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Interventions to Promote and Support Development of Client Self-Advocacy: A Narrative Review of the Literature

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Interventions to Promote and Support Development of Client Self-Advocacy: A Narrative Review of the Literature

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Poster Session Published Online: August 01, 2020
In occupational therapy, not only is advocating for our clients important, but also assisting them in developing self-advocacy skills so they will be able to advocate for themselves if needed. This review explains that there is limited literature about self-advocacy interventions even though it is a domain in the OTPF under the scope of practice for OT's.

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Interventions to Promote and Support Development of Client Self-Advocacy: A Narrative Review of the Literature | American Journal of Occupational Therapy

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JAN: Job Accomodation Network |  free, confidential technical assistance about job accommodations and the Americans with Disabilities Act (ADA). (800) 526-7234 (Voice)   |    (877) 781-9403 (TTY)   |    Live Chat

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JAN: Job Accomodation Network |  free, confidential technical assistance about job accommodations and the Americans with Disabilities Act (ADA). (800) 526-7234 (Voice)   |    (877) 781-9403 (TTY)   |    Live Chat

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This is one of my favorite resources because it is essentially a list of interventions when looking under database for limitations. Please check it out. For working adult clients overcoming trauma or those with mental health or mental fitness components as part of their intersecting identities, this website gives information on how to inform an employer of an invisible or visible health condition, disability, or limitation. It provides guidance on how to request and have in place necessary accommodations post-op. As part of personal health management, self-advocacy and seeking accommodations when needed enhance occupational performance. As occupational therapists, we advocate for our clients by being resourceful and providing information and encouraging them to self-advocate, too. I also appreciate they offer free assistance through chat, therefore considering privacy & reducing barriers to access.

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JAN provides the following A to Z listings by disability, topic, and limitation. This information is designed to help employers and individuals determine effective accommodations and comply with Title I of the Americans with Disabilities Act (ADA). You will find ADA information, accommodation ideas, and resources for additional information.

JAN's A to Z is a starting point in the accommodation process and may not address every situation. Accommodations should be made on a case by case basis, considering each employee's individual limitations and accommodation needs. Employers and individuals are encouraged to contact JAN to discuss specific situations in more detail. To get started, choose one to find what you are looking for.

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A to Z of Disabilities and Accommodations

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If you are looking for information on job accommodations, the Americans with Disabilities Act or Rehabilitation Act, or topics related to disability employment, see the listings below for various topics covered by JAN.

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Burn rehabilitation does not normally begin directly after a skin graft to the hand. However, this article does discuss that participating in range of motion the day after a skin graft can be beneficial without compromising the grafts success. These participants in the study improved quicker in range of motion, grip strength and pinch tests.

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Why Wait? Initiating Range of Motion the Day After a Skin Graft to the Burned Hand

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Abstract. Date Presented 4/21/2018A burn to the hand greatly affects occupational performance. Early mobilization after a skin graft to the hand is not recognized in the burn rehabilitation literature.

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Using an International Role-Modeling Pedagogy to Engage First-Year Occupational Therapy Students in Learning Professionalism

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Using an International Role-Modeling Pedagogy to Engage First-Year Occupational Therapy Students in Learning Professionalism

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Professionalism is very important to occupational therapy service delivery. It’s relevant o consider how we teach professionalism to emerging practitioners as a way to ensure high quality care.

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Using an International Role-Modeling Pedagogy to Engage First-Year Occupational Therapy Students in Learning Professionalism | American Journal of Occupational Therapy

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Self-Reflection as a Support to Evidence-Based Practice (EBP): A Grounded Theory Exploration

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Self-Reflection as a Support to Evidence-Based Practice (EBP): A Grounded Theory Exploration

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We already are aware that occupational therapy is client-centered and evidence-based. But what can we do to support those pillars of practice? This poster session explores self-reflection as a way to support evidence-based practice.

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Self-Reflection as a Support to Evidence-Based Practice (EBP): A Grounded Theory Exploration | American Journal of Occupational Therapy

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Interprofessional Education on Feeding, Swallowing, and Nutrition—Best “Served” With OT, Speech Therapy, and Nutrition

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Interprofessional Education on Feeding, Swallowing, and Nutrition—Best “Served” With OT, Speech Therapy, and Nutrition

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As we finish up our feeding/swallowing projects for OT Process, it made me think about the many areas of practice where the scope of OT overlaps with other professions. This poster session highlights the unique opportunity speech therapists, dietitians and occupational therapists have to work as a team to best serve clients with feeding and swallowing needs. This poster session has important implications for general interprofessional work. Strategies used to maximize therapeutic outcomes when there is interprofessional overlap can be carried over to other interprofessional interactions.

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Interprofessional Education on Feeding, Swallowing, and Nutrition-Best "Served" With OT, Speech Therapy, and Nutrition

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Abstract. Date Presented 04/04/19The innovative use of a feeding, swallowing, and nutrition interprofessional education event gave students the opportunity to learn about and practice various aspects of how OTs, speech therapists, and nutritionists work together.

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Executive Dysfunction and Depressive Symptoms Associated With Reduced Participation of People with Severe Congestive Heart Failure

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Executive Dysfunction and Depressive Symptoms Associated With Reduced Participation of People with Severe Congestive Heart Failure

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As emerging occupational therapists, it’s important to prioritize discussions regarding the  psychosocial aspects of conditions . This article specifically highlights executive dysfunction and depressive symptoms with people who have congestive heart failure and how that affects their occupational participation.

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Executive Dysfunction and Depressive Symptoms Associated With Reduced Participation of People With Severe Congestive Heart Failure | American Journal of Occupational Therapy

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A Service Delivery Model for Addressing Activity and Social Participation Needs of People Living with HIV

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A Service Delivery Model for Addressing Activity and Social Participation Needs of People Living with HIV

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This article overviews the first “comprehensive rehabilitation service delivery model” that focuses on the activity and social participation needs of people with HIV. A study was conducted to evaluate the strengths and limitations of the model. This article is great example of how to produce a practice model for an emerging field of practice within occupational therapy and has important implications for how OTs administer interventions with people who have HIV.

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Credentials Display

Gayle Restall, O.T. Reg. (MB), Ph.D.; Theresa Sullivan, O.T. Reg. (MB), Ph.D.; Tara Carnochan, MA; Emily Etcheverry, O.T. Reg. (MB), Ph.D.; Kerstin Roger, Ph.D.; Pumulo Roddy, Ph.D.

Abstract

Background: Occupational therapy can contribute to the health and well-being of people with human immunodeficiency virus (HIV) who are experiencing health consequences of living long term with this disease. However, there are no comprehensive rehabilitation service delivery models to guide this emerging area of practice. The purpose of this study was to obtain critical feedback about a service delivery model to address the activity and social participation needs of people living with HIV.

Method: We developed a service delivery model from a synthesis of the literature. Using a qualitative research design, we conducted individual and focus group interviews with 35 informants from diverse backgrounds and involvement in HIV-related research, service provision, and policymaking to provide critical feedback about the model. The interviews were audio-recorded, transcribed verbatim, and analyzed using inductive qualitative methods.

Results: The informants identified the strengths and limitations of the model and supports and barriers to its implementation. They highlighted the importance of principle-based services, increasing resources for service navigation, building capacity of rehabilitation services to address the needs of people with HIV, and increasing research and program evaluation targeted to achieving activity and social participation outcomes.

Conclusions: The model provides a framework for occupational therapists to design and evaluate services for this population.

Recommended Citation

Restall, G., Sullivan, T., Carnochan, T., Etcheverry, E., Roger, K., & Roddy, P. (2017). A Service Delivery Model for Addressing Activity and Social Participation Needs of People Living with HIV. The Open Journal of Occupational Therapy, 5(2). https://doi.org/10.15453/2168-6408.1258

DOWNLOADS

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A Service Delivery Model for Addressing Activity and Social Participation Needs of People Living with HIV

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Background: Occupational therapy can contribute to the health and well-being of people with human immunodeficiency virus (HIV) who are experiencing health consequences of living long term with this disease. However, there are no comprehensive rehabilitation service delivery models to guide this emerging area of practice.

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The Psychosocial Aspects of Burn Injuries

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The Psychosocial Aspects of Burn Injuries

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This article gives a wonderful overview of the psychosocial symptoms that can occur during the different phases of severe burn treatment. This article may be very useful for occupational therapists working with this population. As OTs we must think about our clients holistically in order to help them engage in meaningful occupations. Understanding the psychosocial aspects of a burns will only help us as professionals as we strive for this goal.

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ABC of burns

With the increased survival of patients with large burns comes a new focus on the psychological challenges and recovery that such patients must face. Most burn centres employ social workers, vocational counsellors, and psychologists as part of the multidisciplinary burn team. Physiological recovery of burn patients is seen as a continual process divided into three stages-resuscitative or critical, acute, and long term rehabilitation. The psychological needs of burn patients differ at each stage.

Resuscitative or critical stage

The psychological characteristics of this stage include stressors of the intensive care environment, uncertainty about outcome, and a struggle for survival. The intensive care environment can be both overstimulating and understimulating with the monotony of lying in a hospital bed for weeks.

Cognitive changes such as extreme drowsiness, confusion, and disorientation are common during this phase. More severe cognitive changes such as delirium and brief psychotic reactions also occur, usually as a result of infections, alcohol withdrawal, metabolic complications, or high doses of drugs. Patients may also be intubated, which greatly limits direct communication.

Treatment

In depth psychological intervention is of minimal value at this phase, since physical survival is the primary goal. Patients should be encouraged to cope with the frighteningly unusual circumstances of the intensive care unit through whatever defences are available to them, even primitive strategies such as denial and repression. Supportive psychological interventions should focus on immediate concerns, such as sleep, pain control, and protecting patients' coping strategies. Non-pharmacological approaches to pain control, such as hypnosis and relaxation, can be effective.

Medical staff can also effectively intervene during this early stage of recovery by working with a patient's family members. Family members may be anxious and distressed while observing the patient undergo treatment, which fosters the same response in the patient. It is important to help family members understand this effect and help them to convey a sense of hope and calmness to the patient.

Acute stage

The acute phase of recovery focuses on restorative care, but patients continue to undergo painful treatments. As patients become more alert during this phase, they face these procedures with less sedation. Also, patients are more aware of the physical and psychological impact of their injuries.

Table 2

Depression and anxiety -Symptoms of depression and anxiety are common and start to appear in the acute phase of recovery. Acute stress disorder (occurs in the first month) and post-traumatic stress disorder (occurs after one month) are more common after burns than other forms of injury. Patients with these disorders typically have larger burns and more severe pain and express more guilt about the precipitating event. The severity of depression is correlated with a patient's level of resting pain and level of social support.
The psychological needs of patients with burn injuries are unique at each stage of physical recovery
Sleep disturbance -Central to both anxiety and depression is sleep disturbance. The hospital environment can be loud, and patients are awakened periodically during the night for analgesia or for checking vital signs. Patients' mood, agitation, and nightmares can all affect sleep.

Table 3

* Pain-both background and procedural

* Anxiety-both acute stress disorder and post-traumatic stress disorder

* Depression

* Sleep disturbance

* Premorbid psychopathology becomes more apparent

* Drug management of anxiety, pain, sleeplessness, and depression

* Brief counselling

* Teach non-drug approaches to pain management (relaxation, imagery, hypnosis, virtual reality)

Premorbid psychopathology -Compared with the general population, burn patients have a high rate of premorbid psychopathology. Patients with pre-existing psychopathology typically cope with hospitalisation through previously established dysfunctional and disruptive strategies. The most common premorbid psychiatric diagnoses are depression, personality disorders, and substance misuse. Prior psychopathology can have an adverse impact on outcomes, including longer hospitalisations and the development of more serious psychopathologies after injury.

Grief -Patients may now begin the grieving process as they become more aware of the impact of the burn injuries on their lives. Family members, friends, or pets may have died in the incident, and patients may have lost their homes or personal property. In addition to these external losses, patients may also grieve for their former life (such as job, mobility, physical ability, appearance). Mental health professionals and other staff should help patients to grieve in their own way and at their own pace.

Treatment

Brief psychological counselling can help both depression and anxiety, but drugs may also be necessary. When offering counselling, it is often helpful to provide reassurance that symptoms often diminish on their own, particularly if the patient has no premorbid history of depression or anxiety.

Drugs and relaxation techniques may also be necessary to help patients sleep. Informing patients that nightmares are common and typically subside in about a month can help allay concerns. Occasionally patients will benefit from being able to talk through the events of the incident repeatedly, allowing them to confront rather than avoid reminders of the trauma. Staff often make the mistake of trying to treat premorbid psychopathology during patients' hospitalisation. Referrals to community treatment programmes should be made once patients are ready for discharge.

Long term rehabilitation

The long term stage of recovery typically begins after discharge from hospital, when patients begin to reintegrate into society. For patients with severe burns, this stage may involve continued outpatient physical rehabilitation, possibly with continuation of procedures such as dressing changes and surgery. This is a period when patients slowly regain a sense of competence while simultaneously adjusting to the practical limitations of their injury. The first year after hospitalisation is a psychologically unique period of high distress.

Table 4

Physical problems -Patients face a variety of daily hassles during this phase, such as compensating for an inability to use hands, limited endurance, and severe itching. Severe burn injuries that result in amputations, neuropathies, heterotopic ossification, and scarring can have an emotional and physical effect on patients.

Psychosocial problems -In addition to the high demands of rehabilitation, patients must deal with social stressors including family strains, return to work, sexual dysfunction, change in body image, and disruption in daily life. Many people continue to have vivid memories of the incident, causing distress. Patients may also develop symptoms of depression. There is evidence that adjustment to burn injuries improves over time independent of the injury size. Social support is an important buffer against the development of psychological difficulty.

Figure 4

Treatment

It can be helpful to make follow up telephone calls to patients after discharge or to continue to see patients in an outpatient clinic to screen for symptoms of distress and to provide psychotherapy.

Adjustment difficulties that persist more than a year after discharge usually involve perceptions of a diminished quality of life and lowered self esteem. Some studies suggest that burn disfigurement in general leads to decreased self esteem in women and social withdrawal in men. "Changing Faces" is a successful programme for enhancing self esteem. This includes a hospital based programme for image enhancement and social skills plus a series of publications for patients dealing with aspects of facial disfigurement.

Many patients face a lengthy period of outpatient recovery before being able to return to work. Some patients go through vocational challenges. In a recent study of patients hospitalised for burn injury 66% returned to work within six months of their injury, and 81% had returned by one year. As expected, patients who sustained larger burns took longer to return to work. About half of the patients required some change in job status.

Ancillary resources such as support groups and peer counselling by burn survivors can also be important services to burn survivors. Major burn centres ideally have a network of burn survivors who are willing to talk with patients in the hospital.

Summary

A burn injury and its subsequent treatment are among the most painful experiences a person can encounter. The emotional needs of patients with burns have long been overshadowed by the emphasis on survival. Patients undergo various stages of adjustment and face emotional challenges that parallel the stage of physical recovery. Adjustment to a burn injury seems to involve a complex interplay between the patient's characteristics before the injury, moderating environmental factors, and the nature of the injury and ensuing medical care.

Notes

Shelley A Wiechman is acting assistant professor and David R Patterson is professor in the Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA
This is the 10th in a series of 12 articles
The picture of a patient with burnt head and shoulders is reproduced with permission of Science Photo Library.

The ABC of burns is edited by Shehan Hettiaratchy, specialist registrar in plastic and reconstructive surgery, Pan-Thames Training Scheme, London; Remo Papini, consultant and clinical lead in burns, West Midlands Regional Burn Unit, Selly Oak University Hospital, Birmingham; and Peter Dziewulski, consultant burns and plastic surgeon, St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford. The series will be published as a book in the autumn.

Competing interests: See first article for series editors' details.

Further reading and resources

[* Patterson DR, Everett JJ, Bombardier CH, Questad KA, Lee VK, Marvin JA. Psychological effects of severe burn injuries. Psychol Bull 1993;113: 362-78 [PubMed] Google Scholar]

* Patterson DR, Ford GR. Burn injuries. In: Frank RG, Elliott TT, eds. Handbook of rehabilitation psychology. Washington DC: American Psychological Association, 2000: 145-62

* Partridge J. When burns affect the way you look. London: Changing Faces, 1997

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ABC of burns: Psychosocial aspects of burn injuries

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ABC of burns With the increased survival of patients with large burns comes a new focus on the psychological challenges and recovery that such patients must face. Most burn centres employ social workers, vocational counsellors, and psychologists as part of the multidisciplinary burn team.

