Current Occupational Therapy Publications in Home Health: A Scoping Review

Research Articles.

Research articles addressed four major topics: environmental and caregiver interventions for people with dementia, multicomponent home interventions and environmental modifications, general occupational therapy interventions, and occupational therapy practice patterns and role. Supplemental Table 1 (available online at http://ajot.aotapress.net; navigate to this article, and click on “supplemental materials”) summarizes each article.

The environmental and caregiver interventions for people with dementia consist mainly of Environmental Skill Building (ESB) program research (Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001). The ESB program is a 6-mo home program consisting of six occupational therapist visits and three phone contacts using specifically trained occupational therapists providing services to caregivers of people with Alzheimer’s disease. Outcomes reduced problematic behaviors and declines in activities of daily living (ADLs) and instrumental activities of daily living (IADLs; Gitlin, Corcoran, et al., 2001) and increased caregiver ability while reducing upset (Gitlin et al., 2003). Many outcomes were sustained at 12 mo (Gitlin, Hauck, Dennis, & Winter, 2005), and factors predicting success and barriers were identified (Chee, Gitlin, Dennis, & Hauck, 2007). Other authors used shorter interventions, demonstrating similar outcomes in reduced caregiver burden and stress (Dooley & Hinojosa, 2004; Holmes, 2000; Sheldon & Teaford, 2002) and increased quality of life, affect, self-care status, and activity frequency (Dooley & Hinojosa, 2004).

Gitlin, Winter, et al. (2006; Gitlin, Winter, Dennis, & Hauck, 2008) offered a 6-mo program focused on multicomponent home interventions using four 90-min occupational therapist visits and three phone contacts. Outcomes indicated reductions in mortality risk, difficulty with ADLs and IADLs, fear of falling, and home hazards and improvements in self-efficacy and use of adaptive strategies. Most outcomes were sustained at 12 mo, and some factors predicting benefits were identified. Stark (2004) also demonstrated improved occupational performance and satisfaction with the ability to perform everyday activities after an occupational therapy home environment assessment and follow-up visits, with results sustained at 2 yr (Stark, Landsbaum, Palmer, Somerville, & Morris, 2009). McNulty, Johnson, Poole, and Winkle (2003) provided factors predicting success in implementing home safety changes.

Other interventions were described in a documentation analysis in a Medicare home health agency indicating improvements in lower-extremity dressing, toileting, and walking with use of occupational therapy (Matteliano, Mann, & Tomita, 2002). Cohen and Schemm (2007) demonstrated increased life satisfaction and taking on new life roles after an eight-visit occupational therapy home intervention among people with spinal cord injury.

Many studies used occupational therapy in a prescribed role and involved specific instructions for each of the indicated visits. Only one study (Matteliano et al., 2002) examined outcomes from current Medicare home health practice. In addition, much of the research focused on adaptation to and compensation for disability, with few remediation interventions.

Research on the role and practices of occupational therapists in home health consists of both health services research (Boutin-Lester & Gibson, 2002; Toth-Cohen, 2000) and descriptive research and survey data from AOTA (2006). General methods can be found in Supplemental Table 1, and content and outcomes are discussed in the Actual Practices of Home Health Occupational Therapists section.

Professional Practice Articles.

Articles addressed four topics: occupational therapy interventions for specific conditions/situations, practice issues, policy, and case reports, which can be found in Supplemental Table 2 (available online at http://ajot.aotapress.net; navigate to this article, and click on “supplemental materials”). Article content was grouped into subtopics, which are described in the Qualitative Analysis section.

Justification of Need for Services.

The literature justifies the need for services on the basis of two factors: (1) limiting inpatient hospitalizations and encouraging management at home and (2) addressing an increasing emphasis on outcomes. First, inpatient settings no longer provide in-home assessments as part of discharge, leaving a need to evaluate safety and equipment in the home (Sevigny, 2000). Siebert (2007) acknowledged that IADLs are frequently not addressed in inpatient settings. Fagan, Van Oss, Cabrera, Olivas De La O, and Vance (2008) acknowledged that the prevalence of people unable to manage conditions at home has increased. Miller (2003) noted the potential cost-effectiveness of occupational therapy in home safety to reduce injury. Second, Toto (2006) and Siebert (2005) noted that 23 of the 41 OASIS–C outcomes related directly to ADL and IADL performance and opportunities for occupational therapy services. Siebert (2006) noted an additional six OASIS–C outcomes that occupational therapy can address.

