Abstract
Japan is experiencing an unprecedented rate of population aging (Muramatsu & Akiyama, 2011). The Ministry of Health, Labor and Welfare (2016b) is strongly promoting a community-based integrated care system that aims to enrich long-term care, health care supports, and preventive services so that older adults can maintain the lifestyle to which they are accustomed. The community-based integrated care system seeks to ensure the provision of comprehensive health care, nursing care, prevention, housing, and livelihood supports by 2025 (Ministry of Health, Labor and Welfare, 2016b). It will allow older adults to follow their own habits and live in a familiar environment, even when they require long-term care (Ministry of Health, Labor and Welfare, 2016b).
Care managers play an extremely important role in this system (Morikawa, 2014). They draw up care plans for clients, coordinate services according to the level of client need, monitor clients’ care, and adjust care plans when necessary (Morikawa, 2014). Although care managers’ role has grown, several problems related to care management or care planning by care managers have emerged, such as insufficient knowledge, skill, and experience for appropriate care management or difficulty coordinating among different care providers (Matsuda & Yamamoto, 2001; Morikawa, 2014; Yamada et al., 2009). In addition, because of the lack of sufficient information on informal services (e.g., support services by family members, regional volunteers, and nonprofit organizations), available services, and client information (Yagame et al., 2003), care managers perceive their increased workload as burdensome.
The Japanese Association of Occupational Therapists (2014) developed the Management Tool for Daily Life Performance (MTDLP), which is based on a 2008 geriatric health promotion project by the Ministry of Health, Labor and Welfare. The MTDLP is a form used to record the daily life performance of clients as observed by the occupational therapist. Clients also participate in the process by means of interview about or self-assessment of daily life performance. Daily life performance includes all aspects of life, including activities of daily living (ADLs), instrumental activities of daily living (IADLs), work, hobbies, and leisure.
Completion of the MTDLP involves intake, assessment of daily life performance, a daily life performance improvement plan, intervention, reevaluation and revision, and discharge or transfer of the client to case management. The details of the process are described elsewhere (Iokawa et al., 2017). Client transfer is conducted using the Daily Life Performance Transfer Sheet, which addresses a client’s needs, health conditions, and ADL and IADL functions at discharge; occupational therapy program during hospitalization; and continuing interventions and future tasks. The support measures necessary to improve future daily life performance are communicated to professionals involved in supporting clients after discharge, including care managers and care staff.
Stroke is a leading cause of long-term disability, both in Japan and worldwide (Ministry of Health, Labor and Welfare, 2010; Ovbiagele & Nguyen-Huynh, 2011). Considering the aging Japanese population, the incidence of stroke is expected to increase (Van der Cruyssen et al., 2015). Many patients with stroke require rehabilitation to reduce their degree of disability and enhance their likelihood of returning to functional independence at home (Agarwal et al., 2003). In general, stroke rehabilitation in Japan is delivered throughout the acute, convalescent, and maintenance phases (Abo & Kakuda, 2012).
In the context of the community-based integrated care system, stroke rehabilitation involves collaboration between the medical care team and long-term care professionals. This collaboration is crucial to ensure that patients and their family caregivers receive continuous daily living support and that social resources are used efficiently. In particular, such collaboration is important to support patients’ and caregivers’ daily living performance during the early recovery period after patients are discharged from the hospital. However, few studies have reported on the effects of collaboration between occupational therapists in a medical practice and care managers in the community on the care of clients with stroke during this early recovery period.
We previously reported that, among patients with stroke in acute care wards, collaboration between occupational therapists and care managers using the MTDLP resulted in significantly improved ADLs 1 mo after discharge compared with at discharge (Iokawa et al., 2017). Moreover, self-rated health was significantly improved among both acute care and convalescent rehabilitation ward patients with stroke 1 mo after discharge compared with at discharge. We believe that how care managers interpret and use patient information received from occupational therapists greatly affects patients’ postdischarge care plans. However, we have not previously examined how a tool to enable occupational therapists and care managers to collaborate on care planning influences that planning.
In this study, we sought to examine the usefulness of collaboration between occupational therapists and care managers using the Daily Life Performance Transfer Sheet. Our measure of interest was care managers’ subjective assessment of its usefulness in the care management of patients with stroke after discharge.
Method
Participants
Participants were 15 care managers of patients with stroke who were discharged from seven acute care wards and 22 care managers of patients with stroke who were discharged from eight convalescent rehabilitation wards between September 2012 and January 2013. This study was conducted according to the Ethical Standards of the Japanese Association of Occupational Therapists. All participants gave written informed consent.
