Abstract
This case report describes occupational therapy services provided in consultation with a primary care practice for a community-dwelling older adult dyad with mild coronavirus disease 2019. The occupational therapy evaluation included administration of the Canadian Occupational Performance Measure through telehealth to identify priority areas for intervention; the clients selected participation during activities of daily living and mealtime, fall prevention, cooking together, and leisure participation. The intervention process focused on addressing the dyad’s identified priorities as well as managing caregiver stress and preventing hospitalization. Positive outcomes were achieved while adhering to social distancing guidelines set forth by state and national agencies.
This case report describes community-dwelling older adults with mild COVID-19 who received occupational therapist services in collaboration with a primary care practice.
Clara is an 89-yr-old community-dwelling White woman with a history of Alzheimer’s disease, hypertension, asthma, gastroesophageal reflux disease, and arthritis; her surgical history includes total left hip replacement, bilateral cataract surgery, and hysterectomy. In the summer of 2020, Clara began showing symptoms of decreased appetite, fatigue, and dry cough. Roger, Clara’s husband of 60 yr and her caregiver, noticed these symptoms and called their primary care provider (PCP) to determine the best course of action. Roger was instructed to make a telehealth appointment with Clara’s PCP.
During the telehealth appointment, the PCP evaluated Clara’s symptoms and determined that Clara and Roger required testing for coronavirus disease 2019 (COVID-19). Clara and Roger were tested at their local drive-through pharmacy, and both tested positive; Roger was asymptomatic. Roger expressed concerns regarding Clara’s recent functional decline, and the PCP made a referral to the occupational therapist working in consultation with the primary care clinic.
Occupational Therapy in Primary Care
Although occupational therapy integration into primary care clinics is a relatively new practice, evidence shows that this model can have advantages, including assisting older adults to age in place, preventing hospitalization, and minimizing excess health care by increasing appropriate referrals (Bolt et al., 2019). In the primary care practice Clara and Roger attended, the occupational therapist worked on a consultative basis with the physicians. Referrals to occupational therapy were often made after a new patient appointment, regular check-up, or sick visit indicating that the patient had functional limitations or other occupational performance barriers. The goal of the primary care occupational therapist was not to replace formal referrals to outpatient occupational therapy but to provide a timely, team-based approach to improve access to care for patients (Bolt et al., 2019).
Telehealth as the Service Delivery Method
Before the COVID-19 pandemic, appointments with the primary care occupational therapist occurred in person, via telehealth (e.g., phone, secure Web-based video call), or using a combined in-person and telehealth approach. During the pandemic, telehealth visits were deemed the safest delivery mechanism for decreasing the exposure risk and spread of the novel coronavirus (Murphy et al., 2020). In addition to minimizing the risk of COVID-19 transmission, telehealth therapy has been found to be cost-effective and can prevent delays in receiving care (Cason, 2014); these were seen as advantages in this primary care setting. In addition, the use of video telehealth to help clients manage daily life skills and caregiver stress was seen as an important evidence-based feature of care for Clara and Roger (Gately et al., 2019).
Although telehealth has advantages, this delivery format can also create barriers in the occupational evaluation and intervention process. Telehealth impedes the practitioner’s ability to prepare structured observations for formal assessments and may decrease opportunities for informal observations. In addition, many common occupational therapy assessments may not be valid or reliable when delivered via telehealth; some assessments cannot be administered at all because of the need for special equipment or handling procedures. Although telehealth presents limitations to typical hands-on therapeutic modalities, occupational therapy practitioners are creative and able to problem solve under circumstances of change and uncertainty (Chapparo & Ranka, 2008). In the primary care clinic Clara and Roger attended, a hybrid of telehealth and in-person occupational therapy services would normally have been preferred; however, adaptation to telehealth-only service provision was required during the pandemic.
Evaluation
After referral by the PCP, the occupational therapist made a telehealth appointment with Clara and Roger. They were able to use live video conferencing on their home laptop computer, allowing therapy sessions to occur via telehealth. The portability of the laptop also enabled the therapist to view different rooms and tasks within the home environment. The occupational therapist was able to see the dyad in their home environment and thereby understand the environment’s impact on occupational participation.
During the first session, the occupational therapist completed the initial evaluation of Clara, with Roger present. Although Clara was the beneficiary of occupational therapy services, success with the dyad depended on caregiver education to facilitate carryover of strategies and training provided. Focusing on this relationship, the occupational therapist evaluated the daily life of the dyad to identify interventions focused on developing strategies for Roger to address Clara’s occupational deficits and optimize her participation. The initial evaluation included a combination of formal and informal assessments, with the majority of data coming from the occupational profile and the Canadian Occupational Performance Measure (COPM; Law et al., 2019).
