Primary Care for Underserved Populations: Navigating Policy to Incorporate Occupational Therapy Into Federally Qualified Health Centers

Transforming Occupational Therapy for the 21st Century PAIRE: Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity

Theories, models, and frameworks provide the foundation for occupational therapy education, research, and clinical practice. While most have a systems approach focus, other factors, such as societal influences and structural inequities, also contribute to health. Using a cross-sectional design, this study identified the gaps in occupational therapy models of practice and presents a novel approach, the PAIRE (Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity) Model. PAIRE is focused on achieving occupational equity through the reciprocal and intersectional impact of the provider/team, the person/people seeking occupational therapy, and the occupation-in-context, with continuous influences of access, context, and justice. We describe the components of PAIRE and illustrate its functionality in education, research, and clinical practice contexts as well as case examples.

Occupational Therapy in Primary Health Care for Underserved Populations: A Scoping Review

The aim of this scoping review was to identify what current and potential opportunities exist for occupational therapy in primary healthcare for underserved populations. Search phrases were utilized across several databases and Occupational Therapy specific journals were hand searched. Nineteen articles met inclusion criteria: English, 2009-2021, services delivered by occupational therapy practitioners or supervised students, for underserved populations/individuals, in community-based care, and primary health care settings. Five synergistic themes emerged from the literature are discussed: Client-centered, team collaboration, holistic and preventative health and wellness, evidence-based program evaluation, and innovative service delivery.

Patient Consumerism and Its Influence on the Future of Occupational Therapy

The cost of care is shifting to the individual in the form of high-deductible health plans and health savings accounts. The public demands and expects innovation in health care and health delivery and is using quality and cost data to make purchasing decisions. Public expectations for convenience are demonstrated in the use of walk-in clinics, telemedicine, and other technologies. As a result of the responsibility for paying and managing one's own health, consumerism involves a curated approach to selecting health services. This Health Policy Perspectives column examines how consumerism influences health care policy, in particular occupational therapy service delivery. Issues that consumerism creates include (1) a lack of publicly shared cost and quality data about occupational therapy; (2) confusion in measurement of client-centered care, patient satisfaction, and patient experience; (3) inadequate incorporation of patient shared decision-making throughout the occupational therapy process; and (4) payment model restrictions in service delivery. Occupational therapy practitioners must help consumers learn, through patient shared decision-making, that occupational therapy is evidence based and produces desired outcomes, thereby both improving the quality and lowering the cost of health care. Occupational therapy practitioners must advocate for lower cost and convenient service options in the community through an array of technologies. Practice scholarship of the clinical doctorate in occupational therapy must focus on conducting consumer research related to patient experience; enhancing service delivery through quality improvement; and innovating practice for new sites and methods of service delivery, including the use of technology.

Occupational therapy services in primary care: a scoping review

AIM

To examine and describe the current evidence about occupational therapy services in primary care.

BACKGROUND

Interprofessional primary care teams have been introduced to support the changing demographics and provide more comprehensive and coordinated care. Occupational therapists have the opportunity to play an important role in this expanding area of practice. To do so, occupational therapists must develop roles built on evidence and a clear understanding of the care delivery context.

METHODS

A scoping review was conducted based on the scientific and grey literature. Studies that described or examined the occupational therapy role with clients (individuals, groups, communities, populations) of all ages, conditions or occupational issues in a primary care context and that presented or referred to an occupational therapist working in a primary care setting were included. Studies were excluded if they were not in English or French. The Canadian Model of Occupational Performance and Engagement was used to chart the data.

FINDINGS

129 articles were identified, with 62 non-research and 67 research-focussed articles. A total of 268 assessments and 868 interventions were identified. The top interventions offered by occupational therapists were referring to/advocating for/coordinating/linking to and navigating community services (n = 36 articles), chronic disease management (n = 34 articles)/self-management education (n = 28 articles), health promotion (n = 30 articles) and falls prevention (n = 27 articles). The predominant focus in the literature is on adult and older adult populations.

The Occupational Participation of Latinx Cancer Survivors and Their Family Caregivers Living in Survivorship: A Qualitative Exploration Informed by Multiple Stakeholders

The purpose of this study was to examine the lived experiences of Latinx cancer survivors and their family caregivers during survivorship. Eighteen semi-structured interviews were conducted with a variety of stakeholders including Latinx cancer survivors (n = 8), their family caregivers (n = 5), and cancer care providers (n = 5). Data were analyzed thematically to describe occupational participation. Latinx families lived in political, economic, language, and social contexts that facilitated and hindered their well-being. Survivors simultaneously experienced occupational deprivation and posttraumatic growth. To promote occupational justice, occupational therapy practitioners and researchers are called to partner with Latinx survivors and their families to facilitate skills needed for everyday participation.

