Abstract
With the increasing emphasis on interprofessional primary care, it is critical to understand occupational therapy’s role in this setting and the client issues that arise (Donnelly, Brenchley, Crawford, & Letts, 2014; Letts, 2011; Mackenzie, Clemson, & Roberts, 2013; Metzler, Hartmann, & Lowenthal, 2012; Muir, 2012). Primary care should have certain core features; most important is that it is a client’s first contact with the health care system and involves the coordination and integration of all aspects of care (Starfield, Shi, & Macinko, 2005). Primary care is also characterized by comprehensive services that are delivered longitudinally, and it should be person centered (Starfield et al., 2005). Primary care increasingly has a population orientation and includes health promotion, illness and injury prevention, and community development (Aggarwal & Hutchison, 2012; Health Canada, 2012).
Recent articles have urged occupational therapists to consider their role in primary care (Mackenzie et al., 2013; Metzler et al., 2012; Muir, 2012). Muir (2012) stated that in the primary care setting, occupational therapists “could truly provide patient-centered and comprehensive intervention plans” (p. 508). Given the longitudinal nature of primary care, occupational therapists are ideally suited to support people’s health and participation over the life course. However, despite the clear fit between the domain of occupational therapy practice and primary care, there is relatively little research on the role of occupational therapy in primary care and few practice examples (Donnelly et al., 2014).
In 2009, in the province of Ontario, Canada, occupational therapy became a funded profession within interprofessional primary care teams. To date, approximately 40 occupational therapists work on primary care teams (Donnelly et al., 2014). These positions have offered a tremendous opportunity to understand the role of occupational therapy in primary care. Occupational therapists working on primary care teams have provided services across the full life course and spectrum of disease conditions (Donnelly et al., 2014). Although occupational therapists are known to be working as generalists in primary care, no demographic data have been published examining the exact nature of the disease conditions or the frequency with which specific conditions are being seen in primary care. A national survey of occupational therapists working on primary care teams found that the most frequent services being provided were health promotion and prevention activities (71%), including falls prevention (71%) and home safety assessment (69%; Donnelly, LeClair, Wener, Hand, & Letts, 2016).
Although early research has offered an important glimpse into the roles of occupational therapists, it is also critical to understand the occupational issues being identified by clients in primary care and determine outcome measures to evaluate the effectiveness of occupational therapy services in this setting. To date, there has been no published research on occupational therapy outcomes in primary care.
Because of the generalist nature of occupational therapy practice in primary care, measures need to be able to capture outcomes from services that address the extensive physical and mental health issues identified by clients in this practice setting (Donnelly et al., 2014). Occupational therapists have been shown to primarily rely on nonstandardized measures (Colquhoun, Letts, Law, MacDermid, & Edwards, 2010); with primary care’s strong emphasis on outcomes, it is critical to identify standardized outcome measures that are meaningful to both clients and therapists and feasible to use in a diverse primary care environment. Ultimately, a generic occupation-focused outcome measure would be ideal to demonstrate the unique contribution of occupational therapy to primary care.
The Canadian Occupational Performance Measure (COPM; Law et al., 2014) is an individualized outcome measure designed to assess clients’ perception of their occupational performance and satisfaction with that performance. The COPM is consistent with the Canadian Model of Occupation Performance and Enablement (Townsend & Polatajko, 2013) and congruent with the client-centered philosophies of both occupational therapy and primary care. A systematic review of 64 articles across nine clinical and nonclinical settings and practice areas examined the impact of the COPM in clinical practice (Parker & Sykes, 2006). The review found that the COPM enables clients to identify goals for occupational therapy and engage in the therapy process. From a therapist perspective, the COPM supports a collaborative partnership and focuses intervention on occupations. The COPM’s broad applicability makes it an ideal outcome measure for use in primary care. Despite its distribution in 21 countries, its translation into 30 languages, and countless publications, no known research has focused on its use in primary care. Because the COPM is a general occupation-focused measure, has been recommended for use across many areas of occupational therapy practice, and has established strong measurement properties, it is ideally suited for adoption in primary care.
The purpose of this study was to examine the use of the COPM in a primary care setting. We sought to answer two questions: (1) What client issues are being identified through administration of the COPM? and (2) What is the feasibility of using the COPM as an outcome measure in primary care? Results of the study will provide further insights into the use of the COPM in primary care and into the nature of occupational performance issues so that occupational therapy interventions tailored to the primary care setting can be developed or refined.
