Implementation of a Patient-Reported Outcome Measure: A Quality Improvement Project

ABSTRACT

Patient-reported outcome measures (PROMs) are seen as increasingly beneficial to patient-centered clinical practice, but implementation of routine collection and utilization into clinical care can be challenging. Our interdisciplinary quality improvement (QI) team used the Institute for Health Care Improvement Model for Improvement methodology to address this problem in our outpatient neurorehabilitation program. We used a participatory approach to identify the PROM rehabilitation stakeholders found to be most appropriate to implement in the outpatient settings; chart audits were conducted to determine the extent to which clinicians implemented the PROM and documented a PROM-related goal. Opportunistic clinician feedback was collected to determine single PROM usefulness and acceptability. Our 4-month initiative demonstrated increased collection of a PROM, the Patient-Specific Functional Scale (PSFS), and incorporation into patient-centered goal. Use of QI methodology was beneficial when planning and executing our initiative. Future work is needed to examine factors to sustain PSFS use, incorporation into patient-centered goal setting, and maximize meaningful patient outcomes.

Occupational Therapy for Poststroke Anxiety and Depressive Symptoms in Inpatient Rehabilitation

Poststroke anxiety and depressive symptoms (P-SADS) affect one in three people and are associated with decreased participation in activities of daily living. This study sought to characterize occupational therapy (OT) P-SADS care practices and identify factors influencing P-SADS care provision in one U.S. inpatient rehabilitation (IRF) facility. An explanatory sequential mixed-methods study design was used by gathering data from electronic health records (from January 1, 2019 to December 31, 2019) as well as semi-structured interviews with OT practitioners in the IRF. No objective P-SADS screens were documented nor were any P-SADS-focused goals written. Minimal evidence-based P-SADS interventions were identified. Practitioners reported multi-level barriers to OT P-SADS care including limited time, pressure to prioritize physical recovery, and inadequate resources to guide practice. OT practitioner P-SADS care was inconsistent with established evidence-based practice. This research identifies gaps in comprehensive stroke recovery and informs implementation efforts to support evidence-based P-SADS care in IRFs.

Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study

BACKGROUND

Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices.

PURPOSE AND RELEVANCE

Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization.

METHODS

Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs.

RESULTS

Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002).

CONCLUSIONS/IMPLICATIONS

As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.

Evaluating Implementation Strategies and Outcomes in Postacute Stroke Rehabilitation: A Scoping Review

Date Presented 04/02/2022

This research describes implementation strategies and outcomes commonly leveraged to support evidence implementation in adult stroke rehabilitation. Presenters will share findings from their scoping review that examined the effectiveness of implementation strategies with practitioners in stroke rehabilitation settings. This study addresses the research priority concerning the need to progress beyond implementation barriers to examining implementation strategies to overcome them.

Primary Author and Speaker: James Edward Murrell

Additional Authors and Speakers: Janell Pisegna, Lisa Juckett

Translating Evidence to Practice: Development and Dissemination of AOTA’s Knowledge Translation Toolkit

Date Presented 03/31/2022

AOTA’s Knowledge Translation (KT) Tool Kit is designed to support practitioners’ use of evidence in routine practice. The purpose of this presentation is to (1) share survey findings representing the KT needs of more than 800 OT practitioners, (2) describe the development of the KT Tool Kit on the basis of practitioner needs, (3) share tool kit resources, and (4) present examples of how the KT Tool Kit can optimize the delivery of evidence-based care.

Primary Author and Speaker: Lisa Juckett

Additional Authors and Speakers: Kelly Jane Tanner, Aimee Piller

Contributing Authors: Elizabeth Schmidt, Hillary Richardson, Elizabeth G. Hunter, Susan Cahill, Deborah Lieberman

Learning Health Systems Can Promote and Sustain High-Value Occupational Therapy

In the current policy context, the occupational therapy profession must act to promote and sustain high-value care. Stakeholders have delineated efforts, such as defining and measuring high-quality care processes or promoting the adoption of evidence into practice, that can enhance the value of occupational therapy services. There is a growing recognition, however, that low-value care is the product of deficiencies within health care systems and is therefore most amenable to system-level solutions. To date, the specific nature of system-level changes capable of identifying and rectifying low-value occupational therapy has yet to be elucidated. In this "The Issue Is. . ." column, we introduce occupational therapy to the Learning Health System concept and its essential functions. Moreover, we discuss action steps for occupational therapy stakeholders to lay the foundation for Learning Health Systems in their own professional contexts. What This Article Adds: This article is the first to outline concrete action steps needed to transform occupational therapy practice contexts into Learning Health Systems. Such a transformation would represent a system-level change capable of fostering the delivery of high-value occupational therapy services to clients in a variety of practice settings.

Deploying Implementation Strategies to Facilitate Professionals’ Use of the Home Care Frailty Scale

Home- and community-based service (HCBS) organizations play an instrumental role in maximizing the independence of older adults, ages 60 and over. HCBS clients typically have multiple health complications, placing them at great risk of frailty—a complex condition associated with health decline and institutionalization. However, despite their frequent contact with older adults, HCBS professionals are not required to assess the frailty levels of their clients, creating a missed opportunity to monitor the needs of this at-risk population. The purpose of this quality improvement study was to test a package of five implementation strategies designed to support HCBS professionals’ use of the evidence-based Home Care Frailty Scale (i.e., Frailty Scale) with all new clients at one large HCBS organization. Implementation strategies included (a) selecting one professional to serve as the organization’s Frailty Scale “champion,” (b) holding three training sessions with 25 HCBS professionals, (c) modifying client charts to allow professionals to document Frailty Scale results, (d) pilot testing the Frailty Scale with a small group of clients, and (e) completing monthly chart audits to monitor rates of Frailty Scale implementation. During the first three months of Frailty Scale use, HCBS professionals administered the Frailty Scale to 414 out of 467 eligible clients (88.6%). For Month 1, 87.4% of eligible clients were administered the Frailty Scale, followed by 90.8% in Month 2, and 85.6% in Month 3. This quality improvement study suggests that a multifaceted package of implementation strategies can support professionals’ use of an evidence-based frailty instrument in the HCBS setting.

