Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

Importance: Practitioners need to be familiar with, and involved in, managing quality-related adverse events in postacute care. Objective: To determine interventions within the scope of occupational therapy that address preventable adverse events in adult postacute inpatient and home health settings. Data Sources: Articles published from January 1995 through 2019 identified through searches of MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases. Study Selection and Data Collection: Articles were collected, evaluated, and analyzed by two independent reviewers. They were assessed and synthesized with a goal of informing clinical practice. Findings: Twenty-four articles were included in the review. Of the 10 Centers for Medicare & Medicaid Services preventable adverse events, 6 were addressed: diabetes management (n = 2), dysphagia (n = 5), infection control (n = 1), pressure ulcers (n = 6), falls (n = 5), and discharge management (n = 5). There was strong strength of evidence that exercise programs should, when appropriate, be implemented in both inpatient and home health settings to decrease the risk of falls. There was moderate strength of evidence that practitioners could consider implementing a facility wide evidence-based pressure ulcer program; providing multidisciplinary rehabilitation and swallow strengthening exercises for dysphagia; implementing a multidisciplinary, multicomponent falls program; and using a manualized depression intervention in home health to decrease hospital readmission. Conclusions and Relevance: The review highlights the importance of preventable adverse events and of occupational therapy practitioners acknowledging and managing these events to enhance health outcomes and to control health care costs. What This Article Adds: Many interventions typically performed by occupational therapy practitioners address preventable adverse events. The review highlights the importance of practitioners being aware of this category of impairment or injury.

Reducing Hospital Readmissions of Older Adults Pursuing Postacute Care at Skilled Nursing Facilities: A Scoping Review

Importance: Unplanned hospital readmissions can profoundly affect older adults’ quality of life and the financial status of skilled nursing facilities (SNFs). Although many clinical practices focus on reforming these issues, occupational therapy’s involvement remains unclear. Objective: To explore clinical practices aimed at reducing hospital readmissions of older adults pursuing postacute care (PAC) at SNFs and describe how they align with occupational therapy’s scope of practice. Data Sources: We searched CINAHL, Scopus, PubMed, and OTseeker for articles published from January 2011 to February 2020. Study Selection and Data Collection: We conducted a scoping review of peer-reviewed articles with functional outcomes of clinical practices reducing unplanned hospital readmissions of patients older than age 65 yr pursuing PAC services in SNFs. Trained reviewers completed the title and abstract screens, full-text reviews, and data extraction. Findings: Thirteen articles were included and focused on five areas: risk and medical disease management and follow-up, hospital-to-SNF transition, enhanced communication and care, function, and nutrition. Early coordination of care and early identification of patients’ needs and risk of readmission were common features. All clinical practices aligned with occupational therapy domains and processes, but only 1 study specified occupational therapy as part of the research team. Conclusions and Relevance: Comprehensive, multipronged clinical practices encompassing care coordination and early identification and management of acute conditions are critical in reducing preventable readmissions among older adults pursuing PAC services in SNFs. Further research is needed to support occupational therapy’s value in preventing hospital readmissions of older adults in this setting. What This Article Adds: This scoping review maps the presence of occupational therapy’s domains and processes in the clinical practices that reduce hospital readmissions of older adults pursuing PAC services in SNFs. Findings provide occupational therapy practitioners with opportunities to assume roles beyond direct patient care, research, advocate, and publish more, thereby increasing their presence and adding value to occupational therapy interventions that reduce hospital readmissions.