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The Effects of Community-Based Occupational Therapy on Health-Related Quality of Life and Engagement in Meaningful Activities of Women with Breast Cancer

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The Effects of Community-Based Occupational Therapy on Health-Related Quality of Life and Engagement in Meaningful Activities of Women with Breast Cancer

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This article’s research is based off of the need to treat psychosocial and other post-cancer symptoms in women with breast cancer. The results of this randomized control study have important implications for occupational therapy’s role with helping clients with cancer. Occupational therapy was shown to have a positive affect on self-reported quality of life for women with breast cancer, specifically related to their physical functions, role functions, fatigue and their ability to engage in meaningful occupations.

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The article lists assessments used for an adult male with a TBI which included COPM, community integration questionnaire, and the satisfaction with life scale. The OT then used results from the assessments, clients goals, and evidence based practice to formulate an intervention plan for her client; the article describes 3 interventions in detail. I believe this article has great insight to the OT process in an outpatient setting with client with a TBI and a lot of what we have learned in our courses so far is mentioned. In my opinion, I love being able to tie things in together (what we learn in class to what we read, hear, or see in the real world).

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AN OCCUPATIONAL PERFORMANCE PROCESS MODEL: FOSTERING CLIENT AND THERAPIST ALLIANCES

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AN OCCUPATIONAL PERFORMANCE PROCESS MODEL: FOSTERING CLIENT AND THERAPIST ALLIANCES

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A 7-step process model designed to keep client-centeredness and best practices in service delivery in mind.
CJOT February 1997

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 AOTA, APTA, ASHA endorse a paradigm shift to a 3:1 workload model for service delivery in educational settings.

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 AOTA, APTA, ASHA endorse a paradigm shift to a 3:1 workload model for service delivery in educational settings.

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A caseload cap is not a minimum requirement, its a maximum but many ISD's tout it as an economically necessary minimum at the expense of quality service. Cutting ft hours to pt based on cases is unfair labor practice in theory but legally allowed. IEP & documentation time should be covered as paid time & the 3:1 workload model is a small step in the direction valuing labor vs time.

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If the address matches an existing account you will receive an email with instructions to reset your password.

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Unique contribution: Case studies for co-treatments of OT/PT in post-COVID patients

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Unique contribution: Case studies for co-treatments of OT/PT in post-COVID patients

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pzaa204.pdf (silverchair.com)
The PHE of 2020 has challenged therapy providers to find innovative methods of service delivery. Here is a concise case study of reducing in-person contact through usage of video game consoles!

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Abstract

Introduction

Physical therapists and occupational therapists are needed on the frontlines of the novel coronavirus 2019 (COVID-19) pandemic to delay, prevent, or recover the loss of function due to prolonged hospitalization. The typical functional declines observed may be exacerbated during a COVID-19 hospital admission due to the necessary precautions to mitigate viral spread such as keeping patients confined to their rooms and minimizing contact with providers. As a result, physical therapists and occupational therapists in the hospital setting are faced with daily challenges and complex decisions regarding how to deliver rehabilitation services efficiently. Prior to the pandemic, standard acute rehabilitation practice at our facility provided physical therapist and occupational therapist services as separate sessions. A paradigm of separate physical therapist and occupational therapist sessions no longer fits during the COVID-19 pandemic when effective rehabilitation service is needed to maximize function and facilitate discharge planning, while also mitigating viral spread through reduced provider-patient contact and conserving personal protective equipment (PPE).

A solid literature base exists citing rehabilitation approaches effective for the treatment and management of patients with COVID-19. However, answers to clinical decisions regarding how rehabilitation services should be delivered during hospitalized care of patients with COVID-19 is evolving and largely unknown. We present 2 case reports to illustrate how we used technology and developed COVID-19-specific decision-making processes for care delivery. Both patients signed forms regarding permission to release information, and the information presented meets the Health Insurance, Portability, and Accountability Act requirements for disclosure of protected health information.

Overview of Infrastructure Changes to Treat Patients With COVID-19

The Minneapolis Veterans Affairs Health Care System converted clinic space to COVID-19 units and assigned providers to COVID-19 teams. All rooms on the COVID-19 unit had video communication equipment (Cisco DX70 or DX80; Cisco Systems, Inc, San Jose, CA, USA) installed, consisting of movable cameras and monitors that allowed for bi-directional audio and visual capabilities. All staff were trained on the video communication system for use in service delivery. For rehabilitation sessions, the in-room camera and monitor were positioned with the camera and monitor facing the patient. A matching, moveable monitor and camera were located outside the patient's room. Sessions occurred in real-time and were not recorded. A standard combined physical therapist/occupational therapist evaluation template was created to include measures of physical performance (4-Stage Balance Test and 30-Second Sit to Stand) and a cognitive screen (Short Blessed Test). All physical therapists and occupational therapists on the COVID-19 unit completed competencies on all measures to ensure reliability. If additional measures were required during the evaluation, the in-room clinician completed the assessment within their scope of practice and the outside clinician directed the in-room clinician.

Case 1 Description

A 65-year-old male was admitted to the hospital with symptomatic COVID-19. The plan of care, consistent with evidence-based practices,, is presented in the Table. In Figure 1, we outlined our decision-making process for determining which rehabilitation providers were necessary for in-room sessions. The physical therapist/occupational therapist team reviewed the chart and determined the patient was appropriate for evaluation., Next, they reviewed nursing notes that indicated the patient was using an assist of one for out-of-bed mobility and determined that the occupational therapist would be in the room for the evaluation with the physical therapist outside.

Intervention and Plan of Care

We used the International Classification of Functioning, Disability and Health model to prioritize patient needs and determine a combined plan of care of 5 d/wk with 30- to 60-minute physical therapist/occupational therapist co-treatment sessions during acute care and 30-60 minutes of separate physical therapist and occupational therapist sessions in the COVID-19 acute rehabilitation unit (CRU). The plan of care carried over when the patient was discharged from the hospital to the CRU for a total of 16 sessions (3 acute care, 13 CRU). Following the evaluation, the physical therapist/occupational therapist team listed and prioritized impairments and activity limitations in the context of the patient's presentation, prognosis, and needs for return to his prior level of participation ( Fig. 1). The patient presented with significant limitations in aerobic capacity for in-room ambulation (<50 feet at a rate of perceived exertion [RPE] ≥5/10) and standing balance. Findings suggested the physical therapist and occupational therapist were both indicated with needs weighted towards physical therapy; therefore, the physical therapist was in the room for sessions with the occupational therapist present via the video communication system ( Fig. 1). The use of technology allowed clinicians to avoid 3 in-person sessions (1 physical therapist, 2 occupational therapy).Video co-treatments for treating patients with COVID-19 impacted clinician time by using a combined physical therapist/occupational therapist note and having only 1 clinician vs 2 apply/remove PPE. In addition, the physical therapist/occupational therapist could perform nursing cares (eg, deliver meals, change bed linens) to minimize nursing staff exposure and use of PPE for brief tasks. Nursing staff promoted activity recommendations prescribed by the physical therapist/occupational therapist throughout the day via the video communication system or during direct care.

Case 1 Outcomes

Outcomes are presented in the Table, and functional scores at discharge exceeded minimal clinically important differences. Given the complexities of discharging patients from the hospital to post-acute care facilities in the context of a pandemic, our discharge planning process has evolved. To address this, an interdisciplinary team, including rehabilitation, formed a consensus on criteria for admission to the newly created on-site CRU ( Fig. 2) to eliminate the need for transfer to an outside facility for further rehabilitation following hospitalization. At the time, these admission criteria were considered indicators of low viral load., At evaluation, the physical therapist/occupational therapist recommended the patient in Case 1 discharge to the CRU; however, by hospital discharge, the patient met all but 1 intake criteria (not tolerating ≥2 hours of daily rehabilitation). The interdisciplinary team discussed the case and decided admission to CRU was appropriate because the patient was steadily improving his aerobic capacity and demonstrated adherence to daily activity recommendations (ie, ambulation in the room with nursing 3 times per day at RPE < 5/10). Patient rooms in the CRU had video communication capability, yet it was used less as viral load was considered lower. The patient discharged from the hospital after 24 days (7 days acute care, 17 days CRU) to his assisted living facility with prior services and a progressive home exercise program.

Case 2 Description

A 40-year-old male was admitted to the hospital with a positive COVID-19 test ( Table). Based on our decision-making process ( Fig. 1), a chart review revealed the patient required assist of 1 as he fatigued easily with minimal activity and, thus, the physical therapist was in the room for the evaluation, and the occupational therapist remained outside.

Intervention and Plan of Care

The plan of care is outlined in the Table. We used the International Classification of Functioning, Disability and Health model to prioritize the patient's needs and determined a combined rehabilitation plan of care of 5 days per week (30- to 60-minute physical therapy/occupational therapy treatment sessions) was appropriate. The team prioritized the list of problems and determined that the patient's decreased aerobic capacity-defined by an RPE ≥ 5/10 during basic mobility-indicated both physical therapy and occupational therapy were weighted equally and would alternate days of service in-room versus via video communication ( Fig. 1). The use of technology allowed rehabilitation clinicians to avoid 4 in-person sessions (2 physical therapy, 2 occupational therapy).

Case 2 Outcomes

Outcomes are presented in the Table and demonstrated improvement. We initially recommended the patient discharge to CRU due to fatigue with minimal in-room mobility (RPE ≥ 5/10) and difficulty weaning off supplemental oxygen ( Fig. 2). However, he expressed a strong desire to return home. Based on the patient's medical and functional improvements, the discharge recommendation changed to home with outpatient virtual physical therapy. The patient was issued a tablet after the physical therapist/occupational therapist agreed he was cognitively intact (determined by a combination of cognitive status, availability of social support, and clinical judgement) and familiar with the use of tablet devices. At the time the tablet was issued, the patient needed to call to schedule a virtual physical therapy appointment after hospital discharge. In this case, the patient did not call to schedule a virtual physical therapy appointment but did have a phone visit with his primary care physician. The patient discharged from the hospital to home after 17 days (11 days in the intensive care unit).

Role of the Funding Source

The funder played no role in the design, implementation, analysis, or interpretation of results or the decision as to whether or where to publish papers.

Discussion

The COVID-19 pandemic has challenged acute rehabilitation to move beyond traditional in-person sessions and embrace a different model of service across physical therapy/occupational therapy disciplines to deliver essential care. The 2 case reports highlight a model of care that used technology and 2 COVID-19-specific decision-making processes to provide safe and patient-centered care. Both patients with COVID-19 demonstrated functional gains after 2 to 4 weeks of acute rehabilitation and were discharged to prior residences.

To our knowledge, this case report is the first to outline how rehabilitation providers leveraged technology to deliver acute rehabilitation services. The use of an in-room video communication system and physical therapy/occupational therapy co-treatment strategies enabled patients to receive both physical therapy and occupational therapy services while conserving PPE and reducing provider contact. Furthermore, the capability for virtual rehabilitation following hospital discharge allowed the rehabilitation team and patient to comfortably make an informed decision to discharge the patient from the hospital to home (Case 2). However, we experienced potential barriers (eg, scheduling difficulty) to successful adherence to recommended rehabilitation following hospitalization. Virtual rehabilitation is a new program at our facility, and we are currently revising the scheduling process and developing resources to facilitate improved transition of care.

To our knowledge, this case report is the first to outline a decision-making model used to inform the delivery of acute rehabilitation services. The complex decision-making integral to rehabilitation in acute care is intensified by the COVID-19 pandemic when PPE is scarce, minimal contact is recommended, and transfers to post-acute facilities are conservative. All the aforementioned factors greatly impact the delivery of acute rehabilitation services, which often require close patient contact, frequent interaction, and the need to make timely, patient-centered discharge recommendations. Thus, our decision-making model provided structured guidance and standardization to our clinical decisions in the context of providing acute rehabilitation during a pandemic.

While the changes in service delivery outlined in this case report were a practical necessity during a pandemic, a need exists to evaluate and determine what elements to maintain beyond the pandemic's end. First, the role of acute rehabilitation clinicians has traditionally served as a consultation service for discharge planning. However, the increased length of hospital stays and difficulty discharging to outside post-acute rehabilitation facilities has expanded the role of the acute physical therapist/occupational therapist to providing rehabilitation models of care in our facility, which has implications for changes in staffing structures. Second, the use of our collaborative decision-making models and technology appeared to remove physical therapy and occupational therapy silos in our facility. By actively collaborating between disciplines, physical therapists and occupational therapists gained greater insight into discipline-specific approaches and integrated these elements to help patients progress synchronously towards both physical therapy and occupational therapy goals. Third, the increased use of technology has the potential to expand options to deliver acute rehabilitation care in remote areas that serve our patient population and lack adequate rehabilitation workforces at our facility.

This case report is not generalizable. However, the 2 cases illustrate our rapid change to delivering acute rehabilitation services in the context of the COVID-19 pandemic. We believe the treatment delivered and discussion points raised have applicability to other patients without COVID-19 and other health care systems. A second limitation is the lack of formal data regarding patient or clinician satisfaction with the technology and delivery of acute rehabilitation services. However, the COVID-19 physical therapist/occupational therapist team consists of 4 clinicians who worked together to develop the model, suggesting acceptability by providers.

The COVID-19 pandemic continues to confront the health care system and rehabilitation profession with challenges to delivering care. Importantly, the innovative models created in response to the unique challenges of the pandemic are unlikely to cease once the pandemic ends. Future research is needed to determine the effectiveness, costs, scalability, and downstream effects of our approach to acute rehabilitation for patients hospitalized with COVID-19. Furthermore, the application and evaluation of this framework to other non-infectious patient populations in our facility is needed to address the iatrogenic impact of COVID-19 on the delivery of acute care rehabilitation, specifically prolonged hospital stays given barriers to transfers to outside facilities for rehabilitation.

Author Contributions

Concept/idea/research design: T. Livingston, E. Sullivan, G. Wilske, A. Gustavson

Writing: T. Livingston, E. Sullivan, G. Wilske, A. Gustavson

Data collection: T. Livingston, E. Sullivan

Data analysis: T. Livingston, E. Sullivan, A. Gustavson

Providing participants: T. Livingston, E. Sullivan

Consultation (including review of manuscript before submitting): T. Livingston, E. Sullivan, G. Wilske, A. Gustavson

Acknowledgments

We acknowledge Dr Alisha Beckett, PT, DPT, for providing information on the CRU admission process and criteria.

Funding

This project was funded in part by the Veterans Health Administration Office of Academic Affiliations Advanced Fellowship in Clinical and Health Services Research (TPH 67-000) (A.M.G.), and the Minneapolis Center of Innovation, Center for Care Delivery and Outcomes Research (CIN 13-406). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

References

This work is written by US Government employees and is in the public domain in the US.

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Innovative Care Delivery of Acute Rehabilitation for Patients With COVID-19: A Case Report

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Physical therapists and occupational therapists are needed on the frontlines of the novel coronavirus 2019 (COVID-19) pandemic to delay, prevent, or recover the loss of function due to prolonged hospitalization. The typical functional declines observed may be exacerbated during a COVID-19 hospital admission due to the necessary precautions to mitigate viral spread such as keeping patients confined to their rooms and minimizing contact with providers.

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Personalized pulmonary rehabilitation and occupational therapy based on cardiopulmonary exercise testing for patients with advanced chronic obstructive pulmonary disease

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Personalized pulmonary rehabilitation and occupational therapy based on cardiopulmonary exercise testing for patients with advanced chronic obstructive pulmonary disease

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This article served as a new approach for clients with COPD to ease into long-term changes to their daily activities. Previous interventions were to improve exercise capacity as a short-term goal, but it’s essential to keep in mind the long-term effects of intervention.

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EFFECTIVENESS OF INCORPORATING OCCUPATIONAL THERAPY IN REHABILITATION OF HAND BURN PATIENTS

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EFFECTIVENESS OF INCORPORATING OCCUPATIONAL THERAPY IN REHABILITATION OF HAND BURN PATIENTS

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This article would benefit occupational therapists to provide more evidence to support hand therapy for clients with burns. Client with hand burns' primary goal is returning to society. This article studies the effects early intervention has on patients who have hand burns. Clients suffering burn injuries have a limited range of motion and decrease functionality. Early intervention aims to move patients towards a full recovery and return to activities of daily living. This study showed that OT services were valuable for patients with hand burn injuries.

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HIV/AIDS and work: The implications for occupational therapy

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HIV/AIDS and work: The implications for occupational therapy

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This article covers the occupational therapist role in helping those with HIV/AIDS in transitioning back into the workforce. Individuals with HIV/AIDS have trouble transitioning back into work due to fatigue, muscle atrophy, confusion, depression, etc.  As work is the main component of our everyday lives, understanding the emotional, physical, and mental aspects after a diagnosis is crucial to intervention success.