Benefit of the Wayfinder System for Individuals With Cognitive Disabilities and Their Caregivers

Date Presented 04/13/21

The MAPCD project uses the WayFinder3 GPS app and comprehensive trainings to improve community mobility for individuals with cognitive disabilities and their caregivers. Participants used the app in their daily lives, and preliminary findings demonstrate unique and substantial benefits including increased autonomy and improved quality of life. This research advances the field of OT through the implementation of innovative assistive technology to improve independence in community mobility.

Primary Author and Speaker: Kaetlyn E. Culter

Mobility Assistance for People With Cognitive Disabilities: Identifying Implementation Outcomes and Strategies of Innovative Technology

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

The Mobility Assistance for People with Cognitive Disabilities (MAPCD) program, including the WayFinder 3 assistive smartphone navigation app and training program, addresses barriers to community mobility and provides supports to both individuals with cognitive deficits and their caregivers. We describe the MAPCD program and examine strategies that facilitated the adoption of the WayFinder 3 app designed to optimize independent community mobility.

Primary Author and Speaker: Sarah E. Anderson

Additional Authors and Speakers: Lisa Juckett

Contributing Authors: Carmen DiGiovine, Sandra A. Metzler, Ashley Stojkov, Bethany Frick, Kaetlyn E. Culter, and Elizabeth Mance

Implementing IG Best Practices in Community-Based Settings: A Pre-Implementation Study

Programs that intentionally engage unrelated young and old persons often lead to mutual benefits; however, specific implementation strategies that support the use of evidence-based intergenerational programming in community settings are understudied. With strong demand for training resources among intergenerational program providers, this pilot study examined how a multifaceted training strategy facilitated the implementation of 14 distinct evidence-based intergenerational best practices. Intergenerational programming was implemented with nine staff from two small community sites using three implementation strategies including educational meetings, ongoing consultation, and routine practice reminders. Observational analysis of video recorded intergenerational program sessions indicated that staff adopted an average of 81.7% of intergenerational best practices suggesting the feasibility of implementing IG in community settings. Findings yield valuable insight that can inform training refinements, and selection of strategies for improving implementation. Next steps include aligning specific practices with participant outcomes.

Staff and Administrator Perceptions of Fall Risk Management in Home- and Community-Based Service Settings

Older adults who receive home- and community-based services (HCBS), such as home-delivered meals and personal care assistance, are at particular risk for falls due to their extremely high prevalence of fall risk factors. HCBS organizations and their staff are well-positioned to implement fall risk screens with HCBS clients and then refer older adults to fall prevention services as needed; however, the extent to which HCBS organizations manage fall risk has yet to be systematically examined. The purpose of this qualitative study was to explore the barriers to and facilitators of implementing fall risk screens and fall prevention service referrals in HCBS organizations. A total of 26 HCBS staff members and administrators participated in semi-structured interviews and focus groups. Qualitative data were examined using directed content analysis guided by the Consolidated Framework for Implementation Research. HCBS staff expressed that strong rapport with clients allowed for them to address fall risk proactively but were concerned that their lack of fall prevention training precluded them from effective fall risk management. HCBS administrators perceived their organization to have reliable internal communication procedures which enhanced fall prevention care coordination but believed their limited connections with fall prevention service providers served as a barrier to referring at-risk clients to appropriate care. Accordingly, HCBS stakeholders are encouraged to develop strategies, such as providing fall prevention coaching and building a network of fall prevention service providers, that account for these barriers and facilitators in future efforts to support effective fall risk management with HCBS clients.

MENTAL HEALTH AND HUNGER: RISK FACTORS FOR HOSPITALIZATION AMONG HOME-DELIVERED MEAL PARTICIPANTS

Home-delivered meals (HDMs) provided through the Older Americans Act (OAA) are intended to reduce hunger, promote socialization, and maximize wellness. However, HDM recipients are at increased likelihood of being hospitalized due to their complex health needs and risk for social isolation and depression. Drawing data from the OAA-HDM National Survey, we evaluated the predictors of hospitalization among HDM recipients in 2017. From our sample (n = 578), we conducted random forest classification analyses to identify the most important risk factors related to HDM recipient hospitalization. Our random forest model yielded an accuracy rate of 66.3% with risk factors most indicative of hospitalization being attributed to number of co-morbidities, depressive symptoms, and feelings of social isolation. These findings indicate that although HDMs may help alleviate hunger among older adults, innovate strategies are warranted to address the unmet mental health needs of HDM recipients.

Strategies for Implementing Evidence-Based Interventions Into Practice With Community-Dwelling Older Adults

Date Presented 04/04/19

Because of the rapid growth of the older adult population, the OT profession is currently faced with the urgent need to implement effective interventions into practice to meet the needs of community-dwelling older adults. We conducted a scoping review of the OT literature to identify effective implementation strategies for integrating research into practice with older clients. Strategies ranged from interactive workshops and consultations to fidelity vignettes and peer mentoring.

Primary Author and Speaker: Lisa Juckett

Additional Authors and Speakers: Monica Robinson