Abstract
Keywords
Amy Jo Lamb, OTD, OTR/L FAOTA
Christina A. Metzler
The 2010 Patient Protection and Affordable Care Act (ACA; Pub. L. 111–148) is greatly altering the health policy landscape in which the practice of occupational therapy exists. We are rapidly approaching the January 2014 full implementation date, when state health insurance exchanges will begin to operate and Medicaid expansions will take effect. As occupational therapy leaders position the profession to seize opportunities within this landmark policy shift, it is essential to identify, produce, and effectively use evidence demonstrating the value of occupational therapy to nurture the growth of the profession as the system changes.
Defining Value
In March 2009, the Institute of Medicine (IOM) published a brief discussing common themes surrounding health care value. In this brief, the IOM suggested that “to address both the costs and the performance of the health care system, greater consensus will be required on what constitutes value in health care, and how to measure and increase that value” (p. 1). Simply put, policymakers, insurers, providers, employers, manufacturers, and consumers of health care have different variables that identify value, and all of these variables must be considered if true value is to be achieved. This inclusiveness is critically important to occupational therapy as a profession that is client centered, evidence based, and science driven.
Value can be viewed using a health policy lens through what is referred to as the triple aim. Donald Berwick, founder of the Institute for Health Care Improvement (IHI), launched the triple aim framework to promote better ways of providing health care while reducing growth in spending (Beasley, 2009). Berwick, Nolan, and Whittington (2008) identified the triple aim goals as (1) improving the individual experience of care, (2) improving the health of populations, and (3) reducing the per capita costs of care for populations (p. 760). The IHI translated the triple aim into specific actions to improve the health care system, including a focus on individuals and families, redesign of primary care services, population health management, identifying components of cost-control approach, and system integration (Beasley, 2009). The triple aim concept was a foundation for reform discussions leading up to the passage of the ACA and is underpinning its implementation.
The triple aim provides occupational therapy with avenues to link existing research to our role in improving quality of care, increasing the efficiency of the system, and reducing health care costs. The triple aim can also provide a compass for future research demonstrating occupational therapy’s value through improved outcomes for health care recipients, increased efficiency of care transitions and prevention of hospital readmissions, and cost-effectiveness of interventions and programs when effectively and efficiently provided on the basis of best practice.
Opportunities to Demonstrate the Value of Occupational Therapy
Occupational therapy professionals must link the value of occupational therapy to the needs emerging within the greater health care system. Close examination of what policymakers and the system are viewing as important demonstrates a need to address issues such as rehospitalization, lack of care coordination, and chronic conditions.
In 2006, 23.5% of hospital discharges to skilled nursing facilities resulted in readmissions to the hospital, generating a high cost to Medicare of $4.34 billion (Mor, Intrator, Feng, & Grabowski, 2010). In 2011, researchers estimated that inadequate care coordination, including inadequate management of care transitions, resulted in avoidable complications and unnecessary hospital readmissions that were responsible for $25 billion to $45 billion in wasteful spending (Burton, 2012).
Chronic conditions such as diabetes, heart disease, arthritis, obesity, and cancer have steadily risen over recent years. The Centers for Disease Control and Prevention (CDC; 2009) reported that approximately one-fourth of the 133 million Americans living with chronic illness experience significant limitations in daily activities. An estimated 75% of health care costs result from chronic illnesses, many of which are preventable (CDC, 2009).
We need to link what occupational therapy accomplishes, as shown in research and practice, to the solutions to these and other pressing problems. Collaboration among occupational therapy leaders, researchers, practitioners, and others can create powerful partnerships to put the value of the profession forward. The following sections discuss opportunities for such partnerships to demonstrate the value of occupational therapy.
Center for Medicare and Medicaid Innovation
To examine alternative methods and strategies for cost containment, the ACA (§ 3021) created the Center for Medicare and Medicaid Innovation (CMMI) to test innovative payment and service delivery models to reduce program expenditures while maintaining or improving quality of care for those who receive benefits from Medicare, Medicaid, or the Children’s Health Insurance Program (Kaiser Family Foundation, 2011). CMMI’s current priorities also include evaluation and advancement of best practices and engagement of stakeholders in developing additional models to be tested (Centers for Medicare and Medicaid Services [CMS], 2013c). The innovation models currently being tested, several of which are described in the following sections, have potential for occupational therapy involvement; the important part is to step up and become involved.
Independence at Home.
