Date Presented 4/1/2017
This study explored possible roles for occupational therapy in a team-based primary care clinic. Results suggest that cognitive and behavioral challenges interfere with treatment and that patients face occupational limitations that are not addressed. Occupational therapists have unique skills to complement the team and benefit patient outcomes.
Primary Author and Speaker: Jodi Winship
Additional Authors and Speakers: Carole Ivey
PURPOSE: With growing concern over the cost of health care, the U.S. health care system is in the midst of significant changes. Leaders in occupational therapy (OT) envision OT’s role in primary health care delivery as part of the solution to the cost of health care (American Occupational Therapy Association [AOTA], 2014b; Muir, 2012). To be accepted in the primary care world, research needs to demonstrate the potential value of OT in this setting. This study explored the potential need for OT in a primary care setting to answer the following questions: What challenges do primary care providers face in treating people with complex needs? What needs do patients have that could be addressed by OT?
DESIGN: We used a qualitative descriptive design to explore the need for OT in a clinic serving a low-income population with multiple morbidities. All 20 current clinicians (physicians, social worker, psychologists, clinical nurse, nurse practitioner, and pharmacist) were interviewed. Patients were recruited from a clinic-provided list of 36 current patients who had received care at the clinic for at least 1 yr. Thirteen patients agreed to be interviewed. Additionally, we attended and recorded 10 of the clinic’s weekly team meetings.
METHOD: We completed 23 in-person semistructured interviews. Clinician interviews included questions about the clinic process, challenges, successes, patient engagement, and team-based care. Patient interviews included questions about their care and experience at the clinic, including challenges and perceived health changes. Interviews and team meetings were audio recorded, transcribed verbatim, deidentified, and verified for accuracy. We analyzed data in Atlas.ti (Berlin, Germany) using a directed content analysis approach. Predetermined codes were developed from the Occupational Therapy Practice Framework (AOTA, 2014a), and additional codes were identified through an emergent process. The three-member coding team read and coded together a subset of the transcripts until agreement was reached. The remainder of the transcripts were coded independently by two members. Coding was merged, and a consensus process addressed differences. Themes were then developed and conceptually ordered to describe data and explain relationships among themes.
RESULTS: Analysis revealed four domains of challenges consistently identified by the clinicians: (1) medical: management of multiple chronic illnesses, pain management; (2) financial: patients’ limited resources, secondary gains; (3) mental health: mental illness, substance abuse; and (4) cognitive and behavioral: patients’ poor problem-solving skills and engagement, medication adherence, unhealthy habits. In addition to medical concerns, the patients experienced challenges to occupational engagement, including community mobility and basic and instrumental activity of daily living performance.
CONCLUSION: Challenges of working with complex patients fell within the medical, financial, mental health, and cognitive and behavioral domains. The current makeup of the clinic team reflected their intent to directly address these domains. However, cognitive and behavioral challenges were indirectly being addressed through various interventions (though most frequently through education) delivered by any or all of the team members. Although many patients identified limitations in occupational engagement, the issues were not addressed at the clinic. These occupational limitations can impact patients’ ability to actively and effectively engage in their health care.
IMPACT STATEMENT: Results suggest that patient needs are not being fully met by the current care team. Because occupational therapists are trained to look at the person, environment, and occupation, they are uniquely qualified to address patient occupational limitations and cognitive and behavioral challenges. The skills that occupational therapists possess would complement the team and lead to improved patient outcomes.
References
American Occupational Therapy Association. (2014a). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006
American Occupational Therapy Association. (2014b). The role of occupational therapy in primary care. American Journal of Occupational Therapy, 68(Suppl. 3), S25–S33. https://doi.org/10.5014/ajot.2014.686S06
Bodenheimer, T., & Pham, H. H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29, 799–805. https://doi.org/10.1377/hlthaff.2010.0026
Ghorob, A., & Bodenheimer, T. (2012). Share the Care™: Building teams in primary care practices. Journal of the Board of Family Medicine, 25, 143–145. https://doi.org/10.3122/jabfm.2012.02.120007
Metzler, C. A., Hartmann, K. D., & Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy. American Journal of Occupational Therapy, 66, 266–270. https://doi.org/10.5014/ajot.2010.663001
Muir, S. (2012). Occupational therapy in primary health care: We should be there. American Journal of Occupational Therapy, 66, 506–510. https://doi.org/10.5014/ajot.2012.665001