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Team roles:  The Positive Impact of Occupational Therapy in Interprofessional Education 

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Team roles:  The Positive Impact of Occupational Therapy in Interprofessional Education 

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The PCTE Questionnaire

A successful interprofessional healthcare delivery team understands the roles and responsibilities of each profession but it is common for allied healthcare professionals to misunderstand or lack understand regarding what OT's do and how OT's scope of practice is relevant to positive patient outcomes. This study presents the outcomes of physical therapy and physician assistant students on perceived understanding of each profession’s roles and responsibilities. More importantly, the study introduces the Primary Care Training and Enhancement (PCTE) Interprofessional Actual and Perceived Knowledge Questionnaire to assess actual understanding of health professions’ roles and responsibilities.

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Abstract

It is essential that members of a successful interprofessional healthcare delivery team understand the crucial roles and responsibilities of each profession. Participation in interprofessional education and practice has been suggested to improve understanding of the roles of each discipline on an allied health team, however, often understanding of the occupational therapy scope of practice is confusing to other allied health professionals. This study presents the outcomes of a community-based interprofessional practice experience with occupational therapy, physical therapy, and physician assistant students on perceived understanding of each profession's roles and responsibilities. In addition, this study introduces the Primary Care Training and Enhancement (PCTE) Interprofessional Actual and Perceived Knowledge Questionnaire to assess actual understanding of health professions' roles and responsibilities. The inclusion of occupational therapy students in the interprofessional practice experience resulted in a significant increase in physical therapy and physician assistant students' perceived understanding of occupational therapy's scope of practice (an increase of 11.0% and 23.4%, respectively, p

Biography

Dr. Wendie Leveille, OTD, OTR/L is the Program Director and Clinical Assistant Professor of the Master of Occupational Therapy program in the College of Health Sciences at Carroll University in Waukesha, WI. She is also a dedicated faculty member of the HRSA Primary Care Training and Enhancement interprofessional integrative approach to health grant faculty team.

Dr. James Brandes, MD is the Program Director and Clinical Professor of the Physician Assistant Studies program in the College of Health Sciences at Carroll University in Waukesha, WI. He is also the medical director of the HRSA Primary Care Training and Enhancement interprofessional integrative approach to health grant team.

Dr. Karene Boos, PT, JD, DPT is a Clinical Assistant Professor of the Physical Therapy program in the College of Health Sciences at Carroll University in Waukesha, WI. She is also a dedicated faculty member of the HRSA Primary Care Training and Enhancement interprofessional integrative approach to health grant team.

Amy Vega, BS is the full-time Project Coordinator of the HRSA Primary Care Training and Enhancement grant in the Colleg,e of Heath Sciences at Carroll University in Waukesha, WI. The grant is focused on interprofessional integrative approach to health activities in graduate and undergraduate health science programs.

Dr. Barbra Beck, PhD is the Program Director and Associate Professor of Public Health and an adjunct faculty in Physician Assistant Studies in the College of Health Sciences at Carroll University in Waukesha, WI. She is also a dedicated faculty member of the HRSA Primary Care Training and Enhancement grant.

Barbara Ruggeri, MLIS is the Health Sciences Librarian at Carroll University in Waukesha, WI working with and teaching health professional undergraduate and graduate students in the College of Health Sciences. She is also a dedicated member of the HRSA Primary Care Training and Enhancement grant.

Thomas E. St. George, PhD is an Assistant Professor of Mathematics in the College of Arts and Sciences at Carroll University in Waukesha, WI. He is also the Project Evaluator/Statistician for the HRSA Primary Care Training and Enhancement grant.

Jane Hopp, PT, MS, PhD is the Associate Vice President for Academic Affairs - Partnerships and Innovation at Carroll University in Waukesha, WI. She is also the Project Director and Principle Investigator of the HRSA Primary Care Training and Enhancement grant.

Recommended Citation

Leveille, W., Brandes, J., Boos, K., Vega, A., Beck, B., Ruggeri, B., St. George, T. E., & Hopp, J. (2020). The Positive Impact of Occupational Therapy Involvement in Interprofessional Education. Journal of Occupational Therapy Education, 4 (4). https://doi.org/10.26681/jote.2020.040405

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The Positive Impact of Occupational Therapy Involvement in Interprofessional Education

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It is essential that members of a successful interprofessional healthcare delivery team understand the crucial roles and responsibilities of each profession. Participation in interprofessional education and practice has been suggested to improve understanding of the roles of each discipline on an allied health team, however, often understanding of the occupational therapy scope of practice is confusing to other allied health professionals.

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Continuous Quality Improvement in Healthcare: Principles, Process, and Tools by Becky Simon on May 08, 2019

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Continuous Quality Improvement in Healthcare: Principles, Process, and Tools by Becky Simon on May 08, 2019

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Highlights from Lean Six Sigma & PDSA (Plan, Do, Study, Act) in identifying efficiency models and best practices in allied health professing delivery settings.

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Multipart article

Smartsheet Contributor Becky Simon on May 08, 2019

Primary Models for CQI in Healthcare

A number of established models can help organizations perform effective continuous quality improvement. Many of those models originated and are still used in other industries. But they can apply to healthcare organizations. CQI models include the following:

Lean: This model originated with Toyota, a Japanese carmaker. It defines value based on what the customer (or patient) wants, then flows from there. In healthcare, the model focuses on reducing activities that don't add value, making tasks more mistake-proof, and constantly cutting down on waste to improve the delivery of healthcare. Learn more about Lean project management here.

Six Sigma: This model originated in the U.S. manufacturing industry. It works to improve efficiency by minimizing variability in a process, then finding and correcting errors. As errors decrease, so does variability. Learn more about Six Sigma here.

Lean Six Sigma: This model combines Lean and Six Sigma.

Baldrige Quality Award Criteria: Formerly a criteria for an award, this model has transformed into a methodology. It focuses on aligning resources while improving communication, effectiveness, and productivity.

Plan Do Study Act (PDSA): This model begins by determining the specifics and scope of the problem, determining the changes that should happen, planning for those changes, and figuring out what an organization will measure to determine whether change under way. Then you establish whether any of the changes are positive, adjust if needed, and start the process again. Learn more about PDSA in "A Business Guide to Effective Quality Improvement in Healthcare: Principles, Strategies, Templates, and Metrics."

Root Cause Analysis: This method is used most often after an event, usually adverse, to understand the underlying cause. It's based on the presumption that many human errors occur due to an underlying systemic problem.

Deming Plan Do Check Act Cycle: This is another term for the PDSA model that includes the name of William Edwards Deming, a pioneer of quality improvement processes.

Failure Modes and Effects Analysis: This method, part of Six Sigma, tries to prevent errors by identifying all of the ways that they might occur in a process. It then works to change the process to minimize the chance of errors before they happen.

Focus Analyze Develop Execute (FADE): This model is similar to PDSA and outlines a process to collect data, take actions to improve a process, evaluate whether the actions help, and make needed adjustments.

Versions of some of these models focus on healthcare improvement, including the following:

The Institute for Healthcare Improvement (IHI) Model for Improvement: A leading healthcare improvement organization, IHI uses an adapted version of PDSA in its work.

Care Model: This model creates a system in which patients and healthcare providers have more productive interactions with each other during the care process.

Health Failure Modes and Effects Analysis (HFMEA): This method, developed by the VA's National Center for Patient Safety, is a version of FMEA specifically geared toward healthcare.

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Different Types of CQI Studies

A continuous quality improvement program often seeks to look more closely at a wide range of processes within a healthcare organization. But a CQI program also focuses on a specific aspect of an organization's operation. One way to differentiate that focus is to categorize a program as either a CQI process study or a CQI outcomes study.

CQI Process Study: A CQI process study looks at the effectiveness of a healthcare delivery process. These studies focus on how an organization performs a specific task - often a nonclinical task that may be related to a clinical procedure. Here is an example: how patients are scheduled for and informed about follow-up appointments.

CQI Outcomes Study: A CQI outcomes study analyzes patient care and whether the organization is achieving expected results. How are patients doing within a set amount of time after a specific procedure? The study establishes measurements that can appropriately assess outcomes and monitors those measurements closely.

Other Ways to Differentiate CQI Programs

There are other methods of differentiating CQI projects. For example, some CQI efforts focus on how an individual patient in a particular condition is treated; others focus on treatment for a group of patients. Individual-level programs and group programs are described below:

Individual-Level Programs: This kind of program is intended to improve the care for a specific patient. For instance, you may want to determine how to decrease the pain levels for a client through the collaboration of a full medical team: physicians, nurses, occupational therapists, and pharmacists.

Group Programs: This kind of program is intended to improve the care of groups of patients. For instance, you may want to place patients in certain categories based on their risk of pressure ulcers from laying in a hospital bed for a long period. You can assign categories based on their age, health condition, and other variables. Medical providers then give patients different levels of attention and treatments based on a patient's category.

The best CQI programs operate as their name suggests - continuously. But some organizations may have financial limitations that affect how often they can conduct CQI projects. The National Commission on Correctional Healthcare, for example, recommends that correctional facilities have either basic or comprehensive CQI programs according to the size of the facility.

Basic Programs: The commission recommends that correctional facilities with a daily population of 500 or fewer should implement a basic program of at least one CQI process study and one CQI outcomes study at least every year.

Comprehensive Program: The commission recommends that facilities with a daily population of more than 500 should implement a comprehensive program of at least two CQI process studies and two CQI outcomes studies per year.

Continuous Quality Improvement in Healthcare Information Technology - Especially in Electronic Health Records

You can successfully apply - and get help from - technology used in healthcare for your continuous quality improvement efforts. This is the case with the electronic health record (EHR) that exists for every patient.

An EHR is, in essence, a patient's "chart" that at one time existed only on paper. It includes information on all recorded aspects of a patient's health and the healthcare they have received. Recent federal legislation recommended a national goal for the "meaningful use" of EHR technology. That means all medical providers should have easy access to a patient's EHR and use it to improve healthcare for all patients.

Organizations with a good CQI program can use their EHR information to gain a better understanding of the health of their patients, how certain care helped or hindered their well-being, and how to improve overall healthcare.

What Is Continuous Quality Improvement in Healthcare?

Continuous quality improvement in healthcare is an ongoing process to advance healthcare by always asking "How are we doing?" and "Can we do it better?" The goal is to improve healthcare by identifying problems, implementing changes to fix those problems, monitoring whether the changes help, and making further adjustments if they aren't getting the desired results.

You might hear other terms in reference to CQI or to programs that are similar to CQI. They include the following:

Quality improvement (QI)

Quality improvement consulting

Total quality management (TQM)

Clinical practice improvement (CPI)

Total quality control

Standards and Guidelines on Quality Improvement for Healthcare Organizations

Leading organizations involved with assessing healthcare quality have created standards and guidelines to understand what constitutes good healthcare quality and how healthcare can be improved. Here are two important sets of guidelines:

The National Patient Safety Goals: The Joint Commission, which accredits most hospitals and healthcare organizations in the United States, establishes and continually updates patient safety goals for healthcare. The current goals include a focus on the following issues: correctly identifying patients; ensuring medicine is used safely; preventing infections; and preventing mistakes in surgery.

National Quality Strategy: This strategy was first published in 2011 by the Agency for Healthcare Research and Quality. It established three overall aims and six overall priorities to improve healthcare in the United States. Priorities included reducing harm in the delivery of care, ensuring that each patient and their family are partners in their care, and promoting effective coordination of care among providers.

The History of Continuous Quality Improvement in Healthcare

Continuous quality improvement in healthcare is a version of similar processes that began in manufacturing and can be traced back to the 1920s. Some healthcare leaders and academics began thinking more about healthcare quality improvement in the 1960s.

CQI processes were developed further in manufacturing in the 1970s and 1980s, as well as in healthcare in the 1990s. Here are some landmark times and important people in the development of CQI in healthcare.

1910 and 1920s: Walter Shewhart, called the "father of quality control," worked as an engineer in the 1910s and 1920s for Western Electric and Bell Labs, respectively. At Western Electric, he worked in the manufacturing plant to help improve telephone hardware. He began working on improvement processes that became the foundation of quality improvement.

1950s: W. Edwards Deming, an American engineer and statistician, championed Shewhart's work in manufacturing processes. Around the same time, Joseph Juran, an American engineer born in Romania, focused on quality management. He was one of the first management theory leaders to write about the cost of poor quality.

1966: Dr. Avedis Donabedian, a physician, published "Evaluating the Quality of Medical Care." He presented a model for examining an organization's structure, processes, and outcomes to better understand healthcare quality.

1989: The U.S. Congress created the Agency for Healthcare Policy and Research, now known as the Agency for Healthcare Research and Quality (AHRQ). The organization continues to focus on research into what works in treating patients, treatment outcomes, and guidelines for best health practices.

1991: The nonprofit Institute for Healthcare Improvement was co-founded by Donald Berwick, a pediatrician who in 1986 co-founded the National Demonstration Project on Quality Improvement in Health Care. Berwick is considered one of the most important pioneers of quality improvement processes in healthcare. The Institute for Healthcare Improvement remains a leading nonprofit organization in studying and encouraging healthcare improvement.

1999: The Institute of Medicine (IOM) publishes "To Err Is Human," a transformative article detailing the number of medical errors that routinely happen and how many deaths they cause every year.

2001: The IOM publishes "Crossing the Quality Chasm," a follow-up to "To Err Is Human." It outlines several aims for healthcare quality improvement.

Read more about "To Err Is Human" and "Crossing the Quality Chasm" in "A Business Guide to Effective Quality Improvement in Healthcare."

Early Discussion and Analysis of the CQI Movement in Healthcare

Early academic analyses of the CQI movement in healthcare in the late 1990s found that, while the campaign had gained influence, it had yet to show many tangible results.

An 1998 academic study entitled "Assessing the Impact of Continuous Quality Improvement on Clinical Practice" was published in the Milbank Quarterly, a healthcare policy journal. The study authors analyzed 55 continuous quality improvement programs that had been studied and published in academic papers: 42 CQI programs at single sites and 13 CQI programs across multiple sites. They found that the outcomes of care had improved in a number of the cases.

"Particularly important correlates of success appear to be the participation of a nucleus of physicians, feedback to individual practitioners, and a supportive organizational culture for maintaining the gains that are achieved," the authors wrote.

The authors warned, however, that the success of any new CQI program couldn't be assumed from the results of the 55 cases. The CQI programs detailed as part of academic studies might have been more likely to succeed, the authors wrote. They couldn't guess at the number of unsuccessful CQI programs that had never been outlined in academic papers, they wrote.

Another 1998 academic study - "A Report Card on Continuous Quality Improvement," also published in the Milbank Quarterly - highlighted the progress to that point and the challenges of CQI.

Since 1998, CQI has been much more ingrained in the healthcare system and has produced consistently positive results. However, some of the recommendations and lessons detailed in the 1998 "report card" are still important today, including the following:

Involve physicians early, not late, in the effort to improve quality. "Use their time effectively and judiciously, and focus on improving practices that are relevant to them," wrote the "Report Card" authors, David Blumenthal and Charles Kilo. "At least one study found that, rather than alienating them, involving physicians early on facilitated later diffusion of CQI," the authors wrote.

Emphasize clinical, patient-oriented improvement, not just cost reduction. "Clinical projects often have the advantage of producing quicker, more easily quantifiable results than nonclinical projects," Blumenthal and Kilo wrote.

Invest in quality improvement. Professional expertise and credible data are needed to improve clinical processes.

Avoid jargon and management-centric language. Discuss issues in concise, easy-to-understand layman's terms.

Don't conduct mass training of staff at the beginning of a CQI initiative. Instead, conduct more focused and intensive training for appropriate staff when a specific project starts.

Ensure that the healthcare facility's board of directors participates in the initiative. Getting buy-in from high-level stakeholders is crucial.

To learn more primary methods that can help you perform CQI - including Lean, Six Sigma, and others - along with the appropriate organizational foundation for CQI, tips for successful implementation, and the benefits of CQI to healthcare organizations' operations, see "A Business Guide to Effective Quality Improvement in Healthcare."

Applying CQI to Healthcare Clinical Practice

CQI academic researchers have pointed out that applying CQI to clinical practice usually involves three broad categories of problems:

1. Overuse: This refers to the use of healthcare services or procedures when the risks outweigh the benefits. "The services that tend to be overused are the prescription of tranquilizers and sedatives and the performance of carotid endarterectomies, hysterectomies, and upper GI endoscopies," wrote the authors of "Assessing the Impact of Continuous Quality Improvement on Clinical Practice."

2. Underuse: This refers to the failure to provide healthcare services or procedures when the benefits outweigh the risks. "In the underused category are immunization, anticoagulation therapy, assessment for depression, prenatal care, and mammography," wrote the "Assessing the Impact" authors.

3. Misuse: This refers to when an appropriate healthcare service is used improperly. "Common examples of misuse are medication errors and complications or injuries to the patient that are caused by the provider," the paper's authors wrote.

