Transcript Document

St. Luke’s University Health Network
Neuroscience Symposium 2015
DeSales University
March 7, 2015
Dr. Julia Glenn, OTD, OTR/L, C-GCM
Objectives
Background and challenges of acute
care today
 Literature review
 Summary of findings- New
opportunities!
 Conceptual models
 The Future of Occupational Therapy
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Introduction
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US: 700,000 new or recurrent stroke,
1 every 45 seconds
1.25 men>women
½ all acute neurological hospitalizations
50% are hemiparetic, 12-19% are aphasic, 35%
suffer from depression, 26% require nursing
home care, 30% cannot walk, and 24-53%
report complete or dependent assist for ADLS
Health Care Reform
Focus on client centered, occupation based
interventions to:
 Promote engagement
 Prevent psychosocial complications
Background
Occupational therapy and the paradigm shift
towards holism
 Introduces an encompassing definition for OT
services
 Increasing elderly population in the future
 Health Care Reform
 Less insurance denials in acute care/rehab
 Need for evidence based practice to justify
occupation
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Implications of the Changes in
Healthcare in Acute Care
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Shorter length of stay.
Higher demands on productivity.
Less staff to treat increase case loads.
New rules and regulations (60%,40% rule) for
the coverage of acute rehab services are
changing the types of patients OTs treat
Rehab hospitals will be treating more medically
and psychosocially complex patients
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Occupational Therapy and Acute Care
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Administrative transformations
Decrease in staffing to be cost effective=lack of
communication and pursuit of fast paced discharges
Implementation of program improvements for care
Medicare/Medicaid Services will pay health systems
based on quality care
Academic Health Centers need to explore new
approaches to demarcate & integrate holism
Sounds like a need for occupation based practice,
doesn’t it?
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Objectives
Background and challenges of acute
care today
 Literature review
 Summary of findings- New
opportunities!
 Conceptual models
 The Future of Occupational Therapy
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Literature Review: Occupation and Acute Care
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Occupation and Acute Care: Oxymoron?
Reductionistic, biomechanical, medical model
UB ADLs, UE ROM/MMT, and grooming
Impaired our vision- disregard occupation
Pilot study: perceptions of role in acute care
Most studies relate to effectiveness of
intervention strategies
Others focus on mobility and deconditioning
w/o occupation
Psychological well being- rarely addressed
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PICO Question
What are the most effective intervention
strategies for improving function in adults
diagnosed with CVA and depression?
 Can occupational engagement improve overall
affect and mood in adults diagnosed with CVA
and demonstrating signs and symptoms of
depression?
 What are the effects of occupational
engagement on improving functional
independence and overall affect/mood in
adults diagnosed with CVA and demonstrating
signs and symptoms of depression?
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Five Themes Emerged…
1) Participation
 2) Occupational engagement
 3) Social support
 4) Quality of life
 5) Physical therapeutic exercise
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Participation
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5/15 articles (4 level III, 1 level I)
5 were quantitative: 3 cross sectionals, single
case design, 1 meta-analytic systematic review
Rehab should focus on participation in IADLS
and leisure activities
Participation in meaningful activities while
focusing on depression can improve mood and
life satisfaction
Couple psychotherapeutic interventions with
physical engagement to decrease restricted
participation
Participation Continued…
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Initially focus on economic sufficiencies,
independence and social/environmental
participation, then later focus on leisure activities
and occupational participation
Be sensitive to MCI’s impact on participation and
acknowledge these challenges and focus on
returning to participation in all activities
Further research needed on:
 Occupation based interventions improving I/ADL, and role
participation
 The impact habits and contextual/environmental
influence, and strategy training vs task-specific training
have on enabling occupation based participation
Occupational Engagement
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2/15 articles (2 level V’s, 2 qualitative phenomenologies)
Combine re-engagement patterns of old occupations as well
as exploring new occupations is proposed to manage s/s
depression