Body Mass Index and Blood Pressure Improvements With a Pediatric Weight Management Intervention at Federally Qualified Health Centers

OBJECTIVE

The Mind, Exercise, Nutrition, Do It! 7-13 (MEND 7-13) program was adapted in 2016 by 5 Denver Health federally qualified health centers (DH FQHC) into MEND+, integrating clinician medical visits into the curriculum and tracking health measures within an electronic health record (EHR). We examined trajectories of body mass index (BMI, kg/m²) percentile, and systolic and diastolic blood pressures (SBP and DBP) among MEND+ attendees in an expanded age range of 4 to 17 years, and comparable nonattendees.

METHODS

Data from April 2015 to May 2018 were extracted from DH FQHC EHR for children eligible for MEND+ referral (BMI ≥85th percentile). The sample included 347 MEND+ attendees and 21,061 nonattendees. Mixed-effects models examined average rate of change for BMI percent of the 95th percentile (%BMIp95), SBP and DBP (mm Hg), after completion of the study period.

RESULTS

Most children were ages 7 to 13 years, half were male, and most were Hispanic. An average of 4.2 MEND+ clinical sessions were attended. Before MEND+, %BMIp95 increased by 0.247 units/month among MEND+ attendees. After attending, %BMIp95 decreased by 0.087 units/month (P < .001). Eligible nonattendees had an increase of 0.084/month in %BMIp95. Before MEND+ attendance, SBP and DBP increased by 0.041 and 0.022/month, respectively. After MEND+ attendance, SBP and DBP decreased by 0.254/month (P < .001) and 0.114/month (P < .01), respectively. SBP and DBP increased by 0.033 and 0.032/month in eligible nonattendees, respectively.

CONCLUSIONS

%BMIp95, SBP, and DBP significantly decreased among MEND+ attendees when implemented in community-based clinical practice settings at DH FQHC.

Role of Occupational Therapy in Primary Care

The American Occupational Therapy Association (AOTA) affirms that occupational therapy practitioners1 are well prepared to contribute to interprofessional collaborative care teams addressing the primary care needs of individuals across the life course. Because of an increased focus on preventive population health and social determinants of health by health care organizations, synergy between primary care and occupational therapy is growing, with support for client-centered,2 comprehensive whole-person care, health promotion and prevention, disease self-management, and quality of life (Halle et al., 2018). Occupational therapy practitioners’ distinct knowledge of the significant impact that roles, habits, and routines have on health and wellness makes their contribution to primary care valuable (AOTA, 2020b). Occupational therapy’s focus on meaningful engagement in occupations is relevant and vital to participation in individual, family, and community life (AOTA, 2020c). In addition, occupational therapy practitioners’ holistic and population perspectives allow them to be effective both as interprofessional health care team members and as direct care providers to support client, family, and community needs in primary care delivery models (Leland et al., 2017). The purposes of this position paper are to define primary care and to describe occupational therapy’s evolving and advancing role in primary care, including expansion of services into specialty primary care areas such as pediatric primary care and obstetrics and gynecology (AOTA, 2018).

Establishing a pediatric occupational therapy clinic in the public-sector in Trinidad: The quest for clinical and professional expansion

BACKGROUND

Pediatric occupational therapy (OT) in Trinidad is limited to costly private sector provision, which restricts access to only those families that can afford it. Public-sector healthcare, however, is offered free of charge to citizens. Establishing public-sector OT can increase the well-being and quality of life of children with disabilities and their families, as well as broaden the professional paths available to occupational therapists.

OBJECTIVE

In the absence of local studies, primary research was undertaken to demonstrate the demand for services. The results of this study will be presented to government officials to argue for the inclusion of pediatric OT into one public-sector hospital in Trinidad.

METHODS

Eighty-eight parents/caregivers of a child with special needs were surveyed at one public sector-waiting room or two private-sector therapy clinics. Surveys questioned parents' desire for occupational therapy services for their child, their willingness to use public-sector-provided therapy and their belief that such therapy would benefit families in Trinidad, among other items.

RESULTS

Of the 88 participants surveyed, 98.8% believed that occupational therapy offered at one public-sector clinic in Trinidad would benefit families. The main deterrents to accessing the proposed public-sector therapy included satisfaction with the current therapist (40%) and concerns with convenience (33%) and efficiency (27%). Parents whose children were not currently receiving therapy cited cost (67%) and location (38%) as the main barriers.

