The Course and Predictors of Patient Participation in Inpatient Occupational Therapy: Understanding the Impact on Outcomes and Implementation Barriers

PURPOSE: The Patient Protection and Affordable Care Act (2010) recognizes that active participation (engagement) is a keystone of successful patient-centered care. Although studies indicate that intensive therapy may lead to improved functional outcomes, patient participation in the process may play a role in rehabilitation effectiveness. However, no studies have examined the level of patient participation during the course of inpatient occupational therapy (OT), nor is it known whether it will positively affect patient outcomes. Besides, there is inadequate information to describe barriers limiting patient participation in implementation in OT services. The purposes of this study are (1) to examine distinct trajectories (courses) of rehabilitation participation, associated predictors, and outcomes during inpatient OT rehabilitation and (2) to identify barriers to and facilitators of patient participation implementation.

DESIGN: We adopted a mixed-methods design to address these questions. First, we conducted a longitudinal analysis of quantitative data from a multisite SCIRehab project. A total of 1,375 patients with spinal cord injury receiving inpatient OT rehabilitation were assessed on their level of active participation in each session from admission to discharge using the Pittsburg Rehabilitation Participation Scale. Medical information was abstracted from the hospital reports. Second, we conducted a qualitative exploratory study to identify rehabilitation stakeholders’ perceived barriers to and facilitators of patient participation in inpatient rehabilitation.

METHOD: We used latent class growth analysis to identify trajectories of rehabilitation participation. Regression models were used to identify clinical characteristics associated with the trajectories of patient participation and assess the effect of these trajectories on patient outcomes at discharge and 1 yr postinjury. Then we conducted two patient focus groups, two clinician focus groups, and six interviews with administrators and health organization representatives to identify implementation barriers and facilitators. We analyzed transcripts for salient themes using a grounded theory approach.

RESULTS: We identified four distinct trajectories of patient participation over the course of inpatient OT: increasing (10%), slow deteriorating (19%), fast deteriorating (4%), and high–stable (67%). Cognitive function measured at admission, comorbidity, days from injury to rehabilitation admission, and length of stay predicted trajectories, χ²(51) = 236.09, p < .001. Participation trajectories predicted motor function, physical independence, life satisfaction, presence of pressure sores, discharge to home, and rehospitalization (all p < .05). Results from qualitative analysis identified three levels of barriers to patient participation: (1) postacute care policy-level barriers (e.g., inadequate communication across settings and insurance issues), (2) hospital-level barriers (e.g., unrealistic expectations across stakeholders, inadequate support for clinicians), and (3) person-level barriers (e.g., educational gaps, recovery expectations). We also identified two facilitators: (1) hospital culture and (2) resources from professional organizations.

CONCLUSION: Trajectories of patient participation during inpatient OT were associated with both functional and participation outcomes. Means for early identification of at-risk patients who have poor participation are needed. Our study will provide targets for enabling active participation of patients receiving OT care. Future research is needed to develop strategies to optimize patient participation for improving rehabilitation effectiveness at the direct care, organization, and policy levels.

References

Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32, 207–214. https://doi.org/10.1377/hlthaff.2012.1061

Lenze, E. J., Munin, M. C., Quear, T., Dew, M. A., Rogers, J. C., Begley, A. E., & Reynolds, C. F. (2004). Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay. Archives of Physical Medicine and Rehabilitation, 85, 1599–1601. https://doi.org/10.1016/j.apmr.2004.03.027

Patient Protection and Affordable Care Act, Pub. L. 111–148, 42 U.S.C. §§ 18001–18121 (2010).