Reasons for Current Use.

One explanation for the underuse of occupational therapy was decreased awareness of services that occupational therapy can provide (Olivas De La O, 2008b, Siebert, 2005; Toto, 2006). Also, workforce shortages of occupational therapists might result in people from other disciplines filling in for occupational therapists (Olivas De La O, 2008b). Because most resources in home health rehabilitation focus on physical therapy (Krafft, 2006; Metzler, 2003), occupational therapy is often used only if the agency has not met the targeted number of rehabilitation visits (Barnes & Frock, 2003; Olivas De La O, 2008b). Currently, inclusion of occupational therapy depends on decisions made by other team members (Toto, 2006), noting that physical therapists often evaluate the need for occupational therapy (Sevigny, 2000). Krafft (2006) suggested that the justification for this evaluation is a common belief of agencies that physical therapy can address ADLs.

Other authors related the utilization patterns to Medicare policies. Toto (2006) and Metzler (2000, 2003) reinforced that unlike physical and speech therapy, occupational therapy cannot establish patient eligibility for home health services under Medicare. Analysts believe that if occupational therapy were made a qualifying service, a significant number of people would need only occupational therapy, increasing the cost of Medicare home health services (Metzler, 2003).

Suggestions for Improving Use.

One suggestion is to influence Medicare policy by showing that including occupational therapy minimally increases the number of people qualifying for home care, that increased occupational therapy would be cost-effective, or both (Metzler, 2000). To increase client referrals, Olivas De La O (2008b) and Costa (2006) suggested using ADL and IADL deficits indicated by an OASIS–C assessment to trigger an occupational therapy evaluation. Metzler (2009) described new proposed legislation that would allow occupational therapy to complete the initial OASIS–C if a qualifying discipline (physical therapy, skilled nursing, speech–language pathology) was on the physician order. Barney (2001) additionally suggested marketing occupational therapy within and outside home health agencies. Partnerships among AOTA, NAHC, and home health associations of other disciplines have formed to increase use of occupational therapy for Medicare home health beneficiaries (Fagan et al., 2008). In response to workforce shortages, occupational therapy assistants may also be used (Siebert, 2006; Steele, 2006).

Actual Practices of Home Health Occupational Therapists.

Several authors agreed that little research exists on U.S. home health occupational therapy practice (Boutin-Lester & Gibson, 2002; DePalma, 2006; Gitlin & Chee, 2006; Toto, 2006). The studies that do exist have pointed to a lack of meaningful occupations in practice (Boutin-Lester & Gibson, 2002; Toth-Cohen, 2000). Boutin-Lester and Gibson (2002) researched practice patterns of home health occupational therapists, noting most interventions were exercises, with only 1 participant reporting interventions incorporating occupation and the home setting. Toth-Cohen’s (2000) study added that incorporating the patient, family, and home environment during home care was a major shift for occupational therapists from their typical work setting. Time management, purposeful activity, community reentry, teaching caregivers (Olivas De La O, 2008a), and home modifications (Pynoos, Sanford, & Rosenfelt, 2002) were often overlooked. Accounting for this oversight was a decreased emphasis on client priorities and collaboration (Boutin-Lester & Gibson, 2002; Gitlin & Chee, 2006). As a result, clients were often dissatisfied with discharge (Boutin-Lester & Gibson, 2002).

The AOTA (2006) workforce survey added further depth. Compared with the national sample, occupational therapy home health practitioners were more likely to work <30 hr/week (30.8% vs. 22.4%) and to be paid for their work as contractors (32.3% vs. 25.9%). In addition, they were more likely to have direct client intervention as their primary role (94.4% vs. 83.1%) and less likely to have indirect or administrative responsibilities as their primary role (4.5% vs. 8.0%).

Reasons for Current Practices.

Many authors discussed health care system policies and procedures as factors in current occupational therapy practice. Fagan et al. (2008) acknowledged that most home health occupational therapy is provided after acute hospitalizations and is directive and prescriptive (Gitlin & Chee, 2006). Toth-Cohen (2000) offered that the reasoning of home health occupational therapists relates to their roles in institutional and cultural structures in health care and the dominance of the medical model (Siebert, 2003). Siebert (2003, 2005) added that occupational therapy interventions often focus on remediating body structures and functions. In addition, given that many occupational therapists in home care are part-time (AOTA, 2006) per diem employees (Toto, 2006) or contract therapists (Raptosh, 2003), coordination of care with other professionals is difficult (Toto, 2006).