The Independence at Home (IAH) demonstration project is testing a service delivery and payment incentive model that uses home-based primary care teams to improve health outcomes and reduce expenditures for Medicare beneficiaries with multiple chronic conditions (CMS, 2013a). The IAH demonstrations began in June 2012; initial reports from the 18 individual practices and consortia participating in this project are forthcoming. These projects are managed by physicians and nurse practitioners, but the participation of other practitioners is allowed. Many of the pilot projects are in systems where occupational therapy is likely to already be in place; it is not clear, however, whether occupational therapy is involved.
It is incumbent upon members of the profession to identify and monitor what is happening in the IAH demonstrations. The focus may be on physician care and not include rehabilitation or other needs that occupational therapy can address. Researchers and practitioners should monitor where these projects are operating, identify opportunities for occupational therapy, and advocate for our inclusion. It will also be critical to monitor the criteria on which the effectiveness of the demonstrations are evaluated. The preliminary information on evaluation of the projects identifies goals that could and should be affected by occupational therapy:
The primary goals of the evaluation are to understand the changes [in] practices made to provide coordinated and timely delivery of primary care to high-need Medicare beneficiaries in their homes, as well as the resulting impact on health outcomes, utilization of services, Medicare cost, transition to long-term placement in nursing homes and associated Medicaid costs, and patient satisfaction for Medicare beneficiaries enrolled in these practices and their family members and caregivers. (Center on Health Care Effectiveness, 2013)
The challenge is to marry the possibilities of occupational therapy, as confirmed in the research, with the items that will be evaluated. Doing so will take individual and broad-based advocacy as well as targeted research.
Community-Based Care Transitions Program.
The Community-Based Care Transitions Program (CCTP) provides funding to test models for improving transitions from inpatient hospital settings to home or other care settings for high-risk Medicare beneficiaries (CMS, 2012b). The CCTP launched in 2011 and will run through 2015 as models are tested for effectiveness. Occupational therapy is well suited to lead care transitions; for example, “one shared intervention approach across care transition models is to coach patients, teaching them self-care skills and encouraging their active engagement in their own care” (Blumberg, Berger, Cook, & Ruby, 2012, p. 29). Proposals for occupational therapy research on transitions can be brought forward, and because many occupational therapy practitioners already work in community organizations, the CCTP is a natural fit. This is a prime opportunity to demonstrate the value of occupational therapy as part of the care transition team; we bring the critical person–environment–occupation perspective to this difficult time for patients and families.
Accountable Care Organizations and Comprehensive Primary Care Initiative.
The Accountable Care Organization (ACO) model and the Comprehensive Primary Care Initiative are similar in that they attempt to improve coordination of care and achieve better outcomes. In the ACO model,
coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. (CMS, 2012a)
The Comprehensive Primary Care Initiative supports collaboration between third-party payers and Medicare to build the capacity of existing primary care practices to deliver higher quality, more coordinated, and more patient-centered care (CMS, 2012c). The fundamental premise underlying these initiatives is that strengthening primary care and comprehensive service delivery will enhance quality of care, promote efficiencies in the system, and result in lower health care costs.
Occupational therapy has much to offer in the context of Medicare ACOs to promote optimum outcomes in primary care. Occupational therapy professionals are broadly trained in human development, health promotion, disease process intervention, activity analysis, behavior modification, lifestyle interventions, and the use of adaptive equipment, all of which are fundamental in addressing the needs of patients, especially those who have more than one problem or condition. Involving occupational therapy and other services in primary care can reduce fragmentation in health care (Muir, 2012, p. 507). Occupational therapy research that shows how function affects health for people across the age spectrum and across the health care needs spectrum—from acute needs to chronic conditions—must be broadened and emphasized. Getting occupational therapy involved, especially when a new diagnosis is made or when the full impact of a problem is not easily understood, can bring the profession’s expertise in participation in daily life, self-management, and optimum development right to the patient, right when it is needed.
Innovation Advisors Program.
The Innovation Advisors Program was established to create a network of systems change experts around the country to “deepen the capacity for transformation” (p. 1) as it affects Medicare, Medicaid, and other programs (CMS, 2013b). In 2012, after a competition, 72 innovators received stipends to work on their chosen areas. Although this competition was open to allied health professionals employed by any public health or health care facility, institution, or department, no occupational therapy practitioners are among the first group. Another group may have been selected by the time of this publication; we can only hope an occupational therapy practitioner is among them.
Patient-Centered Outcomes Research Institute
The ACA established the nonprofit Patient-Centered Outcomes Research Institute (PCORI) to identify research priorities and conduct research that supports comparative effectiveness (Kaiser Family Foundation, 2011). The research is intended to assist health care providers in making more informed decisions and to provide consumers with a better understanding of prevention, treatment, and care options to make better decisions. The interest of PCORI is to identify and clarify the supporting science behind available options.