Systemic Barriers to Continuous Quality Improvement

You may encounter barriers and challenges with CQI programs, of course. Some of those barriers are due to the inherent structure of healthcare organizations and the healthcare system in the United States. They include the following:

With scant economic competition in some geographic areas, hospitals and healthcare facilities have little incentive to significantly change how they do their work.

Physicians can be very resistant to CQI programs - in part, due to concern for their patients.

Until recent years, medical education has provided little instruction on quality improvement.

Many healthcare organizations continue to look inward to the desires of their staff, rather than outward to the needs of patients.

There is a lack of alignment between the quality improvement process and the resources and planning system that would make it successful. "In my experience, when this kind of program doesn't work, it's because it's been treated as a (temporary) tool, rather than a management methodology and a shift in culture," Larivee says.

There is too little support or engagement from an institution's CEO and other top leaders.

​To learn more about other challenges to performing good continuous quality improvement, see "A Business Guide to Effective Quality Improvement in Healthcare."

Healthcare CQI Programs Cover a Wide Range of Clinical and Other Areas

As healthcare organizations have pursued likely tens of thousands of CQI initiatives or more over the past decade, they've done the work in a wide range of clinical and other areas. CQI work has been performed in hospitals, blood banks, ambulatory palliative care departments, and correctional institution medical departments, among thousands of other places.

CQI work has also focused on the following:

Airway management

Treatment for patients with back pain

Sepsis rates within a hospital

You can learn more about specific examples of CQI efforts in "The Largest Roundup of Healthcare Improvement Examples and Projects."

Patient Surveys That Relate to Quality Improvement in Healthcare

The Centers for Medicare and Medicaid (CMS) and the Agency for Healthcare Research and Quality began developing a patient survey in the early 2000s to assess care for patients admitted to hospitals. The survey was first used in 2006, and results were first publicly reported in 2008.

The survey is called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). It is administered to patients after they've been discharged from a hospital and asks about their experiences at the facility, including the following factors:

How well medical providers communicated with a patient

How responsive the staff was to a patient's needs

How well medical providers helped manage a patient's pain

Whether medical providers offered important medical information to a patient when they were discharged

Results of the survey play a small part in how medical facilities are reimbursed for care of Medicare and Medicaid patients. The results are also publicly available on an HCAHPS website for prospective patients to use in evaluating a hospital. For both reasons, the survey encourages facilities to play close attention to certain areas of patient care and patient satisfaction.

A CQI Project in Healthcare vs. a Medical Research Project: Similarities and Differences

In some ways, a continuous quality improvement project is similar to scientific medical research on a problem. But the two processes are also very different. Here are some distinctions between continuous quality improvement and medical research:

CQI Projects

Research Projects

A CQI project adjusts processes to improve patient care.

A research project tests a hypothesis to add to general medical knowledge on a subject.

A CQI project produces findings for a healthcare facility to improve its operations.

A research project adds to general medical knowledge far beyond the healthcare facility.

A CQI project uses evidence-based standards.

A research project often tests new methods or standards not yet backed by evidence.

A CQI project attempts to make changes that result in patient benefit.

A research project may produce knowledge that has no benefit to a specific patient.

A CQI project often follows a method or cycle, such as the PDSA.

A research project adheres to the study design and often includes randomization of patients who get a new treatment versus those who don't.

A CQI project includes most people who participate in a process.

A research project often includes a part of a specific population, with various patients intentionally included or excluded.

A CQI project requires a Health Insurance Portability and Accountability Act release to use a patient's individual health information.

A research project must identify how it protects a patient's individual health information and requires specific written consent from any patient to be included in the study.

A CQI project might make changes in the process, depending on its findings.

A research project does not change its original protocol; results are analyzed only when the project is finished.

The results of a CQI project are not intended to be published in a scientific journal, although they may be.

The results of a research project are expected to be published in a journal or presented to the medical or scientific community.

A CQI project is typically paid for by the healthcare organization itself.

A research project might be funded by external agencies or organizations.

How One Louisiana Medical Center Successfully Executed CQI Projects

Top leaders of the Thibodaux Regional Medical Center in Thibodaux, Louisiana, knew the medical center needed to continuously improve in order to do well.

Chief Executive Officer Greg Stock set up a steering committee that included physicians and other leaders to spearhead the organization's work in quality improvement. The steering committee, in turn, identified other top physicians and clinical leaders to be part of the work.

The group successfully tackled a number of quality improvement projects, including one to lower the mortality rates of its patients with sepsis, an overwhelming reaction by the human body to infection. Sepsis is a medical emergency and can quickly lead to organ failure and death.

Thibodaux Regional Medical Center leaders estimate that its quality improvement program saves 16 patient lives per year from sepsis. To learn more about Thibodaux Regional Medical Center's sepsis quality improvement program - and dozens of other quality improvement programs - check out "The Largest Roundup of Healthcare Improvement Examples and Projects."

Thibodaux has received a number of awards for its commitment to quality improvement, including an Outstanding Achievement Award from the American College of Surgeons' Commission on Cancer and an award for hospital of the year for clinical excellence in pulmonary disease and respiratory care.

Supporting Your Quality Improvement Program and Maintaining Momentum

It's important that your quality improvement program maintains its momentum beyond the first weeks, when staff enthusiasm might be highest. Here are some important activities and principles to follow to support the program and continually move it forward:

Track performance over time, and communicate that performance to all employees in easy-to-digest ways. You might track metrics on a monthly or (at a minimum) quarterly basis. You should communicate those metrics and overall performance measures in easy-to-understand graphics; also, share those results widely. To learn more about proper measurements and benchmarks in healthcare quality improvement, see "A Business Guide to Effective Quality Improvement in Healthcare."

Communicate your challenges, but also celebrate success. The metrics may show issues that staff should learn about. Moreover, a CQI program can often seem challenging, with staff believing that the organization is not accomplishing enough. That's why it's essential to celebrate even small successes when they happen. Minor celebrations for good work break up routines and encourage people to move forward.

Tools to Help with Quality Improvement

To aid in quality improvement work, you can try a wide range of tools, including the following:

Diagrams that illustrate how a process flows, show the interrelationship among processes, and demonstrate the causes and effects

Data that's recorded over time and analyzed on flow diagrams, etc.

Case studies that illustrate how a CQI process did or or didn't work

Survey results that show how patients feel about their care

Communication tools that allow for sharing a CQI process' particulars and results with employees

Improve CQI in Healthcare with Smartsheet for Healthcare

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Continuous Quality Improvement in Healthcare | Smartsheet

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Smartsheet Contributor Becky Simon on May 08, 2019 A number of established models can help organizations perform effective continuous quality improvement. Many of those models originated and are still used in other industries. But they can apply to healthcare organizations. CQI models include the following: Lean: This model originated with Toyota, a Japanese carmaker.

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Oral Contraceptives & Ischemic Stroke Risk

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Oral Contraceptives & Ischemic Stroke Risk

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This is a topic that was highlighted in one of our sync sessions. According to this study published by the AHA, the risk of stroke for women is higher during pregnancy and each subsequent pregnancy in comparison to taking the pill to prevent pregnancy. The article goes so far as to include that stroke risk with the pill (OCP) and migraines is limited and conflicting but do not address clearly that this confounding information is a result of a lack of medical studies including women - we simply need more EBR on women's health! Although the benefits of the pill (OCP) outweigh the risks in healthy women,, the study opens with an outlier case of a woman with migraine issues and no doubt this is the story that is well remembered and repeated.

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Assistive and Rehabilitative Effects of the Playskin LiftTM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis (nonprogressive neuromuscular orthopedic condition)

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Assistive and Rehabilitative Effects of the Playskin LiftTM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis (nonprogressive neuromuscular orthopedic condition)

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Iryna Babik; Andrea Baraldi Cunha; Michele A. Lobo American Journal of Occupational Therapy, December 2020, Vol. 75, 7501205110. https://doi.org/10.5014/ajot.2020.040972

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Iryna Babik, Andrea Baraldi Cunha, Michele A. Lobo; Assistive and Rehabilitative Effects of the Playskin Lift TM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis. Am J Occup Ther January/February 2021, Vol. 75(1), 7501205110p1-7501205110p10. doi: https://doi.org/10.5014/ajot.2020.040972

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Assistive and Rehabilitative Effects of the Playskin LiftTM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis

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Iryna Babik, Andrea Baraldi Cunha, Michele A. Lobo; Assistive and Rehabilitative Effects of the Playskin Lift TM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis. Am J Occup Ther January/February 2021, Vol. 75(1), 7501205110p1-7501205110p10. doi: https://doi.org/10.5014/ajot.2020.040972 Download citation file: You do not currently have access to this content.

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Use of Electrical Stimulation for People With Spinal Cord Injury: A Survey of Occupational Therapy Practitioners

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Use of Electrical Stimulation for People With Spinal Cord Injury: A Survey of Occupational Therapy Practitioners

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American Journal of Occupational Therapy, April 2020 https://doi.org/10.5014/ajot.2020.035584
This survey from AJOT into AOTA members highlights a need in unifying educational certification and promoting best practices in electrical stimulation. Shockingly, there are no specific treatment protocols and a vast majority neglected to utilize evidence-based research in implementing an Electrical Stimulation intervention.

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Use of Electrical Stimulation for People With Spinal Cord Injury: A Survey of Occupational Therapy Practitioners

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Abstract. Importance: When working with clients who have experienced spinal cord injury (SCI), occupational therapy practitioners can face challenges in achieving desired results during functional activity when using electrical stimulation (ES) interventions. In an effort to understand current pract…

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Guidelines for the Prevention of Stroke in Women | A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

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Guidelines for the Prevention of Stroke in Women | A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

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I find this article particularly relevant because symptom presentation in women tends to be different than men in many medical pathologies. However, the guidelines for symptoms in disease states to watch out for are generally based on medical research where participants are only male. This article considers stroke guidelines and typical presentation in women vs men.

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The Role of Occupational Therapy in Primary Care

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The Role of Occupational Therapy in Primary Care

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This article does a great job in discussing the role of an occupational therapist in the primary care setting.

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Congressional Therapy Champions Reintroduce Bill to Make Occupational Therapy Practitioners Permanent Telehealth Providers

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Congressional Therapy Champions Reintroduce Bill to Make Occupational Therapy Practitioners Permanent Telehealth Providers

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This is from the AOTA website and highlights a bill to make occupational therapy practitioners permanent telehealth providers. I believe with COVID many practitioners had to adapt on how they see their clients. Hopefully, this bill can make it possible for clients to still be seen and receive the therapy they may need.

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Representatives Mikie Sherrill (D-NJ) and David McKinley (R-WV) reintroduced the Expanded Telehealth Access Act (H.R. 2168) on March 23. This bill would enable occupational therapy practitioners to provide occupational therapy (OT) services to Medicare beneficiaries via telehealth even after the current Public Health Emergency (PHE) expires. Legislation is essential because the Centers for Medicare & Medicaid Services (CMS) has indicated that it does not have the authority to extend the current PHE telehealth therapy provisions without Congressional action.

"Waivers issued by CMS to allow occupational therapists and occupational therapy assistants to provide services to Medicare beneficiaries via telehealth during the COVID-19 pandemic have demonstrated the effectiveness of occupational therapy delivered through telehealth and the importance of removing barriers to care," said Wendy C. Hildenbrand, PhD, MPH, OTR/L, FAOTA, President of the American Occupational Therapy Association (AOTA). "AOTA champions the bi-partisan efforts of Representatives Sherrill and McKinley to insure that the provision of occupational therapy delivered via telehealth will remain an option for Medicare beneficiaries once the Public Health Emergency ends."

Representative Sherrill's district includes Morristown, Parsippany, and other towns in northern New Jersey. "The use of telehealth services during this crisis has demonstrated the critical role technology can play in improving health equity," said Rep. Sherrill. "Even now, as vaccinations are being distributed and the country begins to hope for a post-pandemic future, the value of telehealth networks has never been clearer. No one should have to go without care when a video or phone conversation with a health care provider could mean quicker, safer medical attention. I'm so proud to be reintroducing this crucial legislation that will help modernize our health care system and ensure quality care is more accessible to more people."

Representative McKinley's district covers northern West Virginia, including Wheeling and Morgantown. "During the COVID pandemic, healthcare providers adapted and provided telehealth services to serve the needs of millions of vulnerable Americans," said Rep. McKinley. "Telehealth services have been beneficial to the health and well-being of America's seniors and after the public health emergency ends, it's crucial that critical access to telehealth does not abruptly end. This bill ensures seniors will continue to receive quality, accessible care now and after the pandemic."

When the pandemic struck, Congress enacted legislation that enabled CMS to waive restrictions on occupational therapy practitioners' and other therapy providers' ability to provide Medicare services via telehealth. CMS responded by issuing an emergency rule that added a series of therapy CPT® codes to the telehealth services list, then subsequently issued another rule that included occupational therapy practitioners as eligible Medicare telehealth providers, once Congress enacted legislation allowing them to do so. This effectively enabled OTs to provide services via telehealth to Part B Medicare beneficiaries during the COVID-19 emergency; however, these waivers are not permanent.

In addition to H.R. 2168, the Telehealth Modernization Act (TMA) has also been reintroduced in the House and Senate (S.368/H.R.1332). The TMA would make permanent many of the provisions that are essential to enable all qualified health care practitioners to continue to provide services via telehealth in Medicare, including the removal of geographic and originating site restrictions. The TMA would also enable CMS to make the necessary changes to continue OT and other therapy access via telehealth for Medicare beneficiaries. Because H.R. 2168 is the only bill specifically focused on therapy, it provides the opportunity to demonstrate Congressional support for the inclusion of therapy services under the Medicare telehealth benefit. To see this provision signed into law, we need the support of as many co-sponsors as possible. Please go to AOTA's Legislative Action Center and ask your Representative to co-sponsor this legislation. AOTA will continue to work with Congressional champions to ensure that occupational therapy is included when Congress addresses this issue.

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Congressional Therapy Champions Reintroduce Bill to Make Occupational Therapy Practitioners Permanent Telehealth Providers

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Representatives Mikie Sherrill (D-NJ) and David McKinley (R-WV) reintroduced the Expanded Telehealth Access Act (H.R. 2168) on March 23. This bill would enable occupational therapy practitioners to provide occupational therapy (OT) services to Medicare beneficiaries via telehealth even after the current Public Health Emergency (PHE) expires.

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Cognitive Rehabilitation After Traumatic Brain Injury: A Reference for Occupational Therapists

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Cognitive Rehabilitation After Traumatic Brain Injury: A Reference for Occupational Therapists

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This literature review serves as an excellent reference to keep handy during TBI treatments. It covers early intervention, cognitive assessments, remediation approaches, compensation approaches, self-awareness deficits, learning and memory deficits, executive function, attention, and general strategies and methods to target cognitive domains. Research is still required because not every client with a TBI will have the same treatment plan.

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Evaluation of an occupational therapy program for patients with spinal cord injury

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Evaluation of an occupational therapy program for patients with spinal cord injury

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Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary  disease.

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Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary  disease.

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Rehabilitation programs for patients with COPD have been shown to have a number of benefits, such as fewer hospital admissions, improved work tolerance, improved self-esteem, and improved sense of well-being. This study is looking at variables including activities of daily living, quality of life, exercise tolerance and spirometry. The ADL questionnaires were used during this study to compare the variables listed above. This is a great article that can show that rehabilitation programs done by occupational therapist can help clients with COPD after they leave the hospital. As OT’s we want to improve the quality of life for our clients and this article sheds some light into how successful programs can be.

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Exercise therapy improves mental and physical health in schizophrenia

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Exercise therapy improves mental and physical health in schizophrenia

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This is a randomized controlled trial that studied the effects of an exercise program on mental and physical health in patients with schizophrenia. In schizophrenia, poor cardiovascular fitness is a key risk factor for the development of cardiovascular disease. Exercise therapy, when performed once or twice a week, could improve mental health and cardiovascular fitness. Also, reduced need of care in patients with schizophrenia. There were limitations with this study, but collecting more data could help possibly change/add more interventions occupational therapist could use involving exercise.

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Older Adults with Cancer: A Randomized Control Trial of Occupational and Physical Therapy

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Older Adults with Cancer: A Randomized Control Trial of Occupational and Physical Therapy

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The impact of occupational therapy onfunctional outcomes in older adults with cancer is unknown for older adults. If patients were informed about the potential benefits of rehabilitation
for older cancer patients, OT and PT could potentially have significant impacts on health
outcomes. There were barriers that included cost and travel. I believe that more therapy resources need to be available for clients with cancer. I believe that main problem is that clients are unaware that therapy could be beneficial.

