Abstract
Passage of the Patient Protection and Affordable Care Act in 2010 mandated reform of the United States’ existing primary care system. As part of this reform, advanced practice models, including the Patient-Centered Medical Home model, expanded, with the goal of increasing the use of interprofessional teams. Integrating occupational therapy was promoted as an opportunity to enhance the value of care provided in these redesigned primary care practices. However, occupational therapy’s presence in primary care is still extremely limited.
The Patient Protection and Affordable Care Act (ACA; Pub. L. 111-148) defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (p. 515, § 3502). Primary medical care has a significant impact on the U.S. population’s health through improved access to care, a focus on prevention and early management of health conditions, and overall improved quality of care (Starfield et al., 2005). The ACA mandated reform of the expanded advanced practice models of the U.S. primary care system, including the Patient-Centered Medical Home (PCMH), Health Home, and Behavioral Health Home (the latter two are Medicaid-reimbursed practices for people with mental health conditions). As of 2016, 42 states and the District of Columbia have established laws recognizing the PCMH model or some variety of it (Centers for Disease Control and Prevention, 2016). Each advanced-practice model provides the occupational therapy profession the opportunity to establish a presence in primary care. In this article, we specifically focus on the PCMH model, under which care is provided to nearly 40 million patients (Edwards et al., 2014).
The ACA’s emphasis on integrated care provided by primary care teams empowered the occupational therapy profession to advocate for the inclusion of practitioners on these teams (Goldberg & Dugan, 2013; Killian et al., 2015). AOTA and many practitioners have asserted that occupational therapy practitioners’ broad training; client-centered, occupation-based practices; and ability to serve people throughout the life course would enhance the value of these new models of primary care (American Occupational Therapy Association [AOTA], 2013; Dahl-Popolizio et al., 2016; Muir, 2012). AOTA’s initial advocacy efforts appeared to ensure that occupational therapy would assimilate into this new area of practice; however, the profession’s presence in primary care in the United States is still extremely limited. In this article, we specifically illustrate the challenges that obstruct the PCMH model’s ability to achieve the desired goals of the ACA and offer recommendations to increase the presence of occupational therapy within this model of primary care.
Challenges in the Current Patient-Centered Medical Home Model of Care
Challenges in Reducing Costs and Improving Population Health
To reduce cost expenditures and improve population health, PCMH outcomes are measured primarily through diagnostic laboratory tests, medication reconciliation, and preventive screenings such as laboratory tests or mammograms (Centers for Medicare & Medicaid Services [CMS], 2016). However, the current evidence is insufficient to determine whether these outcomes provide sustained cost reductions and improved population health (Ginsburg & Patel, 2017; Sinaiko et al., 2017). Although these measures demonstrate attention to the sequelae of diseases, they do not account for people’s ability to self-manage their conditions. Requiring outcome measures of improved physical functioning, including participation in work and daily living skills, enhances people’s capacity to better manage chronic conditions (Mueller et al., 2017; Richardson et al., 2012).
Challenges in Establishing Interdisciplinary Teams
The PCMH model emphasizes the provision of team-based care and presents the opportunity to incorporate associate (nonphysician) care professionals (ACPs), including occupational therapy practitioners, and expand the scope of services that are offered (Annis et al., 2016). Leach et al. (2017) claimed that the inclusion of ACPs provides additional resources and areas of expertise to reduce time constraints on physicians and improve access to and the quality of care provided. Despite the evidence for including ACPs in PCMHs, no definitive policy has determined which professions are essential to incorporate. Leach et al. also identified the lack of a clear mandate, which devalues the investment in true care coordination, especially for complex populations. Since the 2012 CMS enactment of the Comprehensive Primary Care Initiative, primary care practices have primarily expanded staffing with medical assistants, nurse practitioners, physician assistants, and care managers, whereas larger primary care practices have infrequently incorporated other health professionals, including pharmacists, social workers, health educators, and nutritionists (Peikes et al., 2014). Other challenges hindering actual team-based care are related to continued discrepancies in how services are reimbursed along with the uncertainty of how future reimbursement structures will permit PCMHs to remain financially sustainable (Leach et al., 2017).