CONCLUSIONS

Primary research findings demonstrate that the vast majority of parents/caregivers believe that public-sector pediatric occupational therapy would benefit families. Service free of charge will increase access for many families who cannot currently afford treatment. Implications of a pediatric public-sector clinic also include the expansion of occupational therapy as a profession in Trinidad.

Identifying occupation-based needs and services for individuals experiencing homelessness using interviews and photovoice

BACKGROUND

Homelessness can impact society and individuals in many ways.

OBJECTIVE

The purpose of this project was to examine the current occupation-based needs and services among persons experiencing homelessness (PEH) in a major city.

METHODS

Researchers conducted semi-structured interviews with eight PEH residing in a homeless shelter. Three questions were asked of each participant: What daily personal activities have been most impacted since undergoing homelessness? Which services have been most helpful to you in overcoming homelessness? What other services might you find helpful to individuals experiencing housing insecurity? Researchers also gathered qualitative data utilizing a Photovoice component in which twelve PEH had the opportunity to photograph one object and provide a quote associated with the meaningful object.

RESULTS

Under-addressed areas of occupation, services received, and services requested were identified. Findings suggest that areas of occupation most impacted by homelessness include instrumental activities of daily living (IADLs), activities of daily living (ADLs), leisure, social participation, and rest and sleep. Services received included case management and often met basic self-care needs of PEH. Services requested included group therapy, restructuring of the shelter to support individualization, and staff training.

CONCLUSIONS

Occupational therapy practitioners have the skill set to assess needed services among PEH. Meaningful objects captured by the clients via Photovoice may relate to past, present and future satisfaction despite being homeless.

Primary Care Occupational Therapy: How Can We Get There? Remaining Challenges in Patient-Centered Medical Homes

Passage of the Patient Protection and Affordable Care Act in 2010 mandated reform of the United States' existing primary care system. As part of this reform, advanced practice models, including the Patient-Centered Medical Home model, expanded, with the goal of increasing the use of interprofessional teams. Integrating occupational therapy was promoted as an opportunity to enhance the value of care provided in these redesigned primary care practices. However, occupational therapy's presence in primary care is still extremely limited.

Examining the intersection of policy and occupational therapy: A scoping review

Background.

Policy has direct bearing on occupational therapy practice and is a key dimension of the environment. To date, there has not been a synthesis of how policy is addressed in the occupational therapy literature.

Purpose.

The purpose of this review is to identify and analyze the ways that policy is addressed in the occupational therapy literature.

Method.

We conducted a scoping review of literature on policy and occupational therapy. Articles were analyzed deductively using a policy framework and inductively to identify overarching themes.

Findings.

Sixty-four papers were included for analysis. We present the descriptive information of the included articles according to policy type, sphere of action, stage of policy development, level, and actors. The qualitative analysis uncovered two broad concepts: “awareness” about the relationship between policy and practice and messages pertaining to “action.”

Implications.

There are numerous areas for further research into the policy–occupational therapy nexus, as policy has numerous pathways to shape practice. Practitioners will benefit from better understanding these pathways and actively engaging to align policy with the values of the profession.

Occupational Therapy and Primary Care: Updates and Trends

As our health care system continues to change, so do the opportunities for occupational therapy. This article provides an update to a 2012 Health Policy Perspectives on this topic. We identify new initiatives and opportunities in primary care, explore common challenges to integrating occupational therapy in primary care environments, and highlight international works that can support our efforts. We conclude by discussing next steps for occupational therapy practitioners in order to continue to progress our efforts in primary care.

Chiropractic Management of a Patient With Chronic Pain in a Federally Qualified Health Center: A Case Report

Objective

The aim of this case report is to describe the response of a patient with chronic pain who received chiropractic care in a federally qualified health center.

Clinical Features

A 61-year-old female patient with neck and back pain after a traumatic motor vehicle accident 3 years prior was referred for chiropractic care. She had neck pain, low back pain, knee pain, and pain associated with over 20 surgeries, as well as depression, opioid dependence, and low quality of life.

Interventions and Outcomes

The patient was treated with chiropractic manipulation for her low back and neck pain and was counseled on nutrition and exercise. After 6 months, she reported improvements in pain, improved quality of life, and discontinuation of opioid pain medication.

Conclusion

This patient improved after a course of chiropractic care that was integrated into a federally qualified health center.