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Effects of nutrition and exercise in palliative care cancer patients

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Effects of nutrition and exercise in palliative care cancer patients

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I think this could be a great article to for occupational therapist to help patients with cancer find nutritional or activities for interventions. By eating healthy and exercising it could improve the quality of life for a client.

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Improving student-perceived benefit of academic advising within education of occupational and physical therapy in the United States: a quality improvement initiative 

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Improving student-perceived benefit of academic advising within education of occupational and physical therapy in the United States: a quality improvement initiative 

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Journal of Educational Evaluation of Health Professionals, University of Mississippi, April 2017.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435569/pdf/jeehp-14-04.pdf

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Abstract

Academic advising is a key role for faculty in the educational process of health professionals; however, the best practice of effective academic advising for occupational and physical therapy students has not been identified in the current literature. The purpose of this quality improvement initiative was to assess and improve the faculty/student advisor/advisee process within occupational and physical therapy programs within a school of allied health professions in the United States in 2015. A quality improvement initiative utilizing quantitative and qualitative information was gathered via survey focused on the assessment and improvement of an advisor/advisee process. The overall initiative utilized an adaptive iterative design incorporating the plan-do-study-act model which included a three-step process over a one year time frame utilizing 2 cohorts, the first with 80 students and the second with 88 students. Baseline data were gathered prior to initiating the new process. A pilot was conducted and assessed during the first semester of the occupational and physical therapy programs. Final information was gathered after one full academic year with final comparisons made to baseline. Defining an effective advisory program with an established framework led to improved awareness and participation by students and faculty. Early initiation of the process combined with increased frequency of interaction led to improved student satisfaction. Based on student perceptions, programmatic policies were initiated to promote advisory meetings early and often to establish a positive relationship. The policies focus on academic advising as one of proactivity in which the advisor serves as a portal which the student may access leading to a more successful academic experience.

Keywords: Health occupations, Health personnel, Quality improvement, Student, United States

Introduction

Academic advising is a key role for faculty in the educational process of health professionals; however, the best practice of effective academic advising for occupational and physical therapy students has not been identified in the current literature. Individual student perception of the benefit inherent in the advisor/advisee relationship should be considered in the development of best practice. Current data extrapolated from nursing and medical education suggest that the advisor/advisee relationship may play a critical role in the development of academic skills, personal growth and professionalism among students across the health professions spectrum [ 1- 4]. A link between effective advising and best practices from both the teaching and learning poles of education has been identified [ 5]. Students strongly seek a caring, authentic, available, knowledgeable advisor to serve as a compass and portal to help facilitate their journey towards becoming successful healthcare professionals in the transformational healthcare system of the future [ 2].

The role of academic advising in health professional education differs from that in general undergraduate education in that the advisory process extends beyond course planning for individual degrees, and provides ongoing support for academic success [ 3, 5]. The purpose of this quality improvement initiative was to assess and improve the faculty/student advisor/advisee process within entry-level occupational and physical therapy academic programs within a school of allied health professions, the University of Mississippi Medical Center, the United States in 2015. The academic advisor process was identified as an area of improvement within the educational program because it had become more of a reactive process that intervened when students found themselves in academic difficulties. Advisors were assigned small groups of advisees, but had no defined protocols to guide advisory interaction. The quality improvement project explained here was undertaken to create an advisor/advisee process which was proactive in serving the academic needs of students in order to promote academic success which facilitates the development of professionalism. The overall initiative utilized an adaptive iterative design incorporating the plan-do-study-act (PDSA) model which included a three-step process over a one year time frame utilizing 2 cohorts of the first with 80 students and the second with 88 students as defined in .

Baseline

Baseline method

In order to understand student perceptions of the original advisory process, baseline information was gathered by administering a questionnaire developed by the authors to physical therapy and occupational therapy students at the University of Mississippi Medical Center who had just completed a first full academic year in their respective programs in 2015. The questionnaire included opinion items, yes/no questions, and open ended questions to be answered by the participants. One Likert-type item was included to gather information on student-perceived benefit ( Appendix 1). The authors systematically went through each participant's qualitative comments and analyzed frequencies of words to discover the emerging themes. These themes are reflected in the results. Statistical analysis was conducted using IBM SPSS for Windows ver. 24.0 (IBM Corp., Armonk, NY, USA). Correlations were calculated using Spearman's correlation coefficient, rs, due to the nature of the variables with one being ordinal and the other continuous.

Baseline results

Eighty students (94.1%) participated in the baseline survey out of total 85 subjects. At baseline, 63 students (78.8%) could name his or her academic advisor; however, 50 students (62.5%) had never had an advisory meeting. Only 14 students (17.5%) had met with advisors within the first month of starting the academic program, and those who did not meet with advisors overwhelmingly reported that they felt getting to know the advisor early would have been beneficial (75.8 %).

Students were asked to respond to the statement: "The advisor/advisee mentoring relationship has been beneficial to my overall growth as a student of the health professions." Only 21 (26.3%) agreed or strongly agreed, and these students reported meeting more than 37 combined times with advisors during the first academic year. Forty-one students (51.3%) were neutral on the issue and had met 16 combined times. Sixteen (20%) disagreed or strongly disagree and had met six combined times during the year. This seemed to indicate that more meetings with advisors led to greater benefit for the students. Statistical analysis showed that there was a significant relationship between the number of face-to-face meetings and the level of perceived benefit of the advisory program (r s= 0.40, P< 0.01).

Fifty seven participants (71.3%) reported developing a mentoring relationship with faculty members who were not assigned as academic advisors. When asked what characteristics students identified that made these faculty members seem approachable, the responses were categorized into the following themes: availability to the students; attitude that was perceived as helpful, kind, caring, respectful of the students, trustworthy, and encouraging; and, invested in the whole person (academic and personal).

Students were asked to provide suggestions on how the advisor/advisee process might be made more beneficial, and the categories of responses were weighted as the following: early initial meetings, and regularly scheduled meetings thereafter (36.3%); a conscious effort to build a relationship as a mentor and guide in whom the student can confide for support and help when needed (21.3%); and, a clear definition of the advisory program (7.5%). Given these baseline findings of student perceptions, the quality improvement initiative using the PDSA model was begun with the first cycle being the pilot [ 6]. According to our institutional policy, institutional review board approval was not required for quality improvement activities.

Cycle 1 (pilot)

The PDSA model calls for implementing small systematic changes in processes followed by outcomes assessment before proceeding to a broader scope of procedural transformation [ 6]. The first step in the quality improvement effort included a small number of faculty advisors who agreed to participate in a pilot of the proposed new process. The proposal was to incorporate an initial meeting with student advisees within the first two weeks of entering the academic program, a follow-up meeting within the first semester, and a meeting at least once per semester thereafter. Six advisors with a total of 29 student advisees took part in the pilot; however, all academic advisors and students were actively involved in the usual advisory process during the semester.

Cycle 1 method

In the pilot semester, the participating advisors followed the proposed schedule and tracked the actions and responses from advisees. Each advisor scheduled an individual face-to-face meeting with each student advisee during the first 2 weeks of school to serve as an introductory meeting in which they would explain that the advisor role was for mentoring and growth, and was not just for times of academic difficulty.

A second individual meeting was schedule later in the semester with students prepared to discuss personal strengths and opportunities for improvement that had been identified during the first several weeks of school. Faculty advisors were encouraged to use their own individual communication styles as they establish relationships with the advisees.

Upon completion of the semester a survey was conducted of the students completing their first academic semester in the programs. Eighty-eight (97.8%) out of 90 students participated in the survey. Although only 29 students had been assigned to the participating advisors, student communication among their peers led to unexpected improvement in the advisory process across the entire cohort.

Cycle 1 results

At the end of only one academic semester, 87 (98.9%) the students could name his or her academic advisor, and 66 students (75.5%), up from 17.5% at baseline, reported meeting with advisors within the first month of school. Of the 22 students (25.0%) reporting that they did not meet their academic advisor during the first month of school, 52 students (59.1%) reported that getting to know the advisor early would have been beneficial for them.

When these students were asked to respond to the statement: "The advisor/advisee program has been beneficial to my overall first semester experience." Sixty-one (69.3%) agreed or strongly agreed, and these students represented more than 89 combined meetings with advisors. Twenty-three students (26.1%) were neutral on the issue with only 11 combined meetings, and four (4.6%) disagreed or strongly disagree with the statement; however, none of these participants had met with their advisors. Once again these findings indicated that increasing the number of meetings with academic advisors was significantly correlated with greater perceived benefit by the students (r s= 0.59, P< 0.01).

Cycle 2

Given the positive results, in the following semester the new process was introduced to the entire group of faculty advisors for incorporation as the new advisory process within two health professional academic programs.

Cycle 2 method

With participation across the programs, a follow-up survey was completed at the end of the first full academic year for those students who were the first to experience the new process. Eighty-eight students participated in the survey which served as the final evaluation of the newly incorporated educational advisory process.

Cycle 2 results

Results indicated that all students could name his or her academic advisor (up from 78.8% at baseline), and 68 students (77.3%) reported meeting with academic advisors early in the program, up from 17.5%. The findings revealed an improvement in the advisee's perception of the benefit of the advisory program. At baseline, 26.3% found the process beneficial to their growth as a student of the health professions; however, the final results showed that after one year with the new process, 76.7% found it to be beneficial ().

There was a significant correlation between the number of visits with advisors and the students' perception of the benefit of the program (r s= 0.60, P< 0.01). This positive correlation was seen at each level of the initiative. As the number of meetings with advisors increased the perception of benefit also increased (). Raw data were available from Supplement 1.

Once again the students were asked if they had developed mentoring relationships with faculty members other than the assigned advisors. This category resulted in a similar level to baseline indicating that over time students tend to gravitate to individuals with whom they feel a natural ability to communicate. When asked what characteristics students found in these "unofficial" mentors, the responses were identical to baseline. The participants explained that the characteristics of availability, investment in the whole person, and a caring and helpful attitude made the faculty members approachable.

Conclusion

Defining an effective advisory program with an established framework for interaction led to improved awareness and participation by students and faculty. Early initiation of the academic advisory process combined with increased frequency of interaction with focus on the personal and professional growth in addition to academic performance led to improved student satisfaction. Although this initiative focused solely on student perception, future studies should consider faculty perceptions of the program as well as objective measurements of academic successes that may be directly related to a proactive advisory process. This quality improvement initiative was specific to our institution. It is not intended to be generalizable, but rather an example of a successful quality improvement initiative to improve student perception of benefits of the advisory process.

Based on student perceptions within this quality improvement project, programmatic policies and procedures have been initiated to promote advisory meetings early and often to establish a positive relationship. The new policies place a focus on ensuring that the academic advisory process is one of proactivity in which the faculty advisor serves as a portal which the student may access leading to a more successful academic experience. Additionally, the policies allow for autonomy and individuality of the advisors/advisees in order to optimize the benefit of the interaction.

Appendix 1. Questionnaire use for the survey to occupational and physical therapy students

Advisor/Advisee relationships

Please circle: OT (occupational therapy) / PT (physical therapy)

1. What is the name of your academic advisor?

(If you do not know, please write "I do not know")

2. Over the last year, how many face to face meetings have you had with your advisor, outside of class?

a. 0

b. 1

c. 2

d. 3

e. 4+

3. Did you have an initial face-to-face meeting with your advisor during the first month of your first semester as a student?

a. Yes

b. No

If you answered no, do you think this would have been beneficial to you?

If you answered yes, explain if this was beneficial to you and how.

4. My meetings with my advisor were due to      (Please circle all that apply)

a. Positive curricular discussions

b. Discussions about academic difficulties

c. Casual "getting-to-know-you" conversations

d. I have never met with my advisor

e. Others. Please explain

5. Were your meetings with your advisor beneficial in establishing a professional mentoring relationship?

a. Yes

b. No

c. I have never met with my academic advisor

If yes, or no, please elaborate on your answer:

6. Have you established mentoring relationships with faculty members, who are not your assigned academic advisor?

a. Yes

b. No

If you answered yes, what characteristics made this faculty member approachable?

Please rate the follow question:

The advisor/advisee mentoring relationship has been beneficial in my overall growth as a student of the health professions.

0. Strongly disagree

1. Disagree

2. Neutral

3. Agree

4. Strongly agree

Please give us any feedback on the subject of advisor/advisor relationships and how we can better benefit you in this area:

Footnotes
Conflict of interest
No potential conflict of interest relevant to this article.

Supplementary materials

Supplement 2. Audio recording of the abstract.

References

1. Myhre DL, Sherlock K, Williamson T, Pedersen JS. Effect of the discipline of formal faculty advisors on medical student experience and career interest. Can Fam Physician. 2014;60:e607-e612. [[ PMC free article] [ PubMed] Google Scholar]

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Improving student-perceived benefit of academic advising within education of occupational and physical therapy in the United States: a quality improvement initiative

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Academic advising is a key role for faculty in the educational process of health professionals; however, the best practice of effective academic advising for occupational and physical therapy students has not been identified in the current literature.

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Opportunities for Occupational Therapy on a Primary Care Team | AJOT June 2019

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Opportunities for Occupational Therapy on a Primary Care Team | AJOT June 2019

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This AJOT article highlights the need for improved patient outcomes through an an increase in OT referrals for disregarded ADL's.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813496/pdf/7305185010p1.pdf

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Abstract

Importance: Leaders in the occupational therapy profession have called for occupational therapy's inclusion in primary care, but little is known about the occupational needs of patients in this setting.

Objective: To explore the need for and potential role of occupational therapy in a team-based primary care clinic.

Design: A qualitative descriptive study using a convenience sample of clinicians and patients. Meetings and semistructured interviews were recorded, transcribed, and coded by multiple coders using a general immersion-crystallization approach to identify relevant themes.

Setting: Outpatient complex care clinic of an urban academic medical center.

Participants: The study included a voluntary sample of clinicians and patients from the complex care clinic. Patients were recruited from a staff-provided list; eligible patients had attended the clinic for at least 1 yr. All patients had multiple chronic conditions and were uninsured or received Medicaid.

Results: Researchers attended 10 clinician team meetings and conducted 13 patient interviews and 10 clinician interviews. Four domains of patient need were identified by both patients and clinicians: complex medical management, patients' limited resources, mental health needs, and challenges to occupation. Clinicians also identified cognitive-behavioral challenges affecting care, including lack of engagement and poor problem solving.

Conclusions and Relevance: The makeup of the clinic team reflected their intent to address medical, socioeconomic, and mental health domains. However, cognitive-behavioral challenges and patients' occupational limitations were not consistently addressed. Thus, patients had unmet needs that occupational therapy practitioners were qualified to address.

What this Article Adds: This study adds to the available literature examining patient needs and clinician challenges in a primary care clinic. Patients have occupational needs that are not being addressed in primary care, indicating a need for occupational therapy in this setting.

Rising rates of chronic disease and an aging population are stressing the U.S. health care system and driving change in primary care delivery. More than half of the U.S. population is living with at least one chronic condition, and 40% of the adult population has two or more chronic conditions ( Centers for Disease Control and Prevention, 2019). Not surprisingly, chronic diseases account for 75% of health care costs in the United States ( Milani & Lavie, 2015).

In the traditional health care model, care for chronic disease falls on the primary care physician (PCP). However, the ability of PCPs to efficiently and effectively provide care is becoming progressively difficult because they face time constraints in providing necessary face-to-face patient care ( Milani & Lavie, 2015). It is predicted that by 2035, an additional 44,000 PCPs will be required to meet the needs of the population; however, medical schools are not currently producing enough PCPs to meet this demand. Therefore, the United States is on its way to a PCP shortage ( Petterson et al., 2015).

To address the increasing burden placed on the primary care system, clinicians are developing and testing new team-based models of care. Primary care teams are commonly described as being physician led with team members from various clinical fields ( Hutchison, 2014; Margolius et al., 2012). Team-based care allows physicians to focus on medical diagnosis and acute treatment, whereas the team takes on greater responsibility in the management of chronic conditions and routine prevention. Research has provided examples of the benefits of team-based primary care in managing chronic conditions such as diabetes and hypertension ( Hutchison, 2014; Kravetz & Walsh, 2016).

Although research supports the effectiveness of team-based primary care, studies of primary care teams that include occupational therapy are rare. This lack of inclusion of occupational therapy on primary care teams may be due, at least in part, to the limited understanding of the occupational needs of primary care patients and the potential role that occupational therapy can provide in this setting ( Donnelly et al., 2013). To that end, the purpose of this study was to explore the potential need for occupational therapy at a primary care clinic serving a medically complex population. This study was guided by the following research questions: (1) What needs do primary care patients have that could be addressed by occupational therapy? (2) What challenges do primary care clinicians face in treating patients with complex needs? (3) What unique contributions could occupational therapy provide to the primary care team?