Maximize re-integration or facilitating
adaptation/accommodation for occupation based
engagement
Little research is available that explores the impact of
emotional changes on rehabilitation or effective treatment
approaches to manage post stroke emotional changes
Existing research suggests feelings of incompetency or
incapacity with difficulty with re-engaging in old occupations
-> eliciting emotional changes
Further research is suggested to be conducted to investigate
the impact of the person-centered process on improving
social participation and well-being
Social Support
2/15 articles (2 quantitative, 1 cross sectional,
1 level III, 1 systematic literature review, 1 level
I)
 Time use satisfaction levels are positively or
negatively influenced by the presence or lack
of social support
 Clinically, screening for depression and
promoting frequent, immediate, and intense
positive social support has a definite impact on
improve quality of life and remediating
psychiatric distress
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Quality of Life
4/15 articles (4 quantitative, 4 level III,
3 cross sectionals, 1 single case design)
 Address psychological distress and stressors in
acute phases is important for improving QOL
 Fatigue and motor function were ID’d as
important unmet demands that impede quality
of life
 Depression is often unrecognized and affects
activity participation and fatigue that affects
QOL and life satisfaction
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Quality of Life Continued…
Healthcare does not manage, address, or meet
LTC needs of survivors OR survivors’
perspectives of demands vs expectations are ?
Reasonable
 Depression and emotional changes have a
larger impact in the early phases (12mo) of
recovery and impact QOL
 Improving social support and reducing
emotional problems early on enhances QOL
 Even MCI and mild emotional dysfunctions can
have a LT effect on QOL if left unmanaged
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Physical Therapeutic Exercise
2/15 articles (2 quantitative, 1 pilot study case
control design, 1 cohort design, 2 level III)
 Participants with and without cognitive
impairments/depressive symptoms improved
over time w/ physical therapeutic exercise and
repetitive task practice
 Therapeutic strength and exercise programming
has a positive effect on depressive symptoms,
mood, & QOL in subacute phases
 Depression does not limit gains in function or
impairments attributable to exercise
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Objectives
Background and challenges of acute
care today
 Literature review
 Summary of findings- New
opportunities!
 Conceptual models
 The Future of Occupational Therapy
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Summary of Findings
None relate to latest PICO: In adult stroke survivors,
do mood disorders and life dissatisfaction
significantly impact functional participation and
quality of life?
 14/15 articles at an average of level III evidence with
most certainty support that mood disorders and life
dissatisfaction do significantly impact functional
participation and QOL in adult post stroke survivors
 Conclusions to be made:
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 66% experience dissatisfaction with life due to activity
limitations and restricted participation in IADLS, ADLS, and
work related tasks.
Summary of Findings Cont’d…
 Those w/ and w/o mood disorders experience improved
participation and performance in ADLs, IADLs, and role
participation through client-designation of goal activities and
meaningfulness of the activity.
 Those w/ mild cognitive impairments experience limited
participation in social, educational, high and low demand
leisure activities; though depressive symptoms did not show a
retained participation in comparison to those without
depressive symptom.
 Those w/ emotional changes (depression/lability) directly
impact acute occupational engagement and hinder LT recovery
and re-engagement in occupations.
 Those w/ depression and mood dysfxns that receive
immediate, intensive, consistent, regular, and early initiation of
professional social support can improve emotional regulation
and depressive/psychiatric mood management
Summary of Findings Cont’d…
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Those experiencing life dissatisfaction, when engaging in a
collaborative lifestyle intervention group are able to more
effectively ID limitations in occupations that are meaningful
Those that may not necessarily have depression but do
demonstrate depressive s/s do in fact experience life
dissatisfaction with time use spent in occupational
participation; particularly in those w/ less affectionate support.
Those w/ depression and mood dysfunctions that receive
immediate, intensive, consistent, regular, and early initiation of
professional social support can improve emotional regulation
and depressive/psychiatric mood management.
Those w/ psychological distress and impaired cognitive function
are Ily associated with lower reports of perceived QOL.