Procedures
All acute care ward and convalescent rehabilitation ward patients received MTDLP-based occupational therapy during their hospitalization. Occupational therapists then contacted the care managers before discharge, using the Daily Life Performance Transfer Sheet to ensure continuous daily living supports for maintaining and improving patients’ abilities after discharge. In addition, occupational therapists participated in patients’ home visits and conducted care conferences with care managers as necessary before discharge; however, occupational therapists’ intervention with patients or care managers after discharge was not prescribed. We encouraged but did not enforce care managers’ use of the Daily Life Performance Transfer Sheet in determining patients’ care plan after discharge.
One month after discharge, we distributed a questionnaire to gather subjective assessments of care management and of the usefulness of the Daily Life Performance Transfer Sheet to care managers. The subjective assessment of care management consisted of five items pertaining to understanding of patients’ abilities, short-term care planning, long-term care planning, interprofessional collaboration, and sense of accomplishment. Care managers answered all questions using a 4-point Likert scale (1 = very poor, 2 = somewhat poor, 3 = somewhat good, and 4 = very good).
Data Analysis
We compared acute care managers’ and convalescent rehabilitation ward managers’ subjective assessments of the usefulness of the Daily Life Performance Transfer Sheet and of care management items using the χ2 test. Comparison between five items of care management in each care manager group was performed using the Kruskal–Wallis test. We also used Spearman rank order correlation coefficients to assess the relationship between care managers’ subjective assessments of the usefulness of the Daily Life Performance Transfer Sheet and their subjective assessments of each care management item. A p < .05 indicated statistical significance. All statistical analyses were performed using IBM SPSS Statistics (Version 19; IBM Corporation, Armonk, NY).
Results
The 15 care managers (5 nurses, 5 care workers, 3 social workers, and 2 others) of patients who were discharged from the acute care ward had an average of 6.7 yr (standard deviation = 4.0) experience. The 22 care managers (13 care workers, 3 nurses, 3 social workers, and 3 others) of patients who were discharged from the convalescent rehabilitation ward had an average of 5.0 yr (standard deviation = 3.7) experience.
Table 1 includes care managers’ subjective assessments of the usefulness of the Daily Life Performance Transfer Sheet. They perceived its usefulness with acute care ward patients as very good (53%), somewhat good (27%), and somewhat poor (7%). Among care managers of convalescent rehabilitation ward patients, the Daily Life Performance Transfer Sheet was rated as very good (55%), somewhat good (36%), and somewhat poor (5%). We found no significant difference between the subjective assessments of care managers of acute care ward patients and those of care managers of convalescent rehabilitation ward patients.
Case Managers’ Subjective Assessment of the Usefulness of the Daily Life Performance Transfer Sheet and of Care Management
χ2 test comparison between acute care ward care managers and convalescent rehabilitation care managers
Table 1 also shows the results of the subjective assessment for each care management item. Most items, with the exception of long-term care planning and sense of accomplishment among care managers of acute care ward patients, were perceived as very good or somewhat good by more than 80% of respondents. We found no significant differences between the subjective assessments of care managers of acute care ward patients and those of case managers of convalescent rehabilitation ward patients. Most care managers who participated in the study tended to provide low subjective assessments of long-term care planning and sense of accomplishment, but the difference compared with other items was not significant.
Table 2 shows the relationship between subjective assessments of the usefulness of the Daily Life Performance Transfer Sheet and subjective assessments of the individual care management items. Subjective assessments of the usefulness of the transfer sheet were significantly correlated with all items related to the subjective assessment of care management. Specifically, among care managers of acute care ward patients, subjective assessments of the usefulness of the transfer sheet were significantly correlated with long-term care planning, r = .648, p = .031, and sense of accomplishment, r = .633, p = .027. Moreover, among care managers of convalescent rehabilitation ward patients, subjective assessments of the usefulness of the Daily Life Performance Transfer Sheet were significantly correlated with understanding of patients’ abilities, r = .638, p = .002; short-term care planning, r = .564, p = .008; long-term care planning, r = .540, p = .012; interprofessional collaboration, r = .497, p = .022; and sense of accomplishment, r = .573, p = .008.
Relationship Between Care Managers’ Subjective Assessments of the Usefulness of the Daily Life Performance Transfer Sheet and Their Subjective Assessments of Care Management
*p < .05. **p < .01
Discussion
Our findings indicate that more than 80% of care managers of patients with stroke considered the Daily Life Performance Transfer Sheet useful. In addition, subjective assessments of its usefulness were significantly correlated with all items related to the subjective assessment of care management. These results suggest that the Daily Life Performance Transfer Sheet provides information of high value to care managers.