Method

Design

In this descriptive study, we used qualitative content analyses to explore the potential need and possible roles for occupational therapy in a team-based primary care setting. We used semistructured interviews of patients and staff along with transcriptions of team meetings. The study was developed from a larger project examining the process of care coordination that was approved by the university's institutional review board. Written consent was received from all participants before data collection.

Setting and Participants

The research was conducted at the complex care clinic (CCC) of an academic medical center. The CCC was created to address the complex medical, behavioral, and socioeconomic needs of uninsured and Medicaid patients with six or more comorbid conditions who are high users of the medical system. The CCC model is centered on an interprofessional team to provide holistic care from a single location. The clinic strives to engage the patient, address socioeconomic barriers, and connect patients to appropriate services and resources ( Virginia Commonwealth University, 2013).

Patients were recruited from a staff-provided list of 36 patients, including both patients whom the staff identified as engaged and progressing in the management of their health and those whom they identified as less engaged and who continued to struggle with managing their conditions. All patients had been attending the clinic for at least 1 yr. All patients were contacted via telephone. All CCC team members were recruited for interviews via email.

Data Collection

The CCC team meets weekly to organize patient care. Researchers recorded 10 of these approximately hour-long meetings between October 2014 and January 2015. Clinician and patient interviews were conducted between March and May 2015. The interviews were conducted by a PhD-trained qualitative researcher, a research associate in the Department of Family Medicine, or one of three occupational therapy students. All interviewers were trained in the interview process, although interview experience varied from novice to expert.

The 30- to 60-min clinician interviews were conducted in private spaces in or near the clinic and included questions about the clinic process and procedures, challenges and successes, patient engagement, and team-based care (interview guides are available from the first author). The 30- to 90-min patient interviews were conducted in locations selected by the patient, including the patient's home, space in the academic medical center's hospital, or another public location. The patient interviews included questions about their experience at the clinic, perceived health changes, challenges in working with the clinic, and limitations to occupational performance.

Data Analysis

Audio recordings of the team meetings and the interviews were transcribed verbatim and checked for accuracy. The transcripts were coded and analyzed with ATLAS.ti (Version 7; Scientific Software Development GmbH, Berlin, Germany). A general immersion-crystallization approach was used whereby the coding team engaged in a continuous process of reading and rereading the transcripts and developing codes to understand the significance of the data ( Borkan, 1999).

To develop the codebook, the coding team independently open coded a subset of the transcripts (two each of patient interviews, clinician interviews, and team meetings). Using a directed content analysis methodology in which a predetermined coding framework was used to describe or extend the theoretical framework ( Hsieh & Shannon, 2005), the team first identified and applied codes derived from the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; OTPF-3; American Occupational Therapy Association, 2014; examples of codes include activities of daily living [ADLs], instrumental activities of daily living [IADLs], and habits and routines). Additional codes were identified through an emergent process when data did not fit within the predetermined OTPF-3 codes (e.g., patient engagement and medication adherence). The team met to discuss and compare the preliminary open coding, and codebooks were developed from the discussions. The first author and the research assistant then independently coded the remainder of the transcripts using the codebooks. Coders met to compare coded transcripts, and any discrepancies were discussed until consensus was formed and codes merged. This process was completed for each type of data collected.

After initial coding of all transcripts was complete, the first two authors met to begin identifying themes. Through an iterative process, related codes were combined into themes (e.g., codes for "ADLs," "IADLs," and "community mobility" were combined to form the theme of "occupational challenges"), and some initial themes were ultimately divided into separate themes (e.g., the initial theme of "complex patients" was broken into the final themes of "medical management," "mental health," and "limited resources"). Themes were initially formed for each type of data, and eventually themes were compared and contrasted with each new type of data and reorganized as patterns emerged. After all data were examined together, themes were conceptually ordered to describe the data and explain relationships among themes.

Because the first author had been involved in the original study, had conducted interviews, and had used other sources of data from the CCC (including embedding in the clinic work room for 15 hr), potential biases related to previous experience and understanding were kept in check through constant reflexivity and were documented through the memo process. Moreover, multiple coders were used to allow greater opportunity to ensure that all themes were identified and that data were consistently being interpreted to limit the potential effect of bias or singular point of view. Development of a codebook and use of memos to track how categories and themes were formed allowed for auditability of the analysis.

Results

The clinic director and all 9 CCC clinicians were interviewed ( n = 10). More than half of the patients were unreachable because of disconnected or changed phone numbers or unreturned voicemail messages. Of the 15 patients who were successfully contacted, 14 were eligible for participation (1 patient could not confirm being a CCC patient) and 13 agreed to participate in the study (1 patient was unavailable during the interview period). Patient demographics were not provided, although gender was identified through the interviews. Characteristics of the sample are shown in .

Table 1.

Analysis produced a broad range of patient needs, resulting in challenges for clinicians and patients. On the basis of the patient's needs, four domains of challenges faced at the CCC were identified by both patients and clinicians: medical management, mental health issues, patients' limited resources, and occupational challenges. A fifth domain was identified solely by clinicians: cognitive-behavioral issues. Subthemes were identified within each domain and are discussed in detail next. Representative quotes are provided in .

Table 2.

Theme/Subtheme

Representative Quotes

Medical management

Medication adherence

And the issue . . . he's still messing up his meds . . . I did a search and I found two pharmacies. I'm going to call them and see if they can do bubble pack. (C4) I'm on so many medicines that some run out before the others, and it's like a whole lot for me to keep in my mind. (P10)

Pain management

He has stated that he has done extensive research . . . and the only thing that works for him is heroin. And I told him that that's not gonna work with us, and he can go to the chronic pain group. (C3) But my problem is I have arthritis, and sometime I can't exercise or even walk like I want to because it's painful. (P3)

Complex needs

A patient who I've been working with has depression; he has lots of social needs as well, like employment and housing. (C8) I have sugar diabetes. I have high blood pressure. I have acid reflux. I have-well, I had kidney stones, but they're gone . . . I have gout in my elbow . . . I do have massive headaches. (P6)

Mental health

[The patient] was feeling down and kind of suicidal and having a hard time managing his diabetes. And we worked together-made a recommendation that he go on an antidepressant. (C8) I was home with my mom who has dementia, and I'm dealing with her all day and going through things with my health. She [the clinician] says, "Well, I think you have caregiver anxiety." So she was constantly sending a psychologist . . . in to talk to me. (P9)

Substance abuse

I guess [they] have other priorities. They're not ready to address their health. They . . . are not concerned about their health. They're only concerned about getting their alcohol or their high. (C4) I mean, I'm being brutally honest . . . I still drink. That's not their fault . . . they try to fix me, I mean, fix that, but you have to want to be fixed first. I don't want to be fixed, not right now. (P8)

Limited resources

Making sure they have resources-have they connected with social services? What assistance have they gotten from them? So, making sure, for example, with the insulin . . . are they able to store it in a place? (C4) They'll give me a piece of paper and tell me what I'm supposed to eat and all that, but . . . nobody [has given me] food. I know this is not welfare. This is a hospital. (P2)

Cognitive-behavioral

Unhealthy habits

We can increase the insulin, but what are you going to do? We'll increase the meds, but are you going to exercise, are you going to change your diet? What can I do to help you? Because you have to change. (C1)

Poor problem solving

Because he doesn't know how to problem solve. "I'm off on this day." I mean-I don't think people think about the possibilities. "If I tell them that I'm off on this day, maybe I could get something scheduled on the day that I'm off. Or maybe I can work around it." (C1)

Lack of engagement

[The patient] was supposed to show for an appointment last week and did not show . . . And I know [C4] called the son the day before and spoke with him to remind . . . So let's send them a certified letter too. I'm not sure they just really want to be engaged. They call and then they don't show. (C5)

Occupational challenges

I have a hard time getting out the bathtub . . . And I go and wash my hair, and wash my arms and everything. And then after I finish doing that, "Honey! I need help!" I tried to get out on my own. I slipped a couple of times. (P1)

Community mobility

Transportation is a problem. I'm working with the father on how to do that because he's so incompetent, he can't ride the bus by himself. His father said he's tried many times with him; it's very frustrating. (C3)

I've always sang in my church choir . . . And I miss being able to get in my car and go to rehearsals and stuff like that . . . I just miss my independence and being able to get around. (P3)

Other areas of occupation

I can't dust. I can't vacuum. And . . . making up the bed, you can't get me around that bed like that. Somebody would have to come and resuscitate me. (P9)

Medical Management

Complex Needs.

The complex needs of patients was a consistent theme across all three sources of information. Complex medical histories and current medical needs presented unique challenges to the team and patients because each patient had multiple diagnoses. Although chronic conditions, including diabetes, obesity, and hypertension, were commonly cited, the complexity and combination of diagnoses were distinct to each patient. Portions of the weekly team meetings were spent reviewing patients who were currently hospitalized for acute conditions, such as stroke or pneumonia. Because of the complex medical conditions, managing medications and coordinating care presented a challenge to clinicians and patients.

However, despite the medical complexity, clinicians often spoke matter-of-factly about patient medical needs. Instead, clinicians found the greatest challenge they were presented with was addressing the host of related social, behavioral, and cognitive dimensions on top of the medical needs. These issues were frequently acknowledged in the team meetings where clinicians discussed the patients' lives to better understand the multifaceted nature of their health and illnesses and to problem solve how the team could address these issues.

Medication Adherence.

Adherence to medication plans was identified as a major patient need posing a challenge to clinicians. In fact, one clinician described taking medications as prescribed as the primary way that patients demonstrated responsibility for their health. At the same time, clinicians acknowledged the many barriers that can affect medication adherence. They described numerous strategies that they used to help patients adhere to their medications, including education, filling patients' pill boxes, locating pharmacies that dispense medication in pill packs, and calling patients to remind them to take their medications.

The patients also reported medication adherence to be a challenge. When discussing their medications, most of the patients noted that they were trying to follow the clinician's orders and understood the importance of taking their medications, even if they did not fully understand what they were, as evidenced by a patient who admitted, "I don't know what to do, what to take. But they give me the medicine, so I try to take it" (Patient 2). Several patients reported that they relied on clinic staff or their family to ensure that they were taking their medications correctly.

Pain Management.

Pain management was a theme in both patient and clinician interviews as well as during team meetings. Clinicians often discussed the discordance between the clinic's philosophy of prescribing opioid pain relievers only as a last resort (if at all) and patients who expected, and sometimes demanded, opioids. This contention had the potential to affect the clinician-patient relationship. From the patient perspective, several of those interviewed cited pain as an impediment to their ability to engage in meaningful activities.

Mental Health and Substance Abuse

In addition to the numerous medical needs experienced by clinic patients, many of them also had comorbid mental health needs, including depression, anxiety, and more severe conditions causing hallucinations and delusions. One clinician estimated that 70%-90% of the clinician's patients had a mental illness. Mental health issues were anticipated when the clinic was formed, and behavioral health specialists, including the psychologists and social worker, were explicitly included on the interprofessional team to assist with these issues. Several of the patients interviewed also acknowledged their struggle with mental health issues, such as anxiety and depression, and noted that the clinic was helping them to address it.

Substance abuse issues were a specific mental health issue mentioned by the clinicians as an impediment to the patients' ability to manage their health, although only 1 patient acknowledged a current substance abuse (alcohol) problem as affecting the patient's health. In particular, clinicians discussed their concern that for some patients who were dealing with substance abuse issues, health became less of a priority, and they were less inclined to engage with the clinic. Clinicians did not discuss direct substance abuse interventions other than basic education on the negative outcomes of substance abuse, but they did mention referring patients to community resources, such as Alcoholics Anonymous.

Limited Resources

Both patients and clinicians acknowledged the challenge that patients' limited resources presented for managing health. From the patients' perspective, limited resources affected their ability to follow the clinic's recommendations. Although their insurance plan covered a substantial portion of medical expenses, it did not cover day-to-day expenses that contributed to health and clinic engagement. Many patients also cited difficulty getting to and from the clinic for their appointments because they did not have enough money for the bus or a cab.

The clinicians acknowledged that fundamental needs, such as stable housing, had to be addressed to effectively manage the patients' health and medical conditions. For example, because insulin must be refrigerated, care must be taken when working with a homeless patient about where and how to store his or her medications. Similarly, most homeless shelters would not accept people requiring medical support, such as oxygen, which is a common need for people with severe chronic obstructive pulmonary disease. These needs were frequently discussed at the weekly meetings where the team collaborated to identify workable solutions, such as adjusting treatment and providing referrals for government and community resources (including transportation vouchers, low-cost prescription assistance programs, and assistance in locating affordable housing).

Cognitive-Behavioral Issues

The overarching theme of cognitive-behavioral issues, which includes subthemes of unhealthy habits, poor problem solving, and lack of engagement, was the only theme identified solely in clinician interviews and team meetings and in patient interviews.

Unhealthy Habits.

Clinicians frequently discussed what they considered to be unhealthy behaviors of some patients, including smoking and not maintaining a healthy diet. Several clinicians noted frustration when, in their opinion, patients appeared unwilling or unmotivated to make necessary behavior changes or expected the clinicians to be able to "fix" the behavior for them. Clinicians primarily used education and referral to community resources (such as food banks) to encourage healthier habits.

Poor Problem Solving.

Clinicians suggested that some patients were not able to effectively problem solve, which led to their limited ability to manage their health. An issue that frequently came up during team meetings was lapsed insurance or Medicaid coverage. When difficulty arose in filling out the paperwork or providing documentation, the clinicians noted that, rather than problem solve how to address the issue, some patients just did not complete the required paperwork at all. Although the clinic is staffed with a case manager and social worker to assist patients with the many socioeconomic barriers that they face (e.g., through coordination with the Medicaid office or referral to programs to assist with prescription costs), the clinicians pointed out that some patients in the study skipped appointments rather than reschedule when conflicts arose and even stopped taking medicine when they did not have the money to pay for it, rather than call the clinic to explain the situation and ask for advice and assistance. The clinicians did not mention specific strategies that they used, if any, to improve patients' problem-solving skills. Rather, they relied on detailed instructions and education on when and how to seek assistance.

Lack of Engagement.

A major challenge that the clinicians identified in working with some patients was a perceived lack of engagement. They typically defined an unengaged patient as one who consistently did not keep or show up for appointments. Lack of engagement was also used to describe instances when they believed patients were not fully participating in their health care decisions or taking responsibility for their health management (e.g., not waiting to pick up medications from the pharmacy or not taking their medications).

Although clinicians expressed frustration with some patients' lack of engagement, they often worked toward understanding potential reasons for the lack of engagement, such as work schedules, transportation, and substance abuse. For instance, a clinician discussed the potential health literacy issues that may be affecting patient engagement, asking, "How much do they even understand about health?" (Clinician 8). Clinicians also acknowledged that many of their patients were familiar with the immediacy of receiving care through the hospital's emergency department and had a difficult time transitioning to the clinic process, which required more planning and personal responsibility. Moreover, at team meetings, clinicians discussed patients who were not engaged in the clinic, and they problem solved strategies, such as calling the day before appointments and providing education about health and medications, to stimulate engagement.

Occupational Challenges

Community mobility and IADLs were occupational challenges most discussed by the patients and clinicians. Only 2 patients reported difficulties with ADLs, primarily getting into and out of the tub for bathing. Clinicians tended to talk about ADLs in the context of continuity of care (i.e., when patients were discharging from the hospital or when determining whether home health care was warranted). When staff members became aware of difficulty with self-care or safety issues at home, they discussed possible referrals to outside resources (e.g., home health care, occupational therapy, or physical therapy). However, if a referral was not possible (e.g., would not be covered through insurance), they were left questioning what the clinic could do.

Community Mobility.

Community mobility was the occupational challenge most frequently discussed by both patients and clinicians. Financial barriers affecting patients' ability to get to and from their clinic appointments were previously discussed. However, some patients also faced nonfinancial barriers to community mobility, namely, a lack of knowledge and skills needed to safely and efficiently use the public transportation system. Clinicians identified this knowledge barrier in some patients, but attempts to address the issue focused on identifying alternative transportation methods to get them to the clinic. Community mobility was often voiced as an issue of dependence among patients interviewed. Although the clinic used strategies to assist patients in getting to their medical appointments, patients reported transportation needs extending beyond these appointments.

Other Areas of Occupation.

Occupational challenges beyond ADLs were not discussed by clinicians, but 11 of the 13 patients mentioned at least one IADL, leisure, or social activity that they were unable to participate in or were dependent on others to do so because of their health. When specifically asked about activities that they needed or wanted to do but had difficulty doing, many patients denied any problems or had found ways to adapt to achieve greater independence. For instance, a patient noted, "I can wash dishes in between a lot of breaks" (Patient 9). However, through answers to other questions, occupational needs emerged. Desired activities ranged from exercising and playing sports to cooking, playing with their children, and house cleaning.

