Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

Importance: Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied. Objective: To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type. Design: A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type. Participants: A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation. Intervention: None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care “6-Clicks” measure of daily activity. Results: Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance. Conclusions and Relevance: Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

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.

Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

Importance: Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied. Objective: To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type. Design: A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type. Participants: A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation. Intervention: None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care “6-Clicks” measure of daily activity. Results: Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance. Conclusions and Relevance: Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

Economic Effects of Occupational Therapy Services for Adults in Acute and Subacute Care Settings: A Systematic Review

Importance: Research supports the clinical effectiveness of hospital-based occupational therapy to improve functional outcomes, but no synthesis of economic evaluations of occupational therapy services provided in these settings has been published. Objective: To determine the economic value of occupational therapy services in acute and subacute care settings. Data Sources: MEDLINE, CINAHL, CENTRAL, EconLit, Embase, National Health Services Economic Evaluation Database, PsycINFO, ProQuest (Health and Medicine and Social Science subsets only), OTseeker, and gray literature. Study Selection and Data Collection: Eligible studies used trial-based or modeled economic analyses and included an adult population (ages ≥18 yr) and occupational therapy assessments or interventions provided in acute and subacute care. Two authors independently assessed abstracts and then full text. Articles were then appraised using the Evers Consensus on Health Economic Criteria. Findings: The authors identified 13,176 unique abstracts and assessed 190 full-text articles for eligibility. Ten studies were included in the systematic review; they varied in their primary objectives, methodology, costs, and outcomes. Studies examined the cost–benefit, cost-effectiveness, cost–utility, or cost minimization of a range of occupational therapy services. Five studies suggested that occupational therapy services offer value for money (lower cost, higher benefit); 4 suggested that they offer higher cost and benefits. One study that investigated upper limb rehabilitation did not indicate value for money. Conclusions and Relevance: The findings suggest that occupational therapy for adults poststroke and post–traumatic brain injury, acute discharge planning, and pre– and post–hip replacement is cost-effective, but further research is needed to substantiate these findings. What This Article Adds: The findings provide preliminary evidence of the economic effectiveness of occupational therapy in acute and subacute care.

Occupational Therapy Service Delivery Among Medicaid-Enrolled Children and Adults on the Autism Spectrum and With Other Intellectual Disabilities

Importance: Rates of occupational therapy service utilization among people with autism spectrum disorder (ASD) or intellectual disability (ID) have not been explored in population-based samples. Objective: To describe occupational therapy services delivered to Medicaid-eligible persons younger than age 65 yr identified as having ASD, ID, or both and to evaluate demographic factors associated with occupational therapy service utilization in this population. Design: Retrospective, case–control, cohort study using claims records from Medicaid Analytic eXtract files (2009–2012). Setting: Data from all 50 states and Washington, DC. Participants: Beneficiaries identified as having ASD only, ASD+ID, or ID only who were younger than age 18 yr (N = 664,214) and ages 18–64 yr (N = 702,338). Outcomes and Measures: We analyzed Current Procedural Terminology® and Healthcare Common Procedure Coding System procedure codes, Medicaid Statistical Information System type of service codes, and Center for Medicare & Medicaid Services provider specialty codes. Results: Only 3.7% to 6.3% of eligible adult beneficiaries received occupational therapy; in contrast, 20.5% to 24.2% of children received occupational therapy. Significant predictors of service use varied by group; however, differences by race–ethnicity, eligibility on the basis of poverty, and geographic location were observed. Among children, the most frequent billing code was for “therapeutic activities” (43%–60%); among adults, it was “community/work reintegration training” (29%–39%). Conclusions and Relevance: Billed procedure code patterns do not consistently reflect the unique occupational focus that occupational therapy providers deliver to people with developmental disabilities. Disparities in occupational therapy receipt warrant further attention to understand the social and structural factors affecting service delivery. What This Article Adds: Occupational therapy services paid for by Medicaid are used more frequently by children with ASD and ID than by adults with these diagnoses. Greater understanding of the intersectional factors that drive service delivery and disparities is needed.

Interrater Reliability of a Novel Goniometric Technique to Measure Scapular Protraction and Retraction

Importance: Scapular protraction and retraction are often essential for occupational performance; however, clinical assessment of these movements is uniquely challenging. Objective: To analyze the interrater reliability of a novel goniometric method to measure scapular protraction and retraction. Design: An observational, descriptive design was implemented to evaluate interrater reliability between two experienced occupational therapists who were also certified hand therapists. Setting: Academic institution. Participants: Convenience sample of graduate students (N = 80). Outcomes and Measures: The hypothesis, developed before study implementation, was that the technique would demonstrate clinically acceptable interrater reliability, defined as a standard error of measurement (SEM) <8°. Goniometric measurements of the scapula at rest, in maximal protraction, and in maximal retraction were independently obtained from each participant by each evaluator. The goniometer was aligned on the scapula using the superior angle as the axis of motion to measure the movement of the acromion relative to the frontal plane. The SEM was calculated in each position using the intraclass correlation coefficient values and the average of the standard deviations from the two raters. Results: The SEM values between the two evaluators for the resting, protracted, and retracted positions were 3.46°, 2.93°, and 2.74°, respectively. Conclusions and Relevance: The SEM between the two evaluators for each scapular position was <4°, suggesting that the technique may be clinically reliable. However, additional research regarding the reliability and validity of the technique is recommended. What This Article Adds: The findings of this study support the use of goniometry to measure scapular protraction and retraction in relation to occupational performance. The technique provides a way to quantify baseline scapular mobility and track progress.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

Importance: Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs. Objective: In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity. Data Sources: We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Findings: We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

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.

AOTA 2021 Standards for Continuing Competence in Occupational Therapy

Continuing competence is essential to occupational therapists and occupational therapy assistants for fulfilling their roles and abilities across experience, context, and time. It requires an ongoing process to keep up with new developments related to the profession and specialty areas throughout one’s career (i.e., early, mid-, late, change, or reentry). To build capacity, occupational therapists and occupational therapy assistants must commit to a process of self-assessment, reflecting on, in, and toward action to advance the knowledge, professional reasoning, interpersonal skills, performance skills, and ethical practice necessary to perform current and future roles and responsibilities within the profession. The American Occupational Therapy Association’s Standards for Continuing Competence serve as a foundation for analyzing the occupation in regard to continuing competence. These standards can be viewed separately and collectively and can be combined with other standards documents to gain an overarching perspective.