Policy and Payment Changes Create New Opportunities for Occupational Therapy in Acute Care

Critical Care and Occupational Therapy Practice Across the Lifespan

This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.

Characteristics of Early Interventions for Pain and Function Following Lower Extremity Joint Replacement: Systematic Review

Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.

Identifying Cognitive Impairment in the Acute Care Hospital Setting: Finding an Appropriate Screening Tool

IMPORTANCE

Identifying cognitive impairment in adults in acute care is essential so that providers can address functional deficits and plan for safe discharge. Occupational therapy practitioners play an essential role in screening for, evaluating, and treating cognitive impairment.

OBJECTIVE

To test and compare the psychometrics and feasibility of three cognitive screens and select the ideal screen for use in acute care.

DESIGN

Prospective mixed methods.

SETTING

Acute care hospital.

PARTICIPANTS

Fifty adults.

OUTCOMES AND MEASURES

We examined the interrater reliability, administration time, and usability of the Brief Cognitive Assessment Tool Short Form (BCAT-SF), the Activity Measure for Post-Acute Care "6-Clicks" Applied Cognitive Inpatient Short Form (AM-PAC ACISF), and the Montreal Cognitive Assessment (MoCA). We compared the construct validity, sensitivity, and specificity of the BCAT-SF and AM-PAC ACISF with those of the MoCA.

RESULTS

Interrater reliability was good to excellent; ICCs were .98 for the MoCA, .97 for the BCAT-SF, and .86 for the AM-PAC ACISF. The BCAT-SF and the AM-PAC ACISF both had 100% sensitivity, and specificity was 74% for the BCAT-SF and 98% for the AM-PAC ACISF. The optimal cutoff score for cognitive impairment on the AM-PAC ACISF was <22. Administration time of the AM-PAC ACISF (1.0 min) was significantly less than that of the BCAT-SF (5.0 min) and the MoCA (13.3 min; p < .001).

CONCLUSIONS AND RELEVANCE

Each screen demonstrated acceptable reliability and construct validity. The AM-PAC ACISF had the optimum mix of performance and feasibility for the fast-paced acute care setting. What This Article Adds: Early identification of cognitive impairment using the AM-PAC ACISF can allow for timely occupational therapy intervention in acute care settings.

Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit

IMPORTANCE

Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown.

OBJECTIVE

To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients.

DESIGN

Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015.

SETTING

NCCU in a large urban academic hospital.

PARTICIPANTS

Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables.

RESULTS

Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services.

CONCLUSIONS AND RELEVANCE

Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.

Change in Activity Performance Mediates the Relationship between Occupational Therapy Utilization and Discharge Disposition among Adults with Traumatic Brain Injuries

A retrospective cross-sectional study was conducted on 435 adults with TBI who received occupational therapy services in an acute care trauma center hospital. Outcome measures were (1) occupational therapy utilization based on billed minutes of occupational therapy evaluation and treatment (low vs. high); (2) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" to assess activities of daily living level of assistance; and (3) Discharge disposition (community vs. institution). Community discharge included home and supported living facilities. Institutional discharge involved long term care, rehabilitation facility, short term hospital, and skilled nursing facility. Results indicated that change in ADL performance, between admission and discharge, partially mediated the relationship between occupational therapy utilization and community discharge (OR= 0.80, p = .003). High occupational therapy utilization (vs. low) was associated with greater change in ADL performance (β = 0.39, p < .001). Greater change in ADL performance was associated with lower odds of community discharge (OR= 0.96, p <.001). Independent of change in ADL performance, higher occupational therapy utilization was associated with significantly lower odds for community discharge (OR = 0.57, p = 0.023). In conclusion, patients who received more occupational therapy were less likely to be community discharged, as mediated by change in ADL performance. This result can provide direction for future research exploring acute care occupational therapy utilization and discharge disposition.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement

OBJECTIVES

Understand the association between social determinants of health and community discharge after elective total joint arthroplasty.

DESIGN

Retrospective cohort design using Optum de-identified electronic health record dataset.

SETTING AND PARTICIPANTS

A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018.

METHODS

Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics.

RESULTS

Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively.

CONCLUSIONS AND IMPLICATIONS

Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

The Promise of Interoperability

Despite technological advancements in health care documentation and the proliferation of electronic health records, health information and health data remain disparate. Patients and health care teams benefit from access to comprehensive patient records to make informed health care decisions. Significant governmental policy and investments have been made to promote interoperability of systems that connect health information with the ultimate intent of developing a longitudinal patient record. In this article, we discuss how health data, interoperability, and related systems are influenced by federal policy. The intent is to expand occupational therapy practitioners' understanding of the promise of interoperability and the role the occupational therapy profession can play in advancing the infrastructure needed to optimize health care delivery.

Occupational Therapy: Essential to Critical Care Rehabilitation

The coronavirus disease 2019 (COVID-19) pandemic reshaped the health care landscape, leading to the reassignment of essential health care workers to critical areas and widespread furloughs of providers deemed nonessential, including occupational therapy practitioners. Although multidisciplinary critical care teams often include occupational therapy practitioners, efforts to define, measure, and disseminate occupational therapy's unique contributions to critical care outcomes have been overlooked. This editorial provides recommendations to improve the occupational therapy profession's readiness to meet society's current and future pandemic needs. We propose a three-pronged strategy to strengthen occupational therapy clinical practice, education, and advocacy to illuminate the distinct value of occupational therapy in critical care.

Occupational Therapy's Value in Provision of Quality Care to Prevent Readmissions

Health care systems are prioritizing the quality of outcomes over the quantity of services provided, and health care payers and other stakeholders are focusing on preventing hospital readmissions. This priority supports the effort to reduce the cost of health care by avoiding the most expensive care type and improving the quality of health care by promoting sustained return to the community and remaining in the community. Occupational therapy practitioners have expertise that is critically important in this effort. Occupational therapy places a unique and immediate focus on patients' functional and social needs, which can be important drivers of readmissions if they are not addressed. By addressing activities of daily living, instrumental activities of daily living, functional cognition, psychosocial needs, vision, fear of falling, and safety, occupational therapy practitioners can be a valuable addition to the effort to keep people out of the hospital and participating in their lives. This article reviews the literature supporting the role of occupational therapy in each of these key areas.