Method
Design
A sequential mixed-methods design was used. Mixed methods are ideally suited to understanding complex issues because they integrate both qualitative and quantitative data (Creswell, 2009). For this study, we wanted not only to know the nature of occupational issues identified by the COPM (Law et al., 2014) but also to understand the experience of using the measure in a novel practice setting.
The study was implemented in two phases. Phase 1 occurred over a 10-mo period during which the COPM was administered to all clients seen by the occupational therapists at each of the three study sites. Phase 2 involved a focus group, conducted by a research assistant, consisting of the participating occupational therapists. The goal of the focus group was to explore the use of the COPM as a routine outcome measure in primary care.
Focus groups provide an opportunity for discussion among participants and work well when participants have common experiences and backgrounds (Kreuger & Casey, 2000). Focus group questions focused on the COPM’s fit with primary care, its challenges and strengths in this setting, and feasibility issues.
Participants
The study was conducted at three interprofessional primary care clinics in Ontario, Canada. All three sites were academic primary care clinics and included a range of interprofessional team members, including pharmacy, dietetics, social work, and psychology. Occupational therapists each had assigned clinical rooms in which to complete their assessments and interventions; depending on clients’ needs, community and home visits may also have occurred. The study initially included a fourth site, but because of staffing changes that site was required to withdraw from participating. Three occupational therapists at the three interprofessional primary care clinics participated in the study. The occupational therapists collected COPM data during all routine clinical service delivery and participated in the focus group.
Clients were referred to occupational therapy in several ways, including physician referral, referral by another interprofessional team member, or self-referral. No specific occupational therapy screening processes occurred, and as a result all individuals who were referred were seen by an occupational therapist. Clients were included in the study if they met the following inclusion criteria: (1) able to understand and communicate in English and (2) expected occupational therapy intervention of more than two visits. Clients were excluded from the study if they did not have the cognitive ability to independently identify occupational issues (i.e., advanced dementia). No formal cognitive screen was used, and the client’s ability to complete the COPM was based on the individual therapists’ clinical judgment.
A study by Colquhoun et al. (2010) found that one of the key barriers to COPM completion is cognitive issues as perceived by occupational therapists; therefore, we included it as an exclusion criterion. A data extraction program was written to directly export deidentified electronic COPM (e-COPM) data from the electronic medical record (EMR) on completion of Phase 1. Ethics approval was received by the university’s Health Sciences Research Ethics Board.
Canadian Occupational Performance Measure
The COPM is an individualized, client-centered outcome measure. A semistructured interview enables the client to identify areas of difficulty in the areas of self-care, productivity, and leisure (Law et al., 2014). The client rates the importance of each identified issue on a scale ranging from 1 to 10 (1 = with great difficulty or not satisfied, 10 = with no difficulties or completely satisfied). Clients subsequently rate as many as five identified problems on their perceived level of performance and satisfaction with their performance on each of the five identified issues. On reassessment, clients rate their performance and satisfaction on the issues identified in the initial assessment. A change score is obtained by subtracting the posttreatment score from the initial score. The COPM has been found to be both a reliable and a valid measure across diagnostic categories and treatment settings (Parker & Sykes, 2006).
To facilitate both the administration of the COPM and the extraction of data, an e-COPM was developed. The e-COPM was embedded within each of the sites’ EMR systems. The development of an e-COPM allowed occupational therapists to directly enter data into the e-COPM, and the completed record was immediately available for the primary care team to review on each patient’s chart. Mary Law, one of the authors of the COPM, provided approval to use the e-COPM for the duration of the study.
In preparation for the study, occupational therapists at each of the sites attended a half-day COPM workshop facilitated by one of the authors of the COPM (S. Baptiste) to ensure a common knowledge base and to clarify any questions regarding COPM administration; the lead investigators ensured that the study protocol was explained.
Data Analyses
Quantitative COPM data were analyzed using descriptive statistics, including frequencies, means, and standard deviations. Patient age, COPM issues, and COPM scores were extracted from the EMR directly into a Microsoft Excel spreadsheet (Microsoft, Inc., Redmond, WA). All calculations were completed using Excel formulas. Occupational issues were categorized into self-care, productivity, and leisure, and frequency of issues was determined for the total sample. Mean change scores for both satisfaction and performance were calculated when available.
The focus group was recorded and transcribed verbatim. The principal investigator (Catherine Donnelly) and the research assistant read and reread the transcript to become familiar with the data and begin to identify portions of the transcript related to the clinical utility of the COPM. Preliminary codes were identified, and quotes associated with the codes were indexed and organized in ATLAS.ti (Version 7; ATLAS.ti Scientific Software Development, Berlin, Germany), a qualitative software program. Preliminary codes were provided to all members of the focus group for review. A review and discussion of the preliminary coding structure resulted in full consensus among participants. As a result, no further changes or additions were made to the coding structure.