Summary of Findings Cont’d…
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Those w/ younger age, motor impairments,
unemployment, cognitive and motor impairments, fatigue, and
depressive symptoms have unmet demands relating to work
skills, intellectual fulfillment, and leisure time that impair their
QOL.
Those w/ depression experience the lowest QOL within the first
six months of onset, from six to twelve months is positively
influenced by social support, educational qualifications, and
occupational status.
Those w/ subtle residual deficits (depression, impaired executive
function, attention) have less life satisfaction and QOL.
Those w/ and w/o depressive s/s and w/ and w/o cognitive
impairments can improve in fx’l participation after engagement
in a repetitive therapeutic task practice
Exercise can have a positive effect on mood, modifying its effect
on functional recovery, and improve QOL in stroke survivors w/
depressive s/s
Refocusing of Health Care Goals-New Opportunity!
OT’s need to develop a knowledge base shown
to be effective in enabling those with disability
to live more meaningfully and productively
 Need to abandon biomechanical reasoning and
incorporate psychosocial reasoning as well as
evidence-based practice
 OT’s need to shift from reductionism back to
holism to fully assess quality of life
 OT’s also need to advocate for occupation
based practice and client centered
interventions to address all aspects of
humanism-not just a physical disability!
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Objectives
Background and challenges of acute
care today
 Literature review
 Summary of findings- New
opportunities!
 Conceptual models
 The Future of Occupational Therapy
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Conceptual Models in Acute Care
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Conceptual models
 Lifestyle Performance Model (LSPM)
 Models in psychiatric/mental health settings
 MOHO, PEO, OA, and Ecology of Human
Performance most often used
 Most therapists don’t use just one, they
combine
 Little to no studies on the LSPM
 Some relating to COPM
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The Lifestyle Performance Model
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Designed to give the OT the basis to perform
sophisticated assessment and treatment that
truly impacts a person’s quality of life through
purposeful activity.
Allows for incorporating relevant data into
documentation which guides the intervention
plan.
Can be used with other-treatment based frames
of reference as an over-arching model.
Drives client centered, occupation based practice
interventions for a treatment plan “specially
made” for the client
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The Lifestyle Performance Model (cont.)
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4 Domains of the LSPM patient profile, equal in
importance and socioculturally specific:
- Self-Care/Self-Maintenance
- Intrinsic Gratification
- Societal Contributions
- Reciprocal Interpersonal Relatedness
Environment: All of the above must be
considered given the context in which these
activities take place including how the
environment hinders or contributes to
occupation.
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Communicating findings to practice,
funders, clients, and managers
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Multidisciplinary daily stroke rounds
 Anti-depressants, mood screens, communicate findings
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Family, caregiver, patient education re: mood and emotional
regulation/depression, participation and life satisfaction/QOL
 Make it personal
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Managers can acknowledge the need for consistent caseloads
for maintain consistency/rapport
Improvement in motivation/participation/mood i.e.
screens/assessments can improve function i.e. FIM scores= $
Justifies need for psychosocial management in acute care for
LT prognostic recovery
Ensure documentation reflects functional, medical, skillable
and reimbursable needs
Communicate findings to coworkers, symposiums,
state/international conferences
Objectives
Background and challenges of acute
care today
 Literature review
 Summary of findings- New
opportunities!
 Conceptual models
 The Future of Occupational Therapy
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Overview
Hospitals need new approaches to improve
communication and pt satisfaction
 Health systems are reimbursed based on quality
services
 Patients are most frequently seen longitudinally in
acute care and not only value it- but significantly
benefit from occupation
 OT’s know their role, but are interested in finding
out more information with tools that are quick,
effective, and beneficial…LSPM!
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Conclusion
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OT is moving back to holism
Acute care needs an innovative approach focused on the client with
assuring quality care
Health systems will pay for quality care provided
People need occupation for recovery
People value occupational engagement to promote overall health and
well being by improving functional independence
OT’s value theory and conceptual models though need more education
on how to utilize them
LSPM incorporates 4 holistic domains and is quick, easy, and
encompassing
OT’s are the ones to drive the movement towards improving quality of
life and recovery in acute care through the use of the LSPM to identify
meaningful occupations
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Wrap Up!