Suggestions for Improving Practices.

Toth-Cohen (2000) suggested that comprehensive training programs may be necessary to transition into home care. Therapists should focus on areas that clients report as problematic: serving as consultants, helping clients solve problems, and offering strategy choices (Gitlin & Chee, 2006; Vance & Siebert, 2009). The focus should be on altering activity demands of ADLs and IADLs by means of assisted devices, environmental interventions, or task simplification (Siebert, 2003), emphasizing a balance between remedial and adaptive approaches (Merryman, 2006; Vance & Siebert, 2009). Ultimately, therapy should lead to a change in client health status rather than merely a change in skill or measurable body function (Siebert, 2005). Last, preventing deterioration and stabilization are needed, especially for people with declining conditions (Siebert, 2005). Other recommendations include partnering with home health aides (O’Sullivan, 2003) and providing home health internship programs for new occupational therapy graduates (McCaul, 2005).

Scarcity of Research in This Area.

As discussed, research is scarce, especially in the area of Medicare home health. The research that does exist uses occupational therapy in a role that is different from traditional Medicare-based home care practice. Research involving occupational therapy practice in Medicare home health services is recommended (including a systematic review analyzing the quality of current research), as well as basic research on utilization of and access to occupational therapy services in home care.

Current Occupational Therapy Workforce.

Occupational therapists in home health are more likely to work part time or as contractors and have less contact with other team professionals. Also, workforce shortages might cause other disciplines to perform duties traditionally reserved for occupational therapists. These factors suggest an absence of occupational therapy input on the treatment team that might affect its utilization. This problem might be addressed by starting fieldwork programs and internship programs (McCaul, 2005) and developing training and research partnerships with area universities. Agencies should attempt to integrate and include part-time or contract occupational therapists on the treatment team. In addition, occupational therapy assistants can be used more often (Siebert, 2006; Steele, 2006).

Lack of Occupation-Based Treatment in Home Health Care.

Current occupational therapy interventions might not be in the basic domain of ADLs or IADLs or incorporate the patient, caregiver, and environment, even though research indicates that they should do so (Gitlin, Winter, et al., 2006; Gitlin, Corcoran, et al., 2001). Agency orientation and training programs specific to home health occupational therapy may be limited. Consequently, home care practice may be similar to institutions in which occupational therapists receive more clinical training, as is evident by the focus on remediation of impairments. Agencies might then be less likely to refer to occupational therapists if they cannot address ADL and IADL outcomes important to home care.

I propose that OASIS outcomes in ADLs and IADLs delineate a clear role for occupational therapy. Interventions targeting ADLs and IADLs might address physical and social contexts, body functions and structures, performance skills and patterns, and activity demands (AOTA, 2008) while using a balance of remedial and adaptive approaches. Home care agencies should routinely provide orientation and training for occupational therapists, including areas for intervention and outcomes. Additionally, research determining occupational therapy practice patterns and outcomes is highly warranted to support this study’s preliminary findings.

Limited Knowledge of Occupational Therapy in Home Care.

This lack of knowledge might reflect or be a cause of current utilization. Limited knowledge would in turn limit the expectations for occupational therapy in delivering outcomes. Referring entities might not know to refer to occupational therapy for a specific concern, nor would practitioners be held accountable for delivering outcomes in basic areas of occupation.

As suggested here, scores from OASIS ADL and IADL measures could be a simple way to demonstrate the need for and role of occupational therapy services. Increased knowledge of occupational therapy might be accomplished by clarifying the role of occupation-based practice focused on outcomes. Encouraging professionals to acquire full-time or leadership positions within agencies might also have a positive effect on knowledge and use of occupational therapy.

Medicare Policy Limiting Occupational Therapy as a Qualifying Service.

The existing policy may indeed limit services for people who need occupational therapy. Inclusion of occupational therapy is often dependent on the decisions of other team members, such as physical therapists. Given the lack of knowledge of occupational therapy, whether appropriate referrals are made is unclear. Again, I recommend that scores from OASIS ADL and IADL measures identify the need for occupational therapy. The proposed legislation allowing occupational therapists to complete the initial OASIS (Metzler, 2009) might increase occupational therapy utilization by reducing reliance on non–occupational therapy gatekeepers. Further research is needed to determine the direct cost of a change in policy, as well as the potential cost-effectiveness of home occupational therapy services.