Results
A total of 161 initial COPMs were administered, and 22 were readministered. Thus, change scores could be calculated for 14% of the COPM data (see Table 1). The average age of participants was 56.7 yr (standard deviation [SD] = 17, range = 23–91; 122 women and 39 men). Forty-eight participants (29%) were older than age 65 (mean age = 77.2, SD = 7.0). Participants initially identified a total of 656 issues; self-care goals were identified most frequently (n = 248; 38%), followed by productivity (n = 229; 35%) and leisure (n = 179; 27%). The subset of participants who were older than age 65 identified a total of 167 goals; self-care goals were identified most frequently (n = 82; 49%), followed by leisure (n = 47; 28%) and productivity (n = 38; 23%). The average initial COPM Performance score was 3.8 (SD = 1.5), and the average initial COPM Satisfaction score was 3.0 (SD = 1.6). An average of 4.1 issues (SD = 1.3) were identified per client, with adults older than age 65 identifying an average of 3.6 issues (SD = 1.4). The five most frequently reported problems by occupational performance category are presented in Table 2.
COPM Change Scores for Participants Who Had a Follow-Up Assessment
Note. COPM = Canadian Occupational Performance Measure; M = mean; SD = standard deviation.
Top Three Most Frequently Reported Occupational Performance Issues
The focus group provides further insight into both the COPM results and the process of COPM administration. Analysis of the focus group data resulted in the identification of a total of 14 codes. Sample codes included longitudinally, rapidly evolving practice; scoring; patient priorities; reframing change in primary care; one-time interaction; shift from symptoms to occupation; and the unique occupation lens. From these codes, two broad themes and two subthemes were identified that addressed issues of the COPM’s feasibility and overall fit with a primary care setting. The themes were (1) supporting occupational therapy practice: focusing on function and (2) the unique environment of primary care.
Supporting Occupational Therapy Practice: Focusing on Function
The major strength of the COPM in primary care was its focus on function or occupation. This was seen as particularly important in this setting, in which the focus is traditionally on medical symptoms. “It’s a really nice way to move from symptom focus to a focus on occupation” (Site 2, Occupational Therapist 1 [S2O1]).
The COPM supported therapists in ensuring a unique lens within primary care:
I think [the COPM] forces us as clinicians to ensure that [focus on function] because it’s really easy to focus on the things [the patients] are telling us that are more impairment based because that fits the model of primary care. (S1O3)
Changing people from symptom focus to function focus. (S2O1)
Just as the COPM supports occupational therapists in ensuring an occupational lens, it also helped patients to view their own problems from a different perspective.
People can get very mired down in their symptoms . . . and life gets put on hold, but [when] we start looking at what they can do and how they are changing from a functional perspective it helps them to reframe their perception of how this [has] affected their life. (S2O2)
The COPM enabled patients to see meaningful, positive changes when changes in their medical symptoms may not have been easily identified. Sometimes what people deem as important in their lives are not things that we can easily measure . . . but being able to measure something that actually changed for them because that was important and not just the range of motion in their shoulder. (S2O2)
Unique Environment of Primary Care
Challenge of Reassessment.
The primary care environment provided some unique challenges that have not been previously presented in the literature. Primary care provides health care to patients across the life course. In interprofessional primary care clinics, patients are rostered or signed up with a team that provides them with continuous support and services over time, as needed. As a result, there is no natural start or endpoint, as is the case in traditional settings in which occupational therapists are employed. “We don’t actually discharge” (S2O1). Without a set discharge date, readministration was a challenge. “I think knowing when to rescore in primary health is more of a challenge” (S2O2). “That’s probably another challenge that I’ve faced with, sort of, getting people in for a follow-up measure . . . [in rehab] there’s a date they’re going home so you do your measures beforehand” (S2O2).
A further challenge with reassessment was the focus on screening and assessment, which created short-term interactions with little or no opportunity for follow-up. “There’s a lot of people I’m seeing within a 1-hour confined [appointment]; giving them strategies, tips, referring to some community programs. Then I won’t see them again” (S1O3). As a result, therapists felt the COPM had the best fit with client and situations in which they were going to engage in multiple interactions over time, as in the case with people with complex multiple chronic conditions. For program-based services, such as a chronic pain program or healthy living group, the COPM offered a way to measure change over time. “It’s the more complex clients [with whom] you’re going to engage in a more long-term relationship” (S1O3).