In 2012, the PCORI National Priorities for Research and Research Agenda was finalized and included five areas:
1. Assessment of prevention, diagnosis, and treatment options
2. Improving health care systems
3. Communication and dissemination research
4. Addressing disparities
5. Accelerating patient-centered outcomes research and methodological research. (PCORI, 2012, p. 8)
Although many of these areas are included in other agencies’ research agendas, it is the patient-centered perspective that sets PCORI apart. Merely generating new evidence in regard to diagnostics, treatment strategies, or prevention will not improve the decision making of patients and health care providers. Improved communication methods are necessary to disseminate the resulting knowledge to enable informed choices and improve the health care experience, ultimately improving health outcomes for individuals and populations.
Assessment of Prevention, Diagnosis, and Treatment Options.
A critical area of focus is to link outcome measures and patient-centered research in a way that identifies patient preferences and values. Establishing this link can guide health care providers—and the systems that fund them—in defining the outcomes they aim to achieve (PCORI, 2013). Occupational therapy practitioners use their knowledge of participation and engagement to identify ways to motivate patients’ participation and encourage them to be active members of the care team rather than quiet recipients of care. Occupational therapy practitioners are well placed to translate and disseminate evidence on self-management of chronic conditions, specifically in relation to performance in everyday life.
Recent dialogues at PCORI have identified a need to explore lifestyle and its role in shaping health outcomes in a way that does not exacerbate stigma surrounding conditions such as obesity and mental illness (PCORI, 2013). Occupational therapy research, with its distinct approach to the whole person, is well positioned to answer this call for a thoughtful approach to examining lifestyle and its impact on health outcomes for individuals and populations.
Improving Health Care Systems.
A key component in improving health care systems is to define health care system, which PCORI (2013) suggested defining in the “broadest possible terms, including hospitals, health homes, physicians, nurses, and other clinicians; public health departments, pharmacies, caregivers, patient navigators, as well as community supports, social services, alternative medicine, and telehealth” (p. 6). This broad definition recognizes the role of many different participants in the betterment of health outcomes for individuals.
Further efforts to refine the focus of PCORI’s research identified a need to understand how to better integrate the social determinants of health into the current health care system. Healthy People 2020 identified social determinants such as availability of resources, transportation, and quality educational systems; physical conditions of neighborhoods; and physical barriers and access to parks and other recreational settings that may influence health outcomes (U.S. Department of Health and Human Services, 2013). Occupational therapy research examining methods of integrating social determinants into care would enhance the health care system.
Another significant need in improving health care systems is patient education on issues such as understanding diagnoses, differentiating among treatment options, and understanding potential benefits and risks of each treatment option. Patient education on macro issues—including health systems, insurance benefits and options, and ways to select providers who fit their health needs—is also important. Smith and Gutman (2011) noted that occupational therapy practitioners’ and researchers’ holistic approach to assessment and intervention makes them key players in promoting patients’ health literacy and creating a more health-literate base of health care consumers.
PCORI’s (2013) focus on “improving access to timely and high-quality care” (p. 7) supports research on transitions in care and reduction of gaps in the continuum of care. Inconsistencies in care among hospitals, home health, skilled nursing facilities, and other settings are detrimental to patient outcomes. The ACA’s focus on improving system inefficiencies provides a strong platform for occupational therapy to build a research agenda. Because occupational therapy spans all areas of the health care continuum, issues in care transition and patient and caregiver education are a good fit.
Communication and Dissemination Research.
PCORI’s focus on knowledge translation and comparative effectiveness research is intended to provide patients with information to better understand care options and assist health care providers in making more informed decisions. These distinctly different populations collect information in widely varying ways. For example, researchers typically read and publish in academic journals, whereas patients rely on consumer-oriented publications (PCORI, 2013, p. 4). Researchers need to share their findings in multiple venues and formats to increase access by both patients and providers.
Another theme among PCORI research priorities is exploration of the use of mobile health technology. Webinars, smartphone applications, and social networks are “powerful tools for dissemination” (PCORI, 2013, p. 3). These technologies can also serve as a tool for identifying areas where research is needed.
The research produced in PCORI’s areas of focus has significant potential to drive systematic change. The primary goal—to inform and improve the decision making of patients and health care team members—can significantly improve the health care experiences of patients in the United States. This research also can be used at the macro level to reorganize health care provider education and training, inform interprofessional collaborations, strategically guide organizational administrators in systems issues, and inform the decision making of policymakers.
Addressing Disparities.