Discussion

This study adds to the available literature examining patient needs and clinician challenges in a primary care clinic. Clinician and patient participants indicated needs and challenges associated with medical and mental health management, cognitive-behavioral issues, and limited patient resources. This finding is consistent with the purpose of the CCC because the makeup of the clinic team (e.g., physicians, nurses, psychologists, social worker) reflects their intent to address medical, socioeconomic, and mental health domains. Patients and clinicians mentioned strategies that are in place to address these patient needs, which align with program outcomes in reducing the overall cost of care and reducing emergency room visits ( Virginia Commonwealth University, 2013). However, our study shows that cognitive-behavioral challenges, as perceived by the clinicians, and patients' occupational limitations were not consistently addressed.

The chronic and complex medical needs of the patients, compounded by mental health issues, require a high level of self-management, including medication management, to effectively manage their health. Although the literature on chronic disease self-management tends to treat self-management as skills that can be improved through education (see, e.g., Schulman-Green et al., 2012), it may be better conceived as a complex occupation. In considering self-management as an occupation, the challenges identified by the clinicians can be understood as deficits in performance skills (e.g., poor problem solving) or conflicting performance patterns (e.g., unhealthy habits, failure to meet expectations of patient role).

Our findings also show that patients' occupational needs go beyond chronic disease self-management and also include community mobility, ADLs, and IADLs. Although clinicians acknowledged community mobility needs, the focus remained on the medical and socioeconomic management of their patients and therefore pertained to how patients' limited mobility affected their medical management, that is, how to get patients to their scheduled appointment. Clinicians rarely identified their clients' occupational needs in relation to ADLs and IADLs or how their medical needs were affecting their ability to engage in meaningful activities.

In their interviews with physicians, Loeb et al. (2015) identified four themes of patient complexity that were consistent with our findings: medical complexity, socioeconomic factors exacerbating medical conditions, mental illness exacerbating medical conditions, and patient behaviors and traits. Shippee et al. (2012) further theorized that when a patient's workload (which includes all the tasks and responsibilities that he or she has each day) exceeds his or her capacity, it leads to the behaviors that result in physicians labeling the patient as "complex" (e.g., not adhering to the treatment plan). It is exactly within that "workload" that occupational therapy practitioners are trained to intervene. Thus, occupational therapy practitioners can support the primary care team by focusing on enabling occupation, including self-management activities, to meet the challenges currently faced by clinicians and patients.

The medical professionals on the primary care team were trained to intervene on client factors such as body functions and structures. The inclusion of social work, psychology, and case management allowed the team to address many of the socioeconomic contextual needs of the patients, but it is occupational therapy practitioners who have specialized training in identifying and addressing performance skills and patterns as they relate to occupation. Occupational therapy practitioners' understanding of the link between occupation and health and how illness and injury can disrupt occupational performance can assist patients in developing new habits, roles, and routines to support their health and assist with participation in occupational activities. In fact, there is a strong evidence base to support the use of occupational therapy in helping patients to establish new roles and routines to address unhealthy habits ( Arbesman & Moseley, 2010).

Our findings also suggest that occupational therapy may be useful beyond direct patient care to include consulting for and educating the team itself in addressing many of the challenges they face. For instance, occupational therapy practitioners could develop protocols for using common technologies (such as cell phone calendars and applications) that all staff could use to help patients track and remember appointments or medications, or they could advise on modifying educational materials with the most appropriate font size and colors for the benefit of for instance, patients with low vision. Moreover, practitioners can assist the team in managing complex patients when continuity of care is essential. As patients transition from the hospital to home care and back to the clinic, practitioners can provide follow-up care to maintain occupational performance gains reached in other settings. Having an occupational therapy practitioner on the primary care team would provide a way to address ADL issues that the team is aware of but does not have the resources to address.

Although there has been a call for occupational therapy to be in primary care, a major challenge to integration has been a lack of understanding of the profession's role ( Donnelly et al., 2013). However, research has suggested that when primary care providers understand how occupational therapy can contribute to primary care, they are receptive to including them on a primary care team ( Dahl-Popolizio, Muir, et al., 2017). This study provides important evidence that not only are there occupational needs among patients at a primary care clinic but that occupational therapy practitioners have a unique perspective and focus that would complement the primary care team. Team-based primary care is a promising model, and the CCC is one example of its success; however, challenges still exist. Integrating occupational therapy into primary care teams (both as a direct patient provider and as a resource for the team for adapting current medical and psychosocial interventions to the specific needs of the patients) has the potential to improve patient outcomes even more through improving occupational performance.

Limitations and Future Directions

Our study provided an in-depth look at a team-based urban CCC focusing on a low-income population with multiple chronic medical conditions. However, because we used a single case study and a small sample, our findings cannot be generalized to all primary care clinics or settings. Additional research into the occupational needs of primary care patients in more standard clinical settings serving the general population is needed. Nevertheless, this study provides important insights into a possible role for occupational therapy that warrants further investigation as the profession pushes toward greater inclusion in primary care.

As occupational therapy practitioners enter the primary care workforce, it will also be important to study the process of integration and how clinical roles are determined. Evaluating and comparing practitioners who have effectively integrated into primary care will allow for the identification of best practices that can facilitate the continued growth of occupational therapy in this emerging practice area.

Last, this study was a first step in documenting the need for occupational therapy in a primary care setting. Although current research suggests the value-added benefit of including an occupational therapy practitioner on primary care teams ( Dahl-Popolizio, Rogers, et al., 2017), as health insurance and Medicare policies are evolving and bundled payment initiatives are being rolled out, continued research on how occupational therapy fits into these policies will be essential if the profession is to become a standard part of primary care.

Implications for Occupational Therapy Practice

As the U.S. population ages and chronic disease rates grow, the need for occupational therapy in primary care will become even more apparent. Our study supports the need for occupational therapy practitioners in primary care for the following reasons:

Patients have occupational needs that are not being addressed in primary care.

Occupational therapy practitioners have unique skills and training that address unmet patient needs and clinic challenges and that complement services provided in primary care teams, particularly in the area of chronic disease management.

Occupational therapy practitioners must advocate for the profession if they are to be included on primary care teams.

Conclusion

Primary care patients have occupational needs that are not always apparent to medical care providers working within a disease-based model of problem solving. Understanding chronic disease management as an occupation can provide a broader view of patient needs. An occupational therapy practitioner's ability to assess occupational impairment, analyze activity demands, and address performance skills and patterns can greatly contribute to a primary care team working with complex patients.

Acknowledgments

We thank Lily Damico for her assistance in data collection and coding. Versions of this article were presented at the Virginia Occupational Therapy Association 2016 Annual Conference (Richmond, VA) and the American Occupational Therapy Association 2017 Annual Conference & Expo (Philadelphia).

References

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. 10.5014/ajot.2014.682006 [[CrossRef] Google Scholar]

Arbesman M., & Moseley L. J. (2010). Critically appraised topics: What is the evidence for the effect of occupation and activity-based health management and maintenance interventions on the performance of community dwelling older adults? Bethesda, MD: American Occupational Therapy Association.

Borkan J. (1999). Immersion/crystallization. In Miller W. & Crabtree B. (Eds.), Doing qualitative research (2nd ed., pp. 179-194). Thousand Oaks, CA: Sage. [Google Scholar]

Centers for Disease Control and Prevention. (2019). About chronic diseases. Retrieved from https://www.cdc.gov/chronicdisease/about/index.htm

Dahl-Popolizio S., Muir S. L., Davis K., Wade S., & Voysey R. (2017). Occupational therapy in primary care: Determining receptiveness of occupational therapists and primary care providers. Open Journal of Occupational Therapy, 5(3). 10.15453/2168-6408.1372 [[CrossRef] Google Scholar]

Dahl-Popolizio S., Rogers O., Muir S. L., Carroll J., & Manson L. (2017). Interprofessional primary care: The value of occupational therapy. Open Journal of Occupational Therapy, 5(3). 10.15453/2168-6408.1363 [[CrossRef] Google Scholar]

Virginia Commonwealth University. (2013). VCU Medical Center 2013 annual report. Retrieved from http://www.annualreports.vcu.edu/archive/medical/2013/stories/complexcare.html

# data[].attributes.attachment_link.title
Opportunities for Occupational Therapy on a Primary Care Team

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Importance: Leaders in the occupational therapy profession have called for occupational therapy's inclusion in primary care, but little is known about the occupational needs of patients in this setting. Objective: To explore the need for and potential role of occupational therapy in a team-based primary care clinic.

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file:///C:/Users/katly/Downloads/7406205090p1_1607075226.39331.pdf

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Katharine Preissner, Kathryn Bernice Duke, Catherine Killian, Rachel Luangdilok Ouyang, Eva D. Jarek, Anders Kottorp; The Revised American Occupational Therapy Association Fieldwork Performance Evaluations: Evaluation of Content Validity-Part 1. Am J Occup Ther November/December 2020, Vol. 74(6), 7406205090p1-7406205090p13. doi: https://doi.org/10.5014/ajot.2020.044180

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# data[].attributes.attachment_link.title
The Revised American Occupational Therapy Association Fieldwork Performance Evaluations: Evaluation of Content Validity-Part 1

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Abstract. Importance: Occupational therapy education and practice has changed over time; however, items on the American Occupational Therapy Association's (AOTA's) Fieldwork Performance Evaluations (FWPEs) for the Occupational Therapy Student (OTS) and Occupational Therapy Assistant Student (OTAS) have not been updated in more than two decades.Objective: To explore evidence of validity in relation to test content of the revised FWPEs for the OTS and OTASDesign: A qualitative study using cognitive interviews was conducted to gather perspectives on the revised FWPEs, including updated items and a proposed rating scale.

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Cardiovascular stress during inpatient spinal cord injury rehabilitationDominik Zbogar, PhD,Rehabilitation Research Program, Canadian Institute of Health Research | December 2017

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Cardiovascular stress during inpatient spinal cord injury rehabilitationDominik Zbogar, PhD,Rehabilitation Research Program, Canadian Institute of Health Research | December 2017

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5766325/pdf/nihms7007.pdf

10.1016/j.apmr.2017.05.009

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Dominik Zbogar, PhD, Janice J Eng, PT, PhD, Jeremy W. Noble, PhD, William C Miller, PhD, FCAOT, Andrei V Krassioukov, MD, PhD, and Mary C Verrier, Dip P&OT MHSc

Abstract

Background

Physical activity that challenges cardiorespiratory function is beneficial for individuals recovering following a spinal cord injury (SCI) from a neurological, musculoskeletal, and cardiovascular perspective. However, it is not known how much conventional clinical rehabilitation challenges cardiorespiratory function.

Objectives

1) To measure the amount of a) cardiovascular stress, b) self-reported physical activity and c) accelerometry-measured physical activity by individuals with SCI during physical therapy (PT) and occupational therapy (OT) and, 2) to investigate the relationship between these measures.

Design

Observational study.

Setting

Two inpatient SCI rehabilitation centres.

Subjects

SCI patients (n=87) were recruited from consecutive admissions to rehabilitation.

Methods

Heart rate (HR) was recorded by a Holter monitor, while physical activity was captured by self-report (PARA-SCI questionnaire) and real-time wrist accelerometry during a total 334 PT and OT inpatient sessions. Differences between individuals with paraplegia and tetraplegia were assessed via Mann-Whitney U tests. Spearman correlations were used to explore the relationship between measurements of physical activity and HR.

Results

Time spent at a HR within a cardiovascular training zone (≥ 40% heart rate reserve) was low and did not exceed a median 5 minutes. In contrast, individuals reported at least 60 minutes of higher intensity time during therapy. There was a low, but statistically significant correlation between all measures.

Conclusion

The cardiovascular stress incurred by individuals with SCI during inpatient PT and OT sessions is low and not sufficient to obtain a cardiovascular training effect to optimize their neurological, cardiovascular, or musculoskeletal health; this represents a lost opportunity to maximize rehabilitation. Self-reported minutes of higher intensity PA do not reflect actual time spent at higher intensity measured objectively via a HR monitor.

Keywords: Accelerometry, heart rate, occupational therapy, self-report, spinal cord injuries

Introduction

Cardiovascular disease is a leading cause of death in persons with spinal cord injury (SCI) and has a higher prevalence, earlier onset, and occurs at an accelerated rate after SCI compared to the general population. Exercise training in individuals with SCI has the potential to improve cardiovascular health and alleviate numerous medical complications associated with being physically inactive which underscores the importance of participating in an exercise program after SCI.

Early after SCI, a prolonged amount of bed rest contributes to very low levels of physical activity and cardiovascular fitness. Physical capacity, defined as the combined ability of the cardiovascular and musculoskeletal systems to perform at a given level of activity, is extremely low in individuals with acute SCI and improves over time, likely due to a number of factors including improvements in neurological status, recuperation from trauma, and training effects of the rehabilitation program. There is also increasing evidence that aerobic activity may facilitate neuroplasticity; for example, Leech and Hornby found that increases in serum brain-derived neurotrophic factor were greater with higher intensity exercise in individuals with incomplete SCI. However, little information exists on how much, if at all, conventional rehabilitation protocols (that typically include PT and OT to achieve goals related to functional recovery) in SCI challenge cardiovascular fitness.

It is well known that physical activity of a sufficiently high intensity confers cardiovascular benefits not obtained by lighter activity, and the importance of this fact is accounted for in physical activity recommendations by various organizations. For both able-bodied individuals and individuals with disability it is recommended that, throughout the week, one obtains at least 150 minutes of moderate-intensity, 75 minutes of vigorous-intensity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity in bouts of no less than 10 minutes. More recently, SCI specific guidelines suggest individuals accrue, at a minimum, two bouts of 20 minutes of moderate to vigorous intensity aerobic activity per week. Unfortunately it appears most individuals with chronic SCI do not meet these guidelines at one year following discharge from rehabilitation. Indeed, individuals with SCI have been shown to have the lowest physical activity levels when compared to persons with different chronic diseases. One might assume that the cardiovascular stress experienced after SCI injury would be equally low. However, one study assessed eight individuals with paraplegia and three with tetraplegia over a typical rehabilitation day and concluded that there was sufficient strain to improve aerobic fitness, but there was heterogeneity of the subjects (participants with paraplegia/tetraplegia/walking ability were combined), and subsequently large variability in the data. Clearly more research is required.

The primary goals of physical therapy (PT) and occupational therapy (OT) include motor and functional recovery, however SCI rehabilitation also has opportunity to reverse the cycle of reduced cardiovascular fitness that limits functioning. Cardiovascular stress can improve physical capacity, and in turn contribute to better performance of activities of daily living (ADLs). Furthermore, awareness of the demands placed on the cardiovascular system by rehabilitation interventions may play a role in both patient safety and for optimizing activity prescription.

Non-invasive, low-cost options of physical activity measurement include accelerometry and self-report. Wrist accelerometry is a valid indicator of physical activity for wheelchair-users in laboratory and community-dwelling environments and self-report is the most widely used method for measuring physical activity. While the subjective nature of self-reported physical activity renders it prone to recall error and social desirability bias it does offer information not available from objective measures. For example, accelerometry may measure when and how much an individual moves the upper limbs, while self-report captures information on how difficult this activity was and the purpose of the activity (e.g., leisure, activity of daily living). Despite increasing emphasis on aerobic activity for neuroplastic recovery as well as for cardiovascular fitness, it is not yet known whether accelerometry and self-report physical activity measures reflect the actual intensity of aerobic activity engaged in by patients in rehabilitation.

Therefore, the purpose of this study was 1) to measure the amount of cardiovascular stress experienced by individuals with SCI during inpatient rehabilitation, and 2) to investigate the relationship between this cardiovascular stress and other measures of physical activity (self-reported physical activity, wrist accelerometry) during inpatient rehabilitation. It was hypothesized that the amount of time spent in PT and OT at an intensity sufficient to achieve a cardiovascular training effect (≥ 40% heart rate reserve (HRR)) would be low (not meeting the recommendations of SCI physical activity guidelines). It was expected that the different measures would be correlated since they measure constructs of physical activity.

Research Methods

Participants

Participants were recruited as part of a larger study examining consecutive traumatic and non-traumatic SCI admissions to inpatient subacute care at two stand-alone rehabilitation centres. Non-traumatic SCI was defined as SCI resulting from spinal stenosis, tumour, ischemia, transverse myelitis, and infection. All adults with a new SCI of any aetiology, severity, or level, who were admitted for SCI rehabilitation were eligible. In addition, the admission criteria for Canadian rehabilitation hospitals require patients to be able to tolerate 2-3 hours of rehabilitation therapy daily. Patients were excluded if they were a readmission, had a traumatic brain injury that notably affected the content and delivery of therapy (as determined by their health care team), if consent could not be obtained within the first week of admission, or if their length of stay in rehabilitation was projected to be less than four weeks as it precluded the ability to potentially progress their rehabilitation activities prior to discharge.