Kaiser Permanente’s chronic-care management program stratifies populations with chronic conditions, identifying their complexity and the additional support required to manage them (Sipkoff, 2003). Although most people with one or two chronic conditions effectively manage their health with usual care and support, those with poorly controlled or multiple comorbidities are considered a high risk. These patients require additional support, including disease management programs and case management (Johnson et al., 2015; Regenstein & Andres, 2014). In addition, psychosocial and other predisposing factors, including limited health literacy, social and home environmental factors, and lack of financial resources, can elevate the risk level of patients with chronic conditions (Haime et al., 2015; Regenstein & Andres, 2014).
Supporting high-risk patients adds stress and a degree of burden for primary care teams because of the extensive time involved in coordinating their scope of care (Okunogbe et al., 2018). A care coordinator is an ideal asset to a PCMH practice (Leach et al., 2017). However, most PCMHs do not have a team member focused on coordinating the patient’s needs related to daily living (Killian et al., 2015). Even if a PCMH has the resources to adequately serve high-risk patients, this service contributes additional stress to primary care physicians and is associated with dissatisfaction and burnout (Zink et al., 2017).
Challenges in Attaining Positive Patient Experience of Care
As noted previously, establishing an interdisciplinary team within a PCMH facilitates health providers’ delivery of coordinated care for their patients. However, the patient experience (beyond patient satisfaction) when receiving care through a PCMH is often an underexamined outcome (Tung et al., 2018). Martsolf et al. (2012) proposed that outcomes related to the patient experience of care should specifically include the domains of interpersonal exchange with their physician, treatment goal setting, and out-of-office contact. Fiscella (2017) added support of patient autonomy and competence and success in addressing basic human needs to these outcome measures.
Within the limited research that has examined the patient experience, outcomes often focus on operational procedures, such as obtaining an appointment when needed, time spent waiting to see a health professional, and follow-up communication (Annis et al., 2016; Tung et al., 2018). Results from these limited studies have indicated modest improvement but have been inconclusive regarding a comprehensive perspective on positive experience; they have yet to demonstrate the model’s full potential (Tung et al., 2018).
Feasible Solutions to Integrate Occupational Therapy
The challenges we have identified inhibit the ability of the PCMH model to fully meet the ACA’s intended goals of an innovative, team-based, coordinated care model. Budgen and Cantiello (2017) asserted, “The goal of the PCMH is not only to improve health care outcomes in a clinical sense, but also have a positive impact on the entire experience, from a service standpoint to a financial one, and to continuously improve all aspects of care” (p. 361). Although occupational therapy has yet to be integrated within primary care, the window of opportunity anticipated by AOTA has not yet closed. Understanding the challenges of the PCMH model can enable the occupational therapy profession to truly actualize its presence in this practice area in the United States.
Because occupational therapy’s presence in primary care is lacking, validating its worth in this practice setting is difficult. AOTA (2015; Goldberg & Dugan, 2013) has affirmed that occupational therapy is a viable service that improves patients’ ability to self-manage chronic diseases through prevention, lifestyle modification, and physical and psychosocial approaches, and it has asserted that these interventions could be integrated into primary care practice. Occupational therapy research in the United States has established credible evidence that effective interventions conducted in traditional service contexts (i.e., outpatient) have a positive impact on sequelae of chronic medical conditions, including low vision (Barstow et al., 2015) and arthritis (Murphy et al., 2018), and on medication adherence for patients with those conditions (Schwartz et al., 2017). In addition, international research has demonstrated that population health benefits can be achieved through occupational therapy’s integration into models of primary care and can provide a platform to conduct ongoing research in the United States (Mackenzie et al., 2013; Richardson et al., 2010).