Health Literacy in Surgical Oncology Patients: An Observational Study at a Comprehensive Cancer Center

Background: Low health literacy is associated with increased resource use and poorer outcomes in medical and surgical patients with various diseases. This observational study was designed to determine (1) the prevalence of low health literacy among surgical patients with cancer at an NCI-designated Comprehensive Cancer Center (CCC), and (2) associations between health literacy and clinical outcomes. Methods: Patients receiving surgery (N=218) for gastrointestinal (60%) or genitourinary cancers (22%) or sarcomas (18%) were recruited during their postsurgical hospitalization. Patients self-reported health literacy using the Brief Health Literacy Screening Tool (BRIEF). Clinical data (length of stay [LoS], postacute care needs, and unplanned presentation for care within 30 days) were abstracted from the electronic medical records 90 days after surgery. Multivariate linear and logistic regressions were used to examine the relationship between health literacy and clinical outcomes, adjusting for potential confounding variables. Results: Of 218 participants, 31 (14%) showed low health literacy (BRIEF score ≤12). In regression analyses including 212 patients with complete data, low health literacy significantly predicted LoS (β = −1.82; 95% CI, −3.00 to −0.66; P=.002) and postacute care needs (odds ratio [OR], 0.25; 95% CI, 0.07–0.91). However, health literacy was not significantly associated with unplanned presentation for care in the 30 days after surgery (OR, 0.51; 95% CI, 0.20–1.29). Conclusions: This study demonstrates the prevalence of low health literacy in a surgical cancer population at a high-volume NCI-designated CCC and its association with important clinical outcomes, including hospital LoS and postacute care needs. Universal screening and patient navigation may be 2 approaches to mitigate the impact of low health literacy on postsurgical outcomes.

Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study

Background and Purpose: The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. Methods: We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. Results: In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). Conclusions: This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.

Impact of Delirium on Outcomes After Intracerebral Hemorrhage

Background and Purpose: Delirium portends worse outcomes after intracerebral hemorrhage (ICH), but it is unclear if symptom resolution or postacute care intensity may mitigate its impact. We aimed to explore differences in outcome associated with delirium resolution before hospital discharge, as well as the potential mediating role of postacute discharge site. Methods: We performed a single-center cohort study on consecutive ICH patients over 2 years. Delirium was diagnosed according to DSM-5 criteria and further classified as persistent or resolved based on delirium status at hospital discharge. We determined the impact of delirium on unfavorable 3-month outcome (modified Rankin Scale score, 4–6) using logistic regression models adjusted for established ICH predictors, then used mediation analysis to examine the indirect effect of delirium via postacute discharge site. Results: Of 590 patients (mean age 70.5±15.5 years, 52% male, 83% White), 59% (n=348) developed delirium during hospitalization. Older age and higher ICH severity were delirium risk factors, but only younger age predicted delirium resolution, which occurred in 75% (161/215) of ICH survivors who had delirium. Delirium was strongly associated with unfavorable outcome, but patients with persistent delirium fared worse (adjusted odds ratio [OR], 7.3 [95% CI, 3.3–16.3]) than those whose delirium resolved (adjusted OR, 3.1 [95% CI, 1.8–5.5]). Patients with delirium were less likely to be discharged to inpatient rehabilitation than skilled nursing facilities (adjusted OR, 0.31 [95% CI, 0.17–0.59]), and postacute care site partially mediated the relationship between delirium and functional outcome in ICH survivors, leading to a 25% reduction in the effect of delirium (without mediator: adjusted OR, 3.0 [95% CI, 1.7–5.6]; with mediator: adjusted OR, 2.3 [95% CI, 1.2–4.3]). Conclusions: Acute delirium resolves in most patients with ICH by hospital discharge, which was associated with better outcomes than in patients with persistent delirium. The impact of delirium on outcomes may be further mitigated by postacute rehabilitation.

Role of ADL Independence in Postacute-Care Rehabilitation Service Needs in the Elderly Abdominal Surgery Population

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. More than half of all surgical patients are age 65 and older, and research suggests that a majority of these patients will require postacute-care (PAC) rehabilitation services. Despite the growing costs, characteristics related to requiring PAC in the elderly abdominal surgery population are not well studied. This project aims to describe discharge trends, as well as factors related to requiring placement at a skilled-nursing facility in the elderly abdominal surgery population. Primary Author and Speaker: Erika Dobson Contributing Authors: Rebecca Julian, Hailey Zanette