Occupational Profile
During the initial evaluation, the occupational therapist completed the occupational profile guided by the Occupational Therapy Practice Framework: Domain and Process (4th ed.; American Occupational Therapy Association [AOTA], 2020) and the Occupational Profile Template (AOTA, 2021). The therapist interviewed Clara and Roger and gathered information about their daily lives before the pandemic as well as during the pandemic. The occupational profile is summarized in the sections that follow.
Introduction to Clara
Clara was diagnosed with Alzheimer’s disease 2 yr ago after she became increasingly forgetful and confused. At this point in the disease progression, Clara is no longer aware of her diagnosis and becomes upset when reminded. During the evaluation, Clara was alert and oriented to person and place and demonstrated fair communication skills. Although she was able to make her wants and needs known, she often perseverated on specific desires and frequently repeated questions. Clara was able to follow two-step directions but exhibited poor safety awareness; she frequently required redirection to stay on task and had a limited attention span.
Clara appeared frail but well groomed. She has physical signs of arthritis in her hands, but she is not limited by these changes. She requires the use of a rolling walker for ambulation, which Roger often supervises to ensure she is safe. With exertion, Clara has increased shortness of breath and requires frequent rest breaks.
The Dyad
Clara often looked to Roger to initiate and clarify responses. When the occupational therapist asked questions of a personal and sensitive nature, Roger frequently allowed Clara to respond first and would then clarify and add details. Clara tended to verbalize less than Roger because of her cognitive limitations and difficulty understanding some of the more abstract questions. Roger was also able to provide insight into deficits Clara may be unaware of. When possible, the occupational therapist reframed questions to ensure the responses captured both Roger’s and Clara’s views. In other cases, modified prompts were used so Roger could speculate how Clara would respond. Roger also provided a rich occupational profile for Clara and discussed the impact of COVID-19 on their occupational participation.
Life Before COVID-19
Clara worked as a part-time secretary for 50 yr and loved ballroom dancing. She always valued cooking, homemaking, and companionship. Roger worked full-time as a production officer for a car company and is committed to his family. Clara and Roger live in an independent living facility (ILF) with daily activities and groups to attend. They were both very active within the ILF and with their local church. Roger attended a weekly caregiver support group where he connected with others in similar situations and learned tips for coping with the stress of being a caregiver. Both Clara and Roger enjoyed taking daily walks around the neighborhood and socializing with their neighbors. They also enjoyed preparing simple meals together. Their children and grandchildren live nearby and visited weekly before the pandemic; they also delivered groceries for the week, supporting Clara and Roger’s valued occupation of cooking together at home.
Although Clara was beginning to show cognitive decline, she was able to complete her activities of daily living (ADLs) with setup assist and participate in her desired leisure occupations. Roger typically woke up 30 min before Clara to get himself dressed and prepare Clara’s clothes before she woke up. Roger organized Clara’s medications while she was in the bathroom, providing minimum cuing and physical assistance for her to correctly take them.
Life During the COVID-19 Pandemic
Unfortunately, all the activities and groups in which Clara and Roger participated came to a sudden halt with the onset of the COVID-19 pandemic. Their routines and habits diminished. Because of the novelty and risks associated with the virus, Clara and Roger stopped leaving their apartment. Although the family continued to deliver groceries weekly, they began leaving grocery bags at the door of the apartment for Roger to retrieve. The dyad had no social interaction except with each other.
During this period, Roger began noticing that Clara was becoming increasingly confused and gradually weaker. As the months went by, Roger began assisting Clara more by providing verbal cues to complete her ADLs. With no help and no support group to attend, Roger began to feel overwhelmed in his role as a caregiver.
Life When Clara Is Symptomatic With COVID-19
When Clara became symptomatic with COVID-19, she continued to have regular sleep patterns, which allowed Roger to continue to complete his typical morning routine. When Clara woke up, however, she was resistant to getting dressed and participating in mealtime, and she required moderate assistance to complete ADLs such as her dressing and toileting routine. She began having episodes of incontinence that required total care from Roger. Roger noted that these activities took more than twice the amount of time they used to because of Clara’s need for frequent rest breaks. With the onset of taste and smell loss, Clara had little interest in eating and decreased participation in mealtime, which required Roger to assist with feeding.