Approval for this study was obtained from the university and hospital ethics boards and all participants provided informed consent prior to measurements.

Data collection protocol

Data were collected over two weekdays in the second-last week of inpatient rehabilitation stay as it was expected that at this point in time participants would be near their peak inpatient recovery and would be able to maximally participate in rehabilitation activities. On each day a research assistant met the participant in their room in the morning where they were fitted with a Holter monitor and accelerometer(s). In the evening of each day, when participants had returned to bed, the research assistant returned to collect the Holter monitor and accelerometer(s) and administer the self-report physical activity questionnaire.

On each measurement day, research assistants were present for all PT and OT sessions and collected information on the start, end, and content, of sessions. Therapeutic time was defined as any activity undertaken by the therapist with the goal of treating the patient and included physical rehabilitation, education, assessments, and interventions designed to improve functional independence. Therapy sessions were included for analysis if ≥ 50% of therapeutic time was comprised of physical rehabilitation. Sessions were excluded if more than 50% of therapeutic time was comprised of assessments, equipment fitting, or non-motor issues. If a session did not occur on a scheduled day or did not meet the criteria indicated above, an additional day was collected if it occurred during the 1-week data collection window. Thus, the study criteria allowed for the collection therapy sessions under a best-case scenario.

Demographic information was collected for age, sex, aetiology (traumatic or nontraumatic), American Spinal Injury Association Impairment Scale (AIS) grade, β-blocker status, and length of stay in acute care and rehabilitation.

Physical activity measures

Holter monitoring was used to record and store continuous heart rate data. This device provides 3-channel ECG and consists of five electrodes on the chest and abdomen attached via leads to a small recorder that was worn around the waist, around the neck, or attached to the wheelchair depending on participant preference.

The Physical Activity Recall Assessment for People with SCI (PARA-SCI) is a self-report questionnaire administered via a semi-structured interview and is found valid and reliable where community dwelling individuals with SCI recall their activity at the end of a 3 day period. To minimize recall issues, the PARA-SCI was modified where participants were asked to recall their activity at the end of the day, and this was done over two separate days within a week. The PARA-SCI measures the amount of physical activity individuals with SCI accumulate over a day and provides an estimate of time (in minutes) spent participating in mild, moderate and heavy intensity physical activities, as well as activities with no intensity ("nothing at all").

Actical accelerometers worn on the dominant wrist like a wristwatch quantified the amount and intensity of upper extremity activity using total activity kilocounts. The Actical accelerometer is a small device with a frequency range of 0.3-3 Hz. The unit is sensitive to 0.05-2.0 G-force in three planes and samples data at 32 Hz.

Data Analyses

Heart rate data for all therapy sessions was downloaded to a computer. The ECG waveform was investigated and any artefacts were corrected. Data were entered into MATLAB (MathWorks Inc, Natick, MA USA) where the waveform was converted to beat-by-beat HR by identifying RR-intervals across the analysis period. The HR data was re-sampled to a time series with a sampling frequency of 10Hz, such that the HR could be determined at any point throughout the therapy sessions. Maximal HR was calculated using the formula HR max= 208 − 0.7 x age. A modified formula was used for those individuals on β-blocker medications: HR max= 164 − 0.72 x age. Resting HR was obtained during a 10-minute period of supine rest on a separate day. Heart rates were binned into deciles ranging from 0 to 100% of predicted maximal HR, calculated using the Heart Rate Reserve (HRR) method: HR target= [% intensity (HR max-HR rest)]+HR rest and the time spent in each decile was obtained. The time in each decile was averaged over the two observation days for both PT and OT sessions. The number of minutes spent at ≥ 40% HRR was calculated and used to represent the time spent in a cardiovascular training zone. Participants who met SCI specific physical activity guidelines of ≥ 20 minutes within this intensity were noted and the characteristics of individuals were reported. As per American College of Sports Medicine guidelines, moderate intensity was defined as 40-59% HRR and vigorous intensity as 60-89% HRR.

The accelerometer record was rectified and integrated over 15 second intervals as activity counts and averaged over the two observation days for both PT and OT. Higher activity counts may indicate longer use, more movement, and/or greater intensity of movement.

For the purpose of this study, only PARA-SCI minutes occurring during observed PT and OT sessions were reported, and averaged over the two observations days. The four intensities of the PARA-SCI were binned into two categories: 'lower intensity' comprising nothing or mild intensity and 'higher intensity' comprising moderate or heavy intensity. Moderate and heavy physical activity are intensities recommended by exercise guidelines for accruing health benefits.

Sub-analyses to compare paraplegia and tetraplegia values using Mann-Whitney U tests were performed for HR parameters (resting, mean, and peak HR, and time in cardiovascular training zone), self-reported physical activity, and wrist accelerometry. The Z value and effect size ( r(abs)= Z/√n) (0.1=small effect, 0.3=moderate effect, 0.5=large effect) are documented.

To relate the three measures of activity collected during therapy time, Spearman rho correlations were performed between minutes where HR was in the cardiovascular training zone, self-reported minutes of physical activity at a higher intensity, and accelerometry measured activity kilocounts.

A minimum sample size of 28 was calculated a priori using G*Power version 3.1 (available at http://www.gpower.hhu.de) using a moderate effect size (d=0.5), an alpha of 0.05, and power of 0.80, for a Mann-Whitney U test comparing two dependent means with a directional hypothesis.

Alpha was set at p < 0.05. Statistical analyses were performed using SPSS 20 (SPSS Inc, Chicago, IL USA).

Results

Recruitment to the study is displayed in and demographic information for participants in this study is found in . Demographic variables for the excluded 26 participants were not notably different from those included for analyses. Thirty-six participants were ambulatory at discharge. Observations of 215 PT sessions and 119 OT sessions were undertaken. On occasion more than one PT or OT session occurred on an observation day. The number of valid OT sessions was less than PT, as many OT sessions did not involve physical activity, and thus, were not included in the final analyses.

Table 1

Heart rate during physical and occupational therapy

Heart rate variables are reported in . The resting HR and median HR during therapy was approximately 10 beats/min higher in individuals with paraplegia than individuals with tetraplegia. During PT sessions, the median time spent at an intensity ≥ 40% HRR was 2.4 minutes and in OT sessions it was 0.9 minutes (). For both individuals with paraplegia and tetraplegia, 80 to 90% of OT or PT sessions consisted of activity below 40% HRR. Over half of all therapy time was spent in activity less than 20% HRR except in the case of individuals with paraplegia in PT where 46% of time was spent at an intensity between 20-39% HRR.

Table 2

Self-reported physical activity during physical and occupational therapy

The majority of self-reported physical activity of a higher intensity occurred during PT sessions (). Self-reported minutes of lower and higher intensity activity were similar between individuals with paraplegia and tetraplegia with both groups reporting ≥ 60 minutes of higher intensity activity during therapy.

Accelerometry kilocounts during physical and occupational therapy

Wrist accelerometry kilocounts in PT were over three times that of OT. Individuals with paraplegia accrued more kilocounts (26 kilocounts) than individuals with tetraplegia (17 kilocounts), p=0.027 ().

Correlation between heart rate, self-reported physical activity, and wrist accelerometry

There were low (rho < 0.3) but statistically significant correlations between minutes of HR at intensity ≥ 40% HRR, higher intensity self-reported physical activity, and wrist accelerometry ().

Table 3

Activities engaged in by those who met physical activity guidelines

Only 11 of the 87 individuals met or exceeded 20 minutes of time at an intensity of at least 40% HRR in PT and/or OT (Table 4). These individuals had low injury severity (AIS D) or a low lesion level. Observational logs of their therapy sessions confirmed higher intensity activities including walking (with/without various supports), leg exercises in standing, jumping, leg cycle ergometry, shuttle leg press for high repetitions, and ADLs including dressing (seated), repetitive transfers and bed mobility movements.

Discussion

Measures of heart rate and physical activity during physical and occupational therapy

For HR, current findings indicate that individuals with SCI are spending very little time during PT and OT sessions at the moderate to vigorous intensities required for conferring cardiovascular benefits. The time spent in the training zone during PT or OT is a quarter of that recommended by SCI specific aerobic guidelines. Only 11 of 87 individuals (13%) met the required guidelines of 20 minutes at moderate to vigorous intensity. In fact, over three quarters of time in OT and PT sessions was spent at a HR under 40% HRR, with the largest portion under 20% HRR. These findings are a best-case scenario, as only active therapy sessions were included, β-blocker status was accounted for, and consecutive minutes at the target HR were not required. Results indicate that patients may not be receiving sufficiently intense cardiovascular activity to optimize their neurological, cardiovascular, or musculoskeletal health; this represents a lost opportunity to maximize rehabilitation. It is possible however, that therapists avoided aerobic activity as they perceived that such activity may not be safe for their SCI patients, or alternatively, they did not believe that aerobic activity sufficiently benefited the recovery or health of their patients compared to the need for other treatments.

In contrast to the small amount of cardiovascular activity measured via HR, self-reported physical activity shows that participants perceived that their PT sessions were physically challenging (55 higher intensity minutes). This disparity was corroborated by the very low correlation (0.23) between the two measures. A number of factors may contribute to this mismatch. High intensity measured by the PARA-SCI is derived from perceptions of multiple physical domains (e.g., breathing hard, burning muscles, warm or sweaty skin). A greater reliance on the arms which have relatively small mass compared to the legs may result in a perception of high physical effort, but is not necessarily cardiovascular in nature. In addition, many participants are extremely deconditioned following their acute stay and even a low intensity exercise may be perceived as challenging. Further, there is recall bias, as well as potential for social desirability bias where individuals tend to overrate their physical activity participation during recall questionnaires. Lastly, the PARA-SCI rating is representative of the entire therapy session and not as refined as beat-by-beat HR. Thus, self-report may not be an appropriate tool for gauging time spent within the cardiovascular training zone.

Wrist accelerometry also had a very low correlation with cardiovascular activity. While one might expect wheeling to result in both high accelerometry counts and high HR, there are many other therapeutic activities that do not have this correspondence that likely contributed to this low correlation. For example, a repetitive reach and grasp task to improve fine motor skills would accumulate large accelerometry counts but would not be challenging to the cardiovascular system.

The SCIRehab project, a multi-centre account of numerous facets of SCI rehabilitation in the United States shows that in PT, about half of patients are engaging in endurance activities (e.g. ergometry, walking, using gym machines) and these patients average 7.5±13.3 minutes of time in these activities while no endurance activities occurred in OT. Our research in two Canadian rehabilitation centres extends these findings with objective, continuous HR data showing that individuals with SCI spent 2.4 and 0.9 minutes per session during PT and OT, respectively in moderate/vigorous intensity activities.

It was unexpected that the amount of cardiovascular activity was similar between individuals with paraplegia and tetrapelgia. One might anticipate higher HR responses to exercise from individuals with paraplegia who exhibit cardiovascular responses similar to able-bodied individuals, while individuals with a spinal cord injury above the T6 spinal segment (sympathetic innervation to the heart exits at the T1-T5 level) may experience disruption of sympathetically driven cardiac control, resulting in bradycardia at rest and a blunted chronotropic response to exercise, with a maximal HR in the range of 120 beats per minute. While individuals with paraplegia did have higher resting and average HRs, it is likely that physiological differences were not a factor as both groups (paraplegia and tetraplegia) simply did very little cardiovascular physical activity. The greater accelerometry counts with individuals with paraplegia was surprising as it has been shown previously that observer-counted repetitions of therapeutic upper extremity movement during inpatient rehabilitation sessions are highest in individuals with incomplete tetraplegia. However, an individual with tetraplegia is likely performing a repetition slowly, which would generate little acceleration, while individuals with paraplegia may be practicing wheeling or upper extremity strengthening at higher accelerations. This results in variability that may preclude the finding of any differences due to the plegia type.

Vigorous aerobic exercise confers more benefit than moderate aerobic exercise. However, there is evidence to suggest that deconditioned individuals can incur cardiovascular benefit from activities below 40% HRR. Swain et al. noted that deconditioned persons improved maximal oxygen consumption at intensities equivalent to 30% HRR. If one includes any intensity at or above 30% HRR for a minimum recommended 10 minutes as sufficient for obtaining cardiovascular benefit in this population, this more lenient intensity guideline applied to the study sample would result in 41 of the 87 participants meeting the requirement. Or in other words, 53% of participants are not meeting even these most lenient activity guidelines.

Which activities elicited the highest heart rates?

Participants who were able to accrue at least 20 minutes of activity at 40% of HRR were mostly ambulatory and with AIS D injuries. It was observed that activities garnering HRs in the target zone usually involved ambulation but also included ADLs, suggesting that both types of activities can be utilized in an intervention designed to stimulate cardiovascular fitness in individuals with SCI. It was noted that the ADLs were repeatedly performed during therapy. However, ADLs performed as a part of one's day in a typical fashion (i.e. not repeatedly and not for any length of time), are insufficient for providing fitness gains.

Study Limitations

Using HR as an indicator of intensity may underestimate the response for individuals with a SCI above the T6 spinal segment. Nevertheless, regardless of the status of sympathetic innervation to the heart, the fact remains that individuals are experiencing nowhere near the amount of time required to accrue cardiovascular benefits.

While nine persons with concomitant traumatic brain injury were included, four individuals with severe traumatic brain injury whose therapy had a focus on cognitive, rather than physical rehabilitation, were excluded. Also excluded were nine individuals with a length of stay shorter than four weeks. While the number of participants excluded for these reasons is small, this may limit how well this sample represents the true breadth of the clinical presentation of SCI.

Lastly, the PARA-SCI was modified; activity was recalled after each of two days which may have improved recall over the original PARA-SCI which recalls at the end of a three-day period, but the shorter two-day period may be less representative of typical activity.

Conclusion

The cardiovascular stress incurred by individuals with SCI during PT and OT sessions is very low and insufficient to obtain a cardiovascular training effect. Due to the disparity between self-reported intensity and objectively measured HR, incorporating the use of HR monitors as part of standard practice would provide therapists with important information on optimizing patient therapy through creating baseline assessments and allowing the tracking of intensity and ensuring progression.

Acknowledgments

Preliminary data was sourced for the following abstract: Zbogar D, Eng JJ, Noble JW, Krassioukov AV, Miller WC, Verrier M. Cardiovascular Stress During Inpatient Spinal Cord Injury Physical and Occupational Therapy. Archives of Physical Medicine and Rehabilitation. 2015; 96(10): e67.

D. Zbogar is supported by a Doctoral Frederick Banting and Charles Best Canada Graduate Scholarship from the Canadian Institutes of Health Research.

J.J. Eng is supported by a career scientist award from the Canadian Institutes of Health Research (MSH-63617).

We thank the research assistants for their work, especially Erika Brown MPT, Jenna Homer MPT, and Amanda Mow MPT, and the rehabilitation centers and therapists who participated in this study.

Abbreviations

Footnotes

aHolter monitoring: Nasiff CardioCard ® PC Based Holter Monitoring ECG System, Nasiff Associates Inc., 841 County Route 37, Suite 1, Central Square, New York 13036, USA, https://nasiff.com/holter.html

bAccelerometers: Actical, Bio-Lynx Scientific Equipment Inc., PO Box 8, Station Ahuntsic, Montreal, Quebec H3L 3N5, Canada, http://www.actigraphy.com/solutions/actical

Device Status: Dr. Zbogar has nothing to disclose.

Financial Disclosure: Dr. Zbogar has nothing to disclose.

Contributor Information

Dominik Zbogar, Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Canada; International Collaboration on Repair Discoveries, Vancouver Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver Canada.

Janice J Eng, Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Canada; International Collaboration on Repair Discoveries, Vancouver Canada; Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver Canada.

Jeremy W. Noble, Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada.

William C Miller, Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Canada; International Collaboration on Repair Discoveries, Vancouver Canada; Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver Canada.

Andrei V Krassioukov, International Collaboration on Repair Discoveries, Vancouver Canada; Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver Canada.

Mary C Verrier, University Health Network - Toronto Rehabilitation Institute, Toronto Canada; Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto Canada.

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Cardiovascular stress during inpatient spinal cord injury rehabilitation

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Dominik Zbogar, PhD, Janice J Eng, PT, PhD, Jeremy W. Noble, PhD, William C Miller, PhD, FCAOT, Andrei V Krassioukov, MD, PhD, and Mary C Verrier, Dip P&OT MHSc Physical activity that challenges cardiorespiratory function is beneficial for individuals recovering following a spinal cord injury (SCI) from a neurological, musculoskeletal, and cardiovascular perspective.

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