I don’t know that I would use it as a routine outcome measure. I think that I would say that there are patients where it’s a good measure and I think my sort of gut [feeling] is that it is more complex people [with whom] you know you’re going to be spending a fair bit of time working on perhaps a number of different issues. Or maybe not, maybe just one issue but it’s going to take time to progress with. (S2O1)
Generalist Role.
The generalist focus of primary care was also seen as influencing the nature of the occupational performance problems identified with the COPM (Law et al., 2014). Although the problems of emphasis in rehabilitation settings are self-care in nature, in primary care the issues that were identified spanned self-care, productivity, and leisure.
I’ve just started thinking about my rehab experience and you know it was typically ADLs, mobility . . . getting out in the community. They were a bit more focused and specific. Here it’s a broad range. It could be anything. (S2O2)
Overall, the COPM was seen as a good philosophical fit with primary care, framing medical issues in a functional way and highlighting the broad issues that clients are identifying in occupational therapy.
Discussion
This is the first known study to examine the use of the COPM in a primary care setting. The study focused on occupational performance issues identified by clients in primary care and the overall feasibility of the COPM as an outcome measure. Participants referred to occupational therapy reported a relatively equal distribution of problems among self-care, productivity, and leisure. In contrast, the literature has largely shown that in acute and rehabilitation settings, the greatest emphasis has been on issues related to self-care, with less emphasis on leisure and minimal emphasis on productivity (Chen, Rodger, & Polatajko, 2002; Colquhoun et al., 2010; Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003; Donnelly et al., 2004). Clients receiving services in other community settings, including home-based rehabilitation services or outpatient clinics, have identified COPM occupational performance issues similar to those found in primary care, with a more equal distribution among issues in self-care, productivity, and leisure. This finding suggests that opportunities exist for therapists in community-based settings to address broad occupational performance issues (Appelin, Lexell, & Månsson-Lexell, 2014; Persson, Lexell, Rivano-Fischer, & Eklund, 2013).
This study provides further confirmation that occupational therapists in primary care are very much generalists (Donnelly et al., 2014, 2016). Not only do occupational therapists provide a broad range of services, but the client issues are also wide ranging, suggesting that the primary care setting provides an incredible opportunity to work to the full scope of occupational therapy practice.
This study found that home management (n = 101), functional mobility (n = 91), and active leisure (n = 83) were the top three issues reported, which highlights the fact that clients being seen in primary care are concerned about maintaining their independence within the home and community. Occupational therapists in primary care should consider emphasizing interventions that maintain and promote home- and community-based function or prevent further decline.
A survey examining the role of occupational therapy in primary care found the top three practice areas were the provision of equipment, fall prevention, and chronic disease management (Donnelly et al., 2016). In Australia, Mackenzie et al. (2013) urged occupational therapists to seize the day and develop a fall prevention role in primary care. In Canada, Richardson et al. (2010) examined the impact of occupational therapy and physical therapy among adults with chronic illness in interprofessional primary care clinics. It is interesting that both of these practice areas (falls and chronic disease management) map closely onto the problem areas identified in this study through administration of the COPM and again highlights the focus of primary care on prevention and management of disease and disability. Although neither Mackenzie et al. nor Richardson et al. (2010, 2012) used the COPM, this study suggests that it could be a positive addition to any research or clinical practice in a primary care setting.
The major strength of the COPM in a primary care setting is its focus on function and occupation. Function transcends any specific medical diagnosis, which is particularly important in primary care, in which the focus is traditionally on medical symptoms. Broad applicability of the COPM to a range of clients is congruent with the generalist role of the occupational therapist in primary care. Bringing a functional or activity focus to the interprofessional primary care team provides a unique lens and fits with the increasing emphasis on and importance of activity and balance, particularly in relation to both chronic disease management and healthy aging.
Law et al. (2014) have reported that change scores >2 represent minimal clinically important change. In this study, the COPM Performance and Satisfaction change scores both exceeded this benchmark (at 2.1 and 2.6, respectively), suggesting that the services provided between the baseline and follow-up COPM resulted in an important change in clients’ perception of occupational performance in primary care.
However, despite the number of initial assessments completed, relatively few were readministered, and the focus group data supported the notion that readministration of the COPM is a challenge in primary care settings. Colquhoun et al. (2010) administered the COPM on a routine basis in a hospital rehabilitation setting and had an 82% completion rate. The primary reasons for lack of completion related to challenges due to cognitive issues as perceived by the occupational therapists. However, in this study, the context of the primary care setting appears to be the biggest factor in the COPM readministration rate. An interesting finding relates to the number of COPMs that were completed. In this study, 161 initial COPMs were completed versus Colquhoun et al.’s 45 COPM initial attempts in a rehabilitation setting. Although the duration of data collection was double that of Colquhoun et al. (10 mo vs. 5 mo), the rate of COPM administration in primary care was almost 4 times as great, highlighting the emphasis on screening and assessment in primary care versus ongoing intervention.
