Abstract
Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project. In this Evidence Connection article, I describe a clinical case report of an older adult with a chronic condition and his daughter who received home health occupational therapy services. I discuss the occupational therapy evaluation and intervention processes with these clients to support chronic condition self-management, coping skills, and problem solving, drawing on findings from the systematic review on the effectiveness of interventions for care partners of people with chronic conditions published in the July/August 2021 issue of the American Journal of Occupational Therapy. It is my hope that this Evidence Connection article can be used to inform and guide clinical decision making when working with older adults with chronic conditions and their care partners.
In this Evidence Connection article, the author describes a clinical case report of an older adult with a chronic condition who, with his daughter, received home health occupational therapy services.
As the population continues to age and experience chronic conditions, care partners (i.e., family members and friends who provide care, usually without payment) have become increasingly critical to the long-term care system. In response, many prominent organizations, including the Institute of Medicine and the Institute for Healthcare Improvement, are endorsing a person- and family-centered model of geriatric care (Clay & Parsh, 2016). Key features of this model include collaboration and information sharing, education and training, and active participation and decision making by health care practitioners, older adults, and their care partners. To support this model, payment and coverage innovations in Medicare and Medicaid are beginning to emerge. For example, home health agencies can provide care partner supportive services such as education and training to Medicare beneficiaries (Centers for Medicare & Medicaid Services, 2017; National Academies of Sciences, Engineering, and Medicine, 2016).
In this article, I provide a clinical case report that demonstrates how occupational therapy practitioners can support and participate in this model of care. This case report exemplifies findings of a systematic review on the effectiveness of interventions for care partners of people with chronic conditions, published in the July/August 2021 issue of the American Journal of Occupational Therapy (Rouch et al., 2021). I describe the occupational therapy evaluation and intervention processes for supporting chronic condition self-management, coping skills, and problem solving for an older adult with a chronic condition and his daughter receiving home health occupational therapy services.
Clinical Case Report
John, age 70 yr, was referred to home health occupational therapy because of a recent diagnosis of peripheral neuropathy made during his annual check-up with his primary care practitioner. He self-reported that since his wife died, he has not been managing his Type 2 diabetes well. His peripheral neuropathy has been limiting his ability to do normal activities because of mild numbness and pain in his feet. John’s daughter, Dawn, attended his annual check-up with him for the first time. Dawn was surprised to learn that her father has not been managing his diabetes. Together, John and Dawn decide that she will take a more active role in helping her father improve his health, the role that John’s wife had previously assumed.
Occupational Therapy Evaluation and Findings
Using the American Occupational Therapy Association (AOTA; 2021) Occupational Profile Template as a guide, the occupational therapist, Madeline, conducts an evaluation with both John and Dawn present. The findings reveal the following: John is independent in activities of daily living, including dressing, feeding, functional mobility, and personal hygiene. He is a retired computer programmer and enjoys surfing the web and playing online games. John feels lonely since his wife passed and has not been sleeping well. He enjoys visiting with his daughter and would like her to play a more active role in helping him get back on track with his health. Dawn confirmed that she is willing and able to better support her father. John describes his home as being accessible after changes made to accommodate his wife’s progressive condition. Previous performance patterns included going on short morning walks with his wife, going out to eat with friends, and taking care of all the yard work. Before her death, John’s wife managed the house, including grocery shopping, cleaning, and cooking.
Table 1 presents findings from the other assessments Madeline administered during the evaluation: the Canadian Occupational Performance Measure (COPM; Law et al., 2014), the Brief Health Literacy Screening Tool (Haun et al., 2012), and the Patient-Reported Outcome Measurement Information System (PROMIS) Global Health scale (Version 1.2; Hays et al., 2009).
John’s Baseline Assessment Findings
Occupational Therapy Intervention
Madeline, John, and Dawn decided that occupational therapy would address health management (AOTA, 2020). Madeline reviewed the evidence presented in the systematic review by Rouch et al. (2021) and found the following relevant information: Moderate evidence for group-based interventions in which older adults and their care partners focus on learning and applying chronic condition–specific education, coping skills, and problem solving to improve well-being and quality of life. Moderate evidence for educational interventions in which older adults and their care partners focus on learning how to adapt daily living skills.