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When a patient does what is familiar, enjoyable and
what they want to achieve; they are inadvertently
developing their own treatment program.
Occupation based practice and client centered
interventions drive motivation and willingness to
participate
Find what makes them tick and submerge them in
those meaningful activities to get “flow” to happen
Our expertise is to direct the engagement in
occupation to support participation.
Be the means to achieve!
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Overall Benefits of Occupational Engagement
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Differentiated us from other disciplines and increased
respect for OT throughout the institution.
Has produced improved patient outcomes.
Enhanced meaningful engagement
Positive perception of a good therapeutic experience
Illustrated the benefits of true functional independence
Has significantly increased OT referrals from other
disciplines.
Has increased role clarity for therapists and students.
Influenced multidisciplinary treatment approaches,
therapeutic styles, and holistic interventions
Increased recognition for the power of human engagement
Elicited psychosocial impact with patients and families that
value occupational engagement
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Integrating Occupation into Treatment
Session
Occupation= meaningful activity as a therapeutic
tool.
 Need to define OT’s role, reclaim occupation.
 Looking at Quality of Life and changing life-style
to promote physical, cognitive, and emotional
wellbeing.
 Exploring ways to continue life style roles with
physical/cognitive limitations.
 Need to use assessment tools with data supports
observations.
 Ensure documentation reflects measurable data,
capture the “flow”.
 Exploring patients contributions to society.
 Moving past function Quality and
Balance life-style.
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The Future of Occupational Therapy
For OT to survive and flourish in the rehab setting
we must:
 Learn about all the resources in the community
 Be able to assess and address complex
biopsychosocial issues in a wide variety of
patient population and setting.
 Be able to provide sophisticated, authentic,
occupational therapy based on sound conceptual
models and frames of reference.
 Utilize valid assessment tools to design
treatment and utilize evidence based practice.
 Integrate OTs unique ability to utilize occupation
as a therapeutic tool.
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The Future of Occupational Therapy (cont’d)
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New paradigm shift: the need for evidence based practice
Requires measurable and reimbursable evaluations,
treatment plans, interventions, and holistic assessments.
All OT’s acknowledge need for more research, though few are
doing it!
Few studies exist regarding the use of occupation in acute
care/acute rehab medical settings
NO evidence exists relating to the use of the LSPM as a
conceptual model in this setting
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Speaking of Research:
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Top 5 Research Articles Relating to Occupation in Acute Care as of 2012:
 Studies showing OT has a positive effect in acute care
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Brahmbhatt, N., Murugan, R., & Milbrandt, E.B. (2010). Early mobilization improves functional
outcomes in critically ill patients. Critical Care Medicine, 14: 321.
○ Wressle, E., Filipsson, V., Andersson, L., Jacobsson, B., Martinsson, K., & Engel, K. (2006).
Evaluation of occupational therapy interventions for elderly patients in Swedish acute care: A
pilot study. Scandinavian Journal of Occupational Therapy, 13, 203-210.
 Studies showing the nature of OT in acute care
○ Craig, G., Roberson, L., & Milligan, S. (2004). Occupational therapy practice in acute physical
health care settings: A pilot study. New Zealand Journal of Occupational Therapy, 51(1), 5-13.
○ Griffin, S.D., & McConnell, D. (2001). Australian occupational therapy practice in acute care
settings. Occupational Therapy International, 8(3), 184-197.
 Study showing occupation based intervention use in acute care
○ Eyres, L., & Unsworth, C.A. (2005). Occupational therapy in acute hospitals: The effectiveness of a
pilot program to maintain occupational performance in older clients. Australian Occupational
Therapy Journal, 52, 218-224.
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Any Questions??
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Revised 1/12/2015 per Dr. Julia Glenn, OTD, OTR/L, C-GCM
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