In this study, no data were collected on the number of occupational therapy visits per client or the duration between visits, and further descriptive research is required to better understand how exactly occupational therapy is being delivered in primary care. Unlike traditional settings that have a starting point and an endpoint to interventions, clients in primary care have a lifelong relationship with providers. Thus, there is seldom a discharge meeting or specific point in time for follow-up assessment; instead, the patient returns again when the next health issue arises.
This study also highlights the need for occupational therapists to consciously build outcome measurement into this setting, because this appears to be a challenge. As the role of occupational therapy in primary care settings continues to develop, therapists may become more adept at integrating formal follow-up. Strategies to support outcome measurement could involve booking routine follow-up appointments or incorporating telehealth technology. With an increasing emphasis on patient-centered care and patient-centered research in primary care, the individualized nature of the COPM is philosophically aligned with these approaches; given this, it is important to examine how best to support regular use of the COPM for both initial assessment and follow-up.
An interesting finding was that participants who received a follow-up COPM had initial scores that were lower than the sample as a whole (Performance, 3.4 vs. 3.8; Satisfaction, 2.4 vs. 3.0). This result suggests that occupational therapists provide more intensive and longer term interventions to those with lower perceived function. Although this may be an intuitive conclusion, the COPM scores provide an opportunity to consider how they might be used to predict which clients are in need of more intensive occupational therapy services and which are more appropriate for a short-term consultation. Although the study did not specifically explore these issues, the results raise some important questions and highlight the need for further research to explore how the COPM could be used in primary care to identify and prioritize clients who would benefit from occupational therapy intervention. In a primary care setting, in which caseloads are large and formal discharge does not occur, identifying who could most benefit from occupational therapy services is very important.
An e-COPM template embedded within the EMR offered an opportunity to integrate occupational therapy reporting directly with other medically based reports and clinical examinations (i.e., X-rays, computed tomography, bloodwork, specialist reports). This has potential benefits, including the ability to easily extract data for reporting and quality assurance and more visible access to occupational therapy data in the EMR. Although the e-COPM was developed for the duration of the project, it provided an easy-to-use format and is well-suited for the paperless charting found in many primary care settings. Offering easy access to outcome measures may facilitate regular use and integration into practice and is something occupational therapy as a profession must consider with the increasing push for mechanisms to support continuous quality improvement. In a study of the routine use of the COPM in a rehabilitation unit, however, Colquhoun et al. (2010) found that despite organizational support and the perceived benefit of the COPM by clinicians, the measure was not consistently used. Given that the COPM will now be available in electronic form, it would be valuable to understand what impact this format may have on routine use.
Primary care has a strong emphasis on outcomes and indicators and, to date, primary care research and policy have focused on physician-based indicators (Jaakkimainen et al., 2006). Given the growing focus on interprofessional primary care teams, there is an urgent need to identify primary care indicators and outcomes relevant to nonphysician primary care providers (Jaakkimainen et al., 2006). This study offers the first look at occupational therapy outcomes in primary care and lays the foundation for further work in this area.
The study has limitations that must be acknowledged. It was conducted at three primary care sites in Canada, which may not broadly reflect the occupational issues in primary care or the experiences of occupational therapists working in this type of setting both within and outside of Canada. Clients with cognitive issues were not formally screened, which could have led to errors in the application of the inclusion and exclusion criteria. The study focused on occupational performance issues generally and did not link them to specific conditions or diagnoses, something that could be included in a future study.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
The major strength of the COPM in a primary care setting is its focus on function and occupation.
The COPM is broadly applicable to a range of clients, which is congruent with the generalist role of the occupational therapist in primary care.
Clients referred to occupational therapy reported a relatively equal distribution of problems among self-care, productivity, and leisure.
Conclusion
This study supports the generalist nature of the occupational therapist in primary care and reinforces that primary care is an ideal setting for occupational therapists to offer comprehensive client-centered services. The strength of the COPM in a primary care setting was its focus on occupation and function rather than medical symptoms. Given the lifespan approach and emphasis on screening and assessment in primary care, the challenge was finding an opportunity for readministration, but the COPM was seen as an invaluable tool to guide initial assessments and offer an occupation-focused lens.
Footnotes
Acknowledgments
Project funding was provided by the Ontario Society of Occupational Therapists.