Given that most of the studies in the systematic review had moderate to low strength of evidence, Madeline also reviewed other pertinent sources, including the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; AOTA, 2020), the Centers for Disease and Control and Prevention (CDC), and the Self-Management Resource Center (SMRC). In the OTPF–4, she found descriptions of occupations related to health management. From the CDC and SMRC, she identified recommendations for physical activity and online workshops. Drawing from available evidence, her clinical expertise, and John’s and Dawn’s preferences, Madeline developed a plan of care for home health occupational therapy. Over the course of 2 mo, John and Dawn participated in four in-person home health occupational therapy sessions. Targeted outcomes included improved well-being, quality of life, and knowledge of John’s chronic condition.
Group Self-Management Intervention
After learning from the occupational profile and COPM that John and Dawn wanted to work on building a healthier lifestyle together, Madeline suggested they attend a virtual diabetes self-management group workshop. The workshop lasts 6 wk, requires about 2 hr of work each week, and covers establishing healthy nutrition and exercise habits, communicating effectively with loved ones and health care practitioners, managing medications, and using relaxation and breathing techniques (Cai & Hu, 2016; SMRC, 2021; Toseland et al., 2004). John and Dawn reported that they would sign up to take the online workshop together. Dawn shared that she was particularly interested in talking with other care partners online to find out how they empower their loved ones to improve their health. John and Dawn both expressed that they want to learn strategies to prevent problems caused by peripheral neuropathy (i.e., swollen feet, pain, loss of muscle tone and balance).
Coping Skills Intervention
Findings from the PROMIS Global Health scale indicated to Madeline that John and Dawn are experiencing decreased quality of life and poor mental health. During the first and second occupational therapy sessions, Madeline provided strategies to John and Dawn to help them cope with the recent passing of their loved one. In particular, she helped them establish a journaling routine in which John and Dawn would each record their thoughts and feelings on a daily or weekly basis. She also shared information on the impact of sleep on health and provided some suggestions for building a better nighttime routine, including listening to music, taking a warm bath, and reading a favorite book. Last, Madeline encouraged both John and Dawn to either resume participating in a meaningful hobby or explore a new one (Hood et al., 2015; Hoppes & Segal, 2010; Wolff et al., 2009).
Problem-Solving Intervention
During the third and fourth occupational therapy sessions, Madeline worked with John and Dawn to adapt their daily living skills by using problem-solving strategies. Because John has limited health literacy, Madeline used plain language, visual aids, and the teach-back method when introducing strategies. For example, John identified that he has had a hard time preparing healthy meals and finding time to exercise. Madeline had John brainstorm potential solutions while encouraging Dawn to think about how she could help her father improve his meal preparation and exercise routines. They both decided that they needed to learn how to read nutrition labels and how much exercise is recommended on a weekly basis.
Madeline described the basics of nutrition using good and bad “nutrition facts” labels as examples. She then had John and Dawn teach these facts back to her. Dawn reported that she was willing and able to help her father create a grocery list that included healthier food choices as part of their weekly routine. Madeline also shared that the general recommendation for exercise is about 150 min spread out throughout the week. John and Dawn discussed what it would take for them to establish a walking routine together. They reviewed their schedules and determined that they could meet up at a nearby park to walk the various trails 3 times a week for at least 30 min. Madeline suggested that if they found themselves having a difficult time sticking to this routine, they should evaluate the activity to determine what alterations could be made (CDC, 2020).
Discharge Summary
Through the use of these evidence-based interventions, John and Dawn met their established goals after completing four occupational therapy home health sessions and a 6-wk online workshop. At follow-up, John’s COPM scores had improved from 5 to 9 (of 10) on both the Performance and Satisfaction scales. John and Dawn also started a weekly walking routine, which was improving their well-being and relationship. They have met up to walk the trails at three different parks near their neighborhoods. John and Dawn found the journaling helpful for coping with their recent loss and managing their health. John’s scores on the PROMIS scale improved to 16 (T score = 50.8) for the physical health items and 16 (T score = 53.3) for the mental health items, indicating good global health.
John and Dawn reported that they have not followed through with developing a weekly grocery list and meal preparation plan. They determined that Dawn has been juggling too many work demands to help with this health management–related task. However, they discussed and set up a meal delivery option for John that includes healthier food items that he prepares on his own.