Clara continued to participate in her passive leisure activities of watching television and bird watching, but she stopped participating in active leisure activities such as daily walks and cooking. Roger began spending the majority of his time and energy caring for his wife. Because of the increased assistance Clara required, Roger began to feel extremely overwhelmed in his caregiving role.
Canadian Occupational Performance Measure Interview
The COPM is an interview-based measure of client and caregiver performance and satisfaction with their performance in client-identified areas of self-care, leisure, and productivity (Law et al., 2019). Clients identify specific target areas, rate how important these areas are to address, identify the five activities with the highest importance, and then rate their perceived performance of those activities (1 = worst, 10 = best) and satisfaction with their performance (1 = least, 10 = most). Performance and satisfaction are measured pre- and postintervention to assess change; a change of 2 points is considered clinically important, although clinical significance can vary across individuals (Law et al., 2019).
Using the COPM, the occupational therapist worked with Roger and Clara to identify areas of decreased performance and satisfaction. Roger expressed concerns about his wife’s engagement during meals, participation in ADLs, and leisure participation; specific concerns and COPM scores are listed in Table 1. The occupational therapist used the occupational profile and COPM results to highlight areas of priority and then collaborates with the dyad to determine the most appropriate plan of care.
Canadian Occupational Performance Measure Results for Clara
Note. Scores were derived from a semistructured interview including both Clara and Roger. Clara expressed her thoughts on each category, and Roger assisted by providing a numeric value based on Clara’s response. Importance is scored on a scale ranging from 1 (least important) to 10 (most important). Performance is scored on a scale ranging from 1 (worst performance) to 10 (best performance) and Satisfaction from 1 (least satisfied) to 10 (most satisfied). ADL = activities of daily living.
Intervention
Clara and Roger were seen via telehealth 2–3 times/wk for 60-min sessions over a period of 30 days. The occupational therapist explained that if the dyad was unable to meet their goals within this time frame, a recertification would be initiated. Billing codes used for this case are presented in Table 2.
Medicare Part B Billing Information for Clara and Roger
Note. COVID-19 = coronavirus disease 2019.
During each treatment session, both Clara and Roger participated to increase carryover of strategies and minimize Clara’s functional decline. The occupational therapist provided Roger with an email address in case he wished to discuss topics or information he was not able to express in front of Clara. The model guiding treatment was the Person–Environment–Occupational Performance (PEOP) Model, which focuses on the relationship among the client, physical context, desired occupation, and level of performance and the impact of each on occupational performance (Law et al., 1996). Along with interventions to address Roger’s identified concerns (i.e., participation during ADLs and mealtime, fall prevention, cooking together, and leisure participation), the occupational therapist provided interventions to educate Roger and Clara on ways to manage caregiver stress and prevent hospitalization.
Participation During Mealtime
Clara’s sensory changes (loss of taste and smell) had affected her motivation to eat and altered her normal food preferences. Clara stated that she simply was not hungry during a telehealth session at mealtime. The occupational therapist provided the following strategies to Roger to help increase Clara’s appetite and motivation to eat: arranging foods in an attractive manner on the plate, using strong flavors to make food smell appetizing, presenting precut foods, and moistening foods with gravy or sauce (Gitlin & Piersol, 2014). The therapist also provided education on environmental modifications to increase self-feeding, such as using a contrasting-colored plate, providing finger foods to decrease cognitive load, allowing plenty of time, limiting distractions, and increasing the frequency of nutritious meals (Gitlin & Piersol, 2014).
Participation in the Morning ADL Routine
The occupational therapist used skilled observation via video conferencing to identify barriers to Clara’s dressing and toileting. Clara was able to pick out her outfit for the morning, but after putting on an overhead shirt, she had difficulty donning lower body clothing because of fatigue. Education was provided to Roger on ways to reduce the physical and cognitive demands of dressing for Clara; for example, simple clothing items such as a slip-on dress could reduce these demands. Transitioning to wearing only slip-on dresses also reduced toileting demands for both Clara and Roger; Clara was having difficulty unfastening her pants efficiently, resulting in episodes of incontinence.
Fall Prevention
Roger’s concerns about fall risk began with the onset of Clara’s COVID-19 symptoms, particularly her fatigue and poor activity tolerance. The couple was instructed in an exercise program to complete together. Because Tai Chi has been shown to reduce risk of falls in older adults, the occupational therapist recommended that the dyad also participate in a video-format Tai Chi exercise class (Hu et al., 2016). The dyad was also instructed to take frequent walks to increase Clara’s endurance (Magistro et al., 2014). The therapist was able to assess the environment via video conferencing and provided recommendations for reducing fall risk from an environmental perspective. The recommendations included removing throw rugs and clutter and ensuring that walking pathways throughout the home remained clear and well lit (Marquardt et al., 2011).