Previous reports have suggested that care managers struggle to complete plans of care for clients because of difficulty collaborating with medical doctors, as well as challenges associated with a lack of availability of informal services (e.g., support services by family members, regional volunteers, and nonprofit organizations) and differences between clients’ and families’ needs and opinions (Ministry of Health, Labor and Welfare, 2014). In addition, care managers who lack experience in care planning find it difficult to set long- and short-term goals for their clients (Ministry of Health, Labor and Welfare, 2014). Moreover, researchers have found that only 27% of care managers are satisfied with their care management (Yagame et al., 2003). We believe that the Daily Life Performance Transfer Sheet provides information that is useful in creating long- and short-term goals for patients and that it can be an effective tool for interprofessional and collaborative care planning. The Daily Life Performance Transfer Sheet had a positive effect on care managers’ sense of accomplishment in creating care plans and engaging in interprofessional collaboration.
Care planning is important to enable people with stroke to regain a meaningful life in their own community. The Ministry of Health, Labor and Welfare (2016a) reported that the creation of an effective care plan requires understanding clients’ current state, gathering information on obstacles and daily life requests, analyzing the background of and factors contributing to declining physical and mental functions, and understanding clients’ needs and future possibilities. The Daily Life Performance Transfer sheet addresses nearly all of these domains: patients’ needs, health conditions, ADL and IADL functions at discharge, occupational therapy programs during hospitalization, future tasks, and intervention programs that require continuation.
Many stroke rehabilitation programs continue to focus on the amelioration of basic mobility and self-care deficits, with less emphasis on home and community participation, including social roles and leisure activities (Graven et al., 2016). Poststroke programs that target identified needs, with particular attention to engagement in activities of value to the person, have a positive effect on emotional well-being (Egan et al., 2014). The Daily Life Performance Transfer Sheet focuses on patients’ needs, ADL and IADL function, and tasks and programs that need to continue for patients. Therefore, collaboration between occupational therapists and care managers by means of the Daily Life Performance Transfer Sheet may increase the effectiveness of care planning while promoting independent daily living for people with stroke.
Previous research has indicated that, among people with stroke, ADL performance was significantly decreased 1 mo after discharge (Yoshino et al., 2008). Research has attributed this decrease in ADLs after discharge to poor health services, the effects of bad weather, negative family attitude, mostly indoor activities, and low motivation (Hosoi et al., 2011). Therefore, collaboration between medical and long-term care professionals is crucial to ensure both continuous supports for patients and their family caregivers and efficient use of social resources.
Clearly, the Daily Life Performance Transfer Sheet transmits information necessary for ADL and IADL supports after discharge. To maintain and improve ADLs and IADLs after discharge, it is important that these items are reflected in patients’ care plan within the long-term care system. By systematizing collaboration using the Daily Life Performance Transfer Sheet, occupational therapists can further promote cooperation with care managers and reliably transfer information pertaining to daily living supports for people with stroke after discharge.
Limitations
This study had several limitations. First, the sample size was small. Second, we did not investigate basic characteristics, including age and sex, in either care manager cohort. In addition, we did not determine whether care managers’ years of experience and basic qualifications affected this study’s results. Third, because we did not use a control group, we cannot compare and verify the care managers’ assessments of the transfer sheet’s usefulness in the postdischarge care management of people with stroke. Future studies should include a control group to assess the Daily Life Performance Transfer Sheet’s usefulness in care management. Fourth, the Daily Life Performance Transfer Sheet provides little information on patients’ health condition, medical history, and social history.
The Daily Life Performance Transfer Sheet alone provides insufficient information to create an effective care plan. In general, care managers are provided with information on patients’ health conditions and medical care by the medical doctor or nurse and on family situation and social history by the social worker. Thus, medical and social histories obtained from other professionals may have influenced this study’s results. In the future, an increase in the transfer sheet’s descriptive fields for medical and social histories related to support for daily life performance after the discharge of stroke patients should be considered.
Finally, we did not consider the relationship between care managers’ subjective assessments and the concrete contents of the Daily Life Performance Transfer Sheet. Further study is needed to verify whether the patients’ and caregivers’ conditions and abilities or family information affected care managers’ subjective assessments.
Implications for Occupational Therapy Practice
Collaboration between occupational therapists and care managers is crucial to ensure clients’ continuous performance of ADLs and IADLs. Therefore, we believe that care managers’ interpretation and use of patient information, as communicated by occupational therapists, greatly affects care plans after discharge. The results of this study have the following implications for occupational therapy practice:
Occupational therapists should collaborate with care managers and participate in care planning for clients with stroke after discharge.
Occupational therapists should communicate concrete information about clients’ needs, ADLs, IADLs, future tasks, and intervention programs necessary for care continuation to care managers using the Daily Life Performance Transfer Sheet.
Conclusion
Most care managers perceived the Daily Life Performance Transfer Sheet as useful for understanding the abilities and functional prognosis of clients with stroke. The transfer sheet promotes collaboration between occupational therapists and care managers, which may have positive effects on the creation of an effective care plan for people with stroke after discharge.
