully understand their needs if it’s more targeted at teachers and/or paraprofessionals.

Outpatient peds clinics, on the other hand, don’t tend to have unions. While unions are becoming more popular and it’s your legal right as an employee to unionize, in practice this is a lot harder than it sounds. Many employers don’t want their employees to have a union and will employ subtle or overt tactics to discourage this from happening. 

If union membership is important to you, the choice will probably be pretty easy: pick a school district. 

Student Loan Debt

Because public schools are nonprofit, working in one may qualify you for Public Service Loan Forgiveness (PSLF). Be sure to read up on the details of this program to see if it makes sense for your personal situation. I have also heard of school-based OTs qualifying for teacher loan forgiveness programs. One thing to be careful about here is that currently, you must work directly for the nonprofit/government organization. So, if you’re working for a school district through a private, for-profit contract agency, you likely wouldn’t be eligible. 

Outpatient peds clinics typically aren’t nonprofits, though there are exceptions to this rule. But unless you find one that is, you wouldn’t be eligible for either loan forgiveness program. 

If loan forgiveness is the best financial strategy for you, school-based OT should definitely be a setting you consider. 

school-based OT vs outpatient peds

Working with Parents and Families

In the school setting, you’ll work closely with teachers and paraprofessionals. But overall, the family contact is pretty low. You may only see/talk to your student’s family once a year at their IEP meeting, if even that. While this has shifted a little bit in a post-teletherapy world, school districts still aren’t the best setting if you want to be in constant contact with parents.

Outpatient peds OT is potentially the best setting for working with families, especially if you’re working with younger kids. It can be so rewarding to be a trusted member of that family’s team. You can build incredibly close relationships. I still have families that I’m in touch with today that I used to work with in outpatient peds. And understanding family dynamics is so important to actually helping children.

If you’re looking to work closely with parents and families, outpatient peds OT is the clear winner.

School-Based OT vs. Outpatient Peds Carryover

Oh, carryover. We all know it’s one of the most important aspects in meeting therapy goals, but it’s also one of the most elusive. Luckily, in the school setting, carryover is somewhat naturally built in. You know your student will be at school on a regular basis, so you can set things up in the classroom and work with teachers to ensure your student is practicing skills outside of session. It’s not always perfect, but the school setting is absolutely where I’ve gotten the most consistent carryover. 

Outpatient peds is more of a crapshoot. Yes, you’re working closely with families and often have great rapport with them. Still, even the most well-intentioned families often have trouble fitting in activities for carryover. For some parents, it’s all they can do to get their kid to the weekly therapy session, and getting them to incorporate strategies beyond that is a big ask. This can be very frustrating, but the reality is that you have to meet people where they’re at. Yes, your patient may not meet their goals as quickly. But your families are likely doing the best they can with the resources they have. 

If seeing carryover and quicker progress is important to you, school-based OT is definitely the easier setting to find this. 

Natural Environment

One of the most integral parts of being an OT is considering the natural environment. Luckily, school-based OT has this in droves. A classroom, a gymnasium, or a playground are all some of the most natural environments a kid can be in. As OTs, we know the importance of working in the natural environment, and schools make it easy to do this.

An outpatient peds clinic is somewhat contrived by definition. Yes, you have the potential for so many cool pieces of equipment and activities. But how will your patient meet their sensory needs when they go back home and don’t have access to your collection of swings? While you can still do good work in a space like this, I find it much easier to build skills in the environment where they are actually needed.

If working in the natural environment is important to you, you’ll probably enjoy school-based OT.

School-Based OT vs. Outpatient Peds Paperwork and Documentation 

It’s everyone’s favorite OT task: documentation. And I won’t lie, the documentation in the school setting can be rough. There are many different pieces of documentation you’re responsible for, and they have legal implications if you don’t fill them out on time or correctly. It does get easier with practice, but it can still be a lot, especially if your caseload is too high.

Outpatient can have a fair amount of documentation as well, but overall, the volume was much less for me compared to schools. And while dealing with insurance companies is no fun, there aren’t as many legal implications if you mess up documentation in this setting.

If you hate documentation and paperwork, you may be better off in outpatient peds. 

school-based OT vs outpatient peds

School-Based OT vs. Outpatient Peds Scope and Variety of Cases

The biggest thing to know about school-based OT is that it must focus on deficits that have an educational impact. In a medical model, occupational therapy services can address any deficit area for the sake of remediating a deficit (as long as funding sources allow). But in a school model, OT services only address deficit areas that can be related back to the student’s education. The purpose of school-based OT is to help a child benefit from their educational program. So, in some ways, your scope of practice can feel more limited in this setting. 

In outpatient peds, you can address any deficit that impacts a child’s functioning in any part of their life, not just their role as a student. This can feel more freeing and holistic. Plus, outpatient OT allows more specialization. If you decide you love working with kids with CP, you can decide to only work with these kinds of patients. Or if you decide that younger kids aren’t your jam, you can focus on older students. You have a lot more control over the types of kids you work with and families you serve, whereas in school-based you don’t often have a choice to not work with a student if they need OT.

If you’re looking for more flexibility and control over your caseload, outpatient peds wins for sure. 

Ultimately, school-based OT and outpatient peds each have their own pros and cons. They are similar enough settings that most pediatric therapists will probably be pretty happy in either. But, it’s good to consider if one is a better fit for you. If you have questions, I’d love to have you join my Facebook group where I share school-based OT resources.

Looking to take your learning even further? My course, The Dynamic School OT, is the perfect primer for therapists new to the school system. If you do decide to work in the schools, I would love to have you in the course! 

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