Guest Post by Nancy Dubuar, MOT, OTR/L, CPAM, Occupational Therapist at Allegheny Health Network Healthcare @ Home
As an occupational therapist, when I call my clients to set up my first visit in their home, I am often told, “Honey, I don’t need a job. You don’t need to come see me.” And so the education begins. I ask, “Are there things you have to do every day since you got home that are harder to do because you are short of breath, you lack energy, or you have new pain? Are you having trouble taking a shower, putting on your socks, cooking a meal, managing your medications? These are just some of the things we can address in occupational therapy… all those daily tasks that occupy your time.”
In 2002, Centers for Medicare & Medicaid Services (CMS) introduced Outcome-Based Quality Improvement to home health, measuring change in the daily function of clients from the start of care to discharge. Occupational therapy (OT) focuses on meaningful participation in the occupations of daily living. Clinicians are trained to look at the person, the environment, and the occupation to see where these things overlap or disconnect and to intervene to make adjustments/modifications to promote independence and safety with ADLs/IADLs. The American Occupational Therapy Association (AOTA) 2013 Fact Sheet: OT’s Role in Home Health points out that,“Occupational therapy practitioners find the right fit between clients’ abilities, needed and desired activities, and their home environment so clients can manage safely and productively—at home.”
In the changing healthcare reimbursement environment, the cost of medication nonadherence will be shifting to providers. Interdisciplinary collaboration between nursing and occupational therapy can improve medication adherence. While nurses monitor side effects and educate clients on the medication to promote health, the OT practitioner can help the client integrate medication management into the daily routine. The practitioner can help identify and remove barriers to success, including: addressing difficulties due to low vision, decreased fine motor skills and coordination needed to manipulate the pills and pill containers. Practitioners can also educate clients and trial adaptive strategies or devices that provide reminders at key times of the day.
The OT practitioner collaborates within the home health team in managing chronic diseases. Clinicians help clients adapt regular health management tasks, such as taking blood sugars and giving insulin shots, who also struggle with hemiplegia, weakness, or tremors in the hand. Clinicians adapt ways to don compression garments and to integrate and educate on positioning programs to improve edema management and to promote joint and skin integrity. Other interventions include training and integrating energy conservation and pacing techniques into the daily routines of home to reduce the fatigue caused by many chronic conditions with significant improvement to the client’s quality of life.
As the AOTA 2015 Fact Sheet: Occupational Therapy’s Role in Chronic Disease Management reminds us, “It is not enough for clients to learn and demonstrate the skills. To be effective, they must be consistently, habitually, and correctly performed; and they must be integrated into existing routines. Occupational therapy practitioners look at barriers that prevent clients from integrating health management tasks successfully into their daily routines and, if necessary, incorporate adaptations to overcome these barriers.” OT recognizes that people are more than their diseases and symptoms; they are complex beings and occupational therapy interventions help them balance what is necessary with what is meaningful in order to live life to its fullest.
OT practitioners recognize the importance and role of the family caregiver. Caregivers are essential in supporting people with cognitive deficits such as dementia. Multiple research studies show the best interventions address both the caregiver and the person who has dementia. OT practitioners collaborate and set goals with the caregiver to address the existing problems with daily tasks. OT interventions include the caregivers and address problem solving, technical skills, simple home modifications strategies, and adaptive devices, along with referral to community resources. Best practice shows that educating caregivers into the disease progression and providing strategies to manage behavior challenges improves caregiver self-efficacy and results in less frustration and less time spent in caregiving. It also supports the client in his home environment.
AOTA collaborates with the National Highway Traffic Safety Administration and the Centers for Disease Control on an Older Driver Safety Initiative. The home health therapist is often questioned by the family of older drivers looking for answers about driving safety or driving cessation. A home health OT practitioner can help frame the discussion by pointing out the skills and deficits of the client, the risks to performance inherent in specific diseases, and the possible impact on driving. The practitioner can also educate on simple adaptions and equipment needed to address decreased range of motion and other physical deficits as a driver or as a passenger and, if necessary, can provide a referral for more comprehensive services.
Occupational therapist Dr. Pamela Toto, Board Certified in Gerontology and a Fellow of the AOTA, stated in a recent presentation that occupational therapy “is uniquely prepared to address the success of clients in their home. We address the intersection of a person’s capabilities with the activity and where they live. We can not only improve the official score of the OASIS functional outcome measures, but can make sustainable change that will last long beyond the episode of care.”
Clients, along with our healthcare partners, are seeking value from their healthcare expenditures. It is not enough to simply heal a wound or clear an infection. To provide value, we must also create positive change. The clients, with or without a caregiver, must be able to perform and successfully manage the daily demands of the many facets of self-care and manage their health conditions, and do so with minimal risk in their home. Occupational therapy is an integral component of the team to create this value of sustainable change.