Further discussions at PCORI (2013) have involved the research needed to address health disparities, including ethnic and cultural differences, physical and intellectual disabilities, health literacy, mental health issues, and distance from care and from high-quality care (p. 4). Occupational therapy research can help practitioners close the gap between existing strengths of people with disabilities who can live independently (e.g., those with autism spectrum disorders) and the community supports they need for independent living.
Included in the focus on disparities is the need for research on the integration of mental health into other health care services. Occupational therapy research in this area promotes a patient-centered approach to care. For example, people with neurodegenerative disorders (e.g., multiple sclerosis, Parkinson’s disease) may also experience depression, which too often is not addressed as part of the treatment process. Research connecting mental health issues to physical conditions has significant potential to improve patients’ health care experience and quality of life.
The PCORI (2013) research agenda also includes a focus on multicultural coordination of care by utilizing health workers from community-based organizations to more deliberately organize patient care activities to meet the health needs of diverse community residents. The Well Elderly 2 study (Clark et al., 2012) provides an excellent foundation for occupational therapy research on facilitation of aging-in-place supports using multicultural coordination of care.
Accelerating Outcomes and Methodological Research.
Programs are under way to accelerate patient-oriented outcomes research and methodological research. A study in progress at San Francisco State University, “Mind the Gap—Targeting Differences in Patients’ Current and Preferred Abilities,” addresses health care in the gap between a patient’s current and preferred health status. Researchers are using the Movement Ability Measure (MAM), a self-report outcome tool, to record patients’ current perceived ability in six dimensions of movement and the ability they desire to attain for daily activities and participation in life roles (PCORI, 2013). This pilot study is taking place in a physical therapy outpatient practice to identify appropriate exercise routines to help patients progress toward the abilities they value.
Occupational therapy researchers could add to this study by providing a second set of data using the MAM to describe patients’ current and desired movement ability in performing activities of daily living and instrumental activities of daily living. The MAM allows for exploration of roles, routines, and habits that support the development of behaviors and choices within patients’ control to help them advance toward the abilities they desire in their valued daily occupations. This second data set would add to the pilot study by addressing patients’ ability to more fully participate in the activities they need and want to do.
A study at Yale University, Development of a Supported Decision-Making Tool for Persons With Chronic Illness, is developing a supported decision-making tool that can help people with chronic illnesses identify and communicate their preferences about treatment and health outcomes and make decisions that are consistent with their preferences and values (PCORI, 2013). Occupational therapy practitioners understand the impact of chronic disease on the everyday life of patients and would be well positioned to pilot this tool in practice to examine the correlation between perceived barriers to and potential facilitators of shared decision making for increased participation in daily life.
A randomized controlled trial at Columbia University Medical Center, Creation of the Person-Centered Wellness Home Across the Life Course, is evaluating use of the Chronic Disease Self-Management Program and wellness coaching by lay community leaders to support older adults who have two or more chronic diseases (PCORI, 2013). This project has potentially significant implications for occupational therapy in the area of wellness and prevention. This project aims to create a person-centered wellness home to provide better access to comprehensive wellness services; the goal is to support chronic disease self-management and build community supports to improve outcomes for older adults. Occupational therapy can partner with person-centered wellness homes to further build the evidence solidifying our role in wellness and prevention.
It is anticipated that PCORI will soon release a funding announcement to further explore fall prevention with older adults, examining the comparative effectiveness of interventions. Leland, Elliot, O’Malley, and Murphy (2012) provided evidence for the profession’s role in fall prevention:
As part of a multidisciplinary team, occupational therapy practitioners have a role in the other recommended areas listed in the American Geriatrics Society and British Geriatrics Society 2010 [fall prevention] guidelines, including medication management, postural hypotension management, and recommendation of appropriate footwear, because those areas also affect occupational performance. (p. 150)
Statistics clearly document the fall risk among older adults and that some falls are preventable. This opportunity could serve as a critical juncture to further develop the comparative effectiveness data necessary to demonstrate the value of occupational therapy in fall prevention programs.
Returning to Value
What do patients value? What does the health care team value? What does your organization value? What do policymakers value? What does society value? Understanding the variables these groups associate with value will help occupational therapy fully participate in and influence system redesign. The value of occupational therapy spans the health care continuum from prevention to intervention, from rehabilitation to recovery. Ensuring occupational therapy best practice, combined with effectively using research and reaching high and wide to conduct new research, will expand our ability to view patients holistically from a variety of perspectives and meet their health and occupational needs in their everyday lives and roles. We must use occupational therapy’s rich vein of possibility—as reflected in our fundamental principles, our research, and our everyday practice—as the basis for assertive and focused actions to ensure that the new system and all its components fully use the skills and benefits of occupational therapy.