To establish the profession’s value in this setting, AOTA and the American Occupational Therapy Foundation (AOTF) should support research that builds on existing evidence to specifically examine the impact of occupational therapy’s involvement in U.S. primary care models. Conducting expanded efficacy studies would evaluate occupational therapy’s value in enhancing patients’ health and meeting established primary care outcome measures (Halle et al., 2018; Murphy et al., 2017). Academic researchers should lead students in conducting research to answer these questions. OTD capstone projects also offer a great opportunity to progress this research agenda and could be coordinated across educational programs.
Another challenge with integrating occupational therapy practitioners into PCMH practices is the lack of evidence regarding who should ideally be included on the PCMH team. Annis et al. (2016) claimed that outcomes at the PCMH practice level “do not provide information on how or to what extent care is distributed among team members or how various combinations of team-based care affect outcomes” (p. 363). AOTA (2015) declared that occupational therapy’s contributions to chronic disease management include “developing coping strategies, behaviors, habits, routines, and lifestyle adaptations to support physical and psychosocial health and well-being” (p. 1). These contributions provide a focal point to market the profession’s contribution to PCMH practices. They would define occupational therapy practitioners’ role as experts in helping patients improve their understanding of lifestyle factors and establish positive habits and routines to mitigate secondary complications of their chronic conditions. Prioritizing interventions to address patient factors and performance patterns related to contexts and environments, and carefully documenting them, will shape the profession’s identity and formalize its contribution to team-based care.
Emphasizing the development of invested, long-term relationships enhances the likelihood of patients’ compliance with treatment and their ability to achieve positive health outcomes, which in turn provide for improving patients’ experience with the care they receive (Xin et al., 2017). International occupational therapy research has validated that the provision of occupational therapy services in primary care enables patients to improve their quality of life, feel more satisfied with services received, and improve interactions with their primary care physicians for goal setting and problem solving (Eklund et al., 2015; Garvey et al., 2015; Richardson et al., 2010, 2012). AOTA encourages the use of the Occupational Profile (see https://www.aota.org/∼/media/Corporate/Files/Practice/Manage/Documentation/AOTA-Occupational-Profile-Template.pdf) profile because it is unique to occupational therapy, is patient centered, and gathers information from the patient’s perspective. The Occupational Profile reveals critical information to combine with medical test results, providing a comprehensive understanding of the patient’s health status, needs, and priorities. It informs the team about patients’ perceived barriers (physical, social, cultural, etc.) to help the team prioritize a realistic, patient-centered treatment plan.
Uncertainty about reimbursement for occupational therapy services may be the biggest obstacle for occupational therapy to overcome (Halle et al., 2018). Therefore, a detailed how-to manual needs to be developed as a resource for occupational therapy professionals and PCMHs. All parties need to clearly understand PCMH financial structures and legal guidelines to articulate billing possibilities for occupational therapy services (Murphy et al., 2017).
Finally, occupational therapy practitioners practicing in primary care should present their models at professional conferences and submit articles outside of the profession, where the stakeholders and decision makers in primary care obtain their information (Halle et al., 2018). These actions will help other professions understand what occupational therapy can offer to integrative care to improve the future success of the PCMH.
Conclusion
Since passage of the ACA, the primary care system in the United States has significantly expanded through the establishment of advanced-practice models, including PCMHs. Early analysis indicates that the PCMH model is making some progress in reducing cost expenditures but has not had a sustained impact on improving population health. In addition, changes to the payment structures have not been sufficient to support the addition of associated care professionals. These continued challenges contribute to the ongoing unactualized integration of occupational therapy into primary care. The profession needs coordinated advocacy efforts from AOTA, AOTF, and faculty researchers. A specific, informed approach to support, guide, and coordinate practitioners who seek to break through these barriers would be an asset. Future advocacy efforts from the profession need to shift the focus from proclaiming occupational therapy’s value to validating how its integration into PCMHs actually contributes to the model’s fully realized potential.