Cooking Together
To address the priority area of cooking, the occupational therapist and dyad worked together to brainstorm and strategize methods for increasing engagement. The therapist was able to observe a portion of one mealtime to gain an understanding of problem areas. The therapist provided education to Roger on reducing clutter in the environment, providing setup assistance, cuing Clara to facilitate the just-right challenge, making meals of interest to Clara, and developing simple and familiar steps for meal preparation.
Leisure Participation
Clara and Roger were educated on methods to continue their leisure participation and social engagement while social distancing during COVID-19. They were encouraged to set up a weekly video call with their family to increase their well-being and decrease feelings of loneliness (Chopik, 2016). Roger was also educated on virtual caregiver support groups to increase his social network and resources available during the difficult time. The dyad was encouraged to continue participating in their valued occupation of bird watching on their porch or indoors and embedded it into their routine after breakfast. Although Roger was initially concerned about Clara losing interest in watching television, this leisure occupation was not affected by COVID-19, and they benefited from the routine that television programming provides (e.g., watching a favorite show each day at noon).
Continued Role of Occupational Therapy
Throughout the 30-day certification period, the occupational therapist modified the treatment plan as needed on the basis of the client’s and caregiver’s response to intervention. At the start of each session, the therapist asked Clara and Roger what successes and difficulties they had encountered when implementing the strategies discussed in prior sessions. Depending on their responses, the therapist tailored the interventions and strategies to promote Clara’s occupational success and decrease Roger’s burden. Throughout the certification period, the therapist discussed symptom management of COVID-19 with Clara and Roger, including the use of a pulse oximeter, blood pressure cuff, and thermometer; the couple was trained to enter values into a daily log to provide relevant information to the PCP. Because Roger had also tested positive for COVID-19, he maintained a daily log of his basic vital signs to ensure he remained healthy. The occupational therapist and PCP communicated on a weekly basis, discussing the daily log and Clara’s progress and collaborating on areas of continued focus. The PCP was also able to identify additional signs and symptoms to monitor in light of new evidence gathered during the pandemic.
Outcomes
Reevaluation using the COPM took place via telehealth at the end of the occupational therapy intervention period. Clara and Roger had achieved clinically significant changes in valued areas of occupation. Performance and satisfaction scores improved by 2 points or more in participation during mealtime, participation in the morning ADL routine, fall prevention, and cooking. No change was found in leisure engagement. Along with these clinically significant COPM results, Clara and Roger described improvement in their mood and understanding of the COVID-19 disease process, which helped them successfully prevent the need for hospitalization.
Implications for Occupational Therapy Practice
This case report has the following implications for occupational therapy practice:
Occupational therapists play a unique role in health management during a pandemic of a novel virus.
Telehealth was found to be an effective delivery model for occupational therapy for community-dwelling older adults.
Collaboration between a primary care physician and an occupational therapist assists with symptom and condition management, leading to decreased hospitalizations.
Conclusion
Working closely with a PCP enabled an occupational therapist to provide effective services to two community-dwelling older adults with COVID-19, one of whom had several comorbidities. The occupational therapist successfully used a telehealth platform to evaluate and provide interventions to the dyad with a focus on addressing client-identified areas of priority, managing caregiver stress, and preventing hospitalization.
Although primary care is an underrepresented practice area for occupational therapy, this case report exemplifies the benefits of including occupational therapy practitioners in interprofessional primary care teams. The body of evidence for the effectiveness of occupational therapy practice in primary care remains small, and the use of evidence-based telehealth interventions for clients with the novel coronavirus disease are still emerging. In spite of this gap in research, we believe that occupational therapy practitioners have the skill set to examine relationships among the client, the environment, and desired occupations. Occupational therapy practitioners are uniquely positioned to develop creative, thoughtful, and holistic treatment plans and to implement effective interventions to address the global pandemic.
Footnotes
Acknowledgments
The authors thank Tracey Vause-Earland, Brooke Salzman, and the staff at Jefferson Geriatrics for providing the opportunity and mentorship needed to integrate occupational therapy into a primary care clinic. This opportunity was created through Thomas Jefferson University’s occupational therapy doctoral program. We also thank our American Occupational Therapy Association liaisons for guiding us in the creation of this case report.
This case report is based on the authors’ accumulated experiences with multiple patients in a geriatric primary care setting. The authors have no conflicts of interests to disclose.