Abstract
With the continued evolution of health care reform and payment models, it is imperative that the occupational therapy profession consistently and clearly articulate its distinct value. As payment models shift from paying for the volume of services provided to paying for the value of services, the field of occupational therapy must be sure to implement high-quality care by translating evidence into practice and facilitating improvements in client outcomes. Yet the process of translating evidence-based interventions and programs to real-world settings can be quite complex, and successful implementation often requires active collaboration across occupational therapy stakeholders. In this Health Policy Perspectives article, we provide occupational therapy educators, practitioners, and researchers with key recommendations for how the profession can translate evidence into practice, ultimately leading to the improvement of client outcomes and the provision of value-based care.
This Health Policy Perspectives article provides occupational therapy educators, practitioners, and researchers with recommendations for how the profession can translate evidence into practice, ultimately leading to improved client outcomes and the provision of value-based care.
The occupational therapy profession is responsible for ensuring that client populations receive high-quality care that is grounded in the best available evidence, leading to the achievement of client-centered goals and improved outcomes (American Occupational Therapy Association [AOTA], 2020). The provision of high-quality care is characterized by the implementation of interventions, programs, and tools that are deemed effective and are well supported by empirical studies (Brownson et al., 2017). To do this, the occupational therapy profession must be able to translate findings from empirical studies into practice while meeting the unique needs of diverse clients, their family members, and their caregivers (Juckett et al., 2019; Upton et al., 2014). The successful translation of evidence-based interventions, programs, and approaches into practice, otherwise known as knowledge translation (KT), should ultimately result in improved client outcomes and enhanced occupational performance.
Knowledge translation is defined as the synthesis, dissemination, and application of knowledge and evidence to improve the health of clients and strengthen the greater health system (Canadian Institutes of Health Research, 2016). Terms such as knowledge-to-action, research utilization, and knowledge transfer have all been used synonymously with KT to refer to moving research into practice or policy (Thomas & Bussières, 2016). For the purposes of this article, we define KT as a process of using evidence to inform decision making, particularly decisions made by occupational therapy stakeholders (e.g., educators, practitioners, researchers), and how those decisions influence value-based care. In this Health Policy Perspectives article, we (1) describe the importance of KT and evidence-based practice (EBP) in the value-based care environment; (2) present a collection of resources to assist the profession in the provision of high-quality care, which affects value-based reimbursement; and (3) recommend strategies for how educators, practitioners, and researchers can use KT principles to optimize client outcomes and demonstrate the distinct value of occupational therapy services.
Value-Based Care in Occupational Therapy
The Triple Aim in health care, first defined in 2008, consists of three pillars: (1) improving the patient experience of care, (2) improving the health of populations, and (3) reducing the per capita cost of health care (Berwick et al., 2008). These pillars continue to be crucial as payment reform evolves in the United States and as payment models shift from paying for volume of care to paying for value of care. Value is determined by payers, who assess the quality of services provided, as indicated by improvements in client outcomes across the continuum of care. With increased national attention to quality care and client outcomes, health care payment models have experienced continued evolution, particularly in recent years. Both the Patient-Driven Payment Model, implemented in skilled nursing facilities in October 2019 (Centers for Medicare & Medicaid Services [CMS], 2021), and the Patient-Driven Groupings Model, implemented in home health in January 2020 (CMS, 2020), changed how Medicare provided payment for services in these practice settings. To achieve value-based care in occupational therapy, the profession must leverage principles from the fields of KT, and application of these principles requires active involvement from a range of stakeholders, including occupational therapy educators, practitioners, and researchers. Here, we describe how the involvement of these stakeholders can improve the delivery of high-quality occupational therapy services.
Considerations for Educators
Educators are germane to the development of all occupational therapy professionals—practitioners, advocacy leaders, administrators, and scientists. They influence how people enter the profession and to what extent they learn to implement EBP. In addition to teaching students how to identify evidence-based interventions and programs in the literature, critically appraise articles, and use evidence to guide clinical decision making, it is also critical to teach students how value-based payment models influence the extent to which occupational therapy services can be reimbursed and how reimbursement affects practitioners, clients, and students.
Teaching Value-Based Payment Models
It is vital that occupational therapy students learn the skills that will allow them to be advocates for value-based occupational therapy services. These skills include understanding current payment models and quality reporting programs, as well as discussing the benefits of services with patients, other providers, and regulators. To help in this process, AOTA has created the Everyday Advocacy Decision Guide (AOTA, 2021a) to provide tips on engaging in these advocacy efforts and outline ways in which students, as well as practitioners, can prepare themselves to have everyday advocacy conversations. AOTA has also compiled a collection of resources for practice, advocacy, and policy discussions (AOTA, 2021b, 2021c, 2021d) that educators may find useful when introducing payment and delivery system reform to students, whose understanding of reimbursement models is likely to vary greatly.
Teaching to Support the Translation of Knowledge to Practice
In these times of innovative and ever-evolving health care models, the traditional teaching approach of merely identifying evidence to use in routine care is no longer sufficient in the training of future practitioners. It is vital that students be able to readily translate this knowledge into implementable steps while keeping abreast of payment model shifts and value-based care changes. Research supports educators’ essential role in teaching health professional students how to identify evidence and apply a process to translate that evidence into practice (Cole et al., 2019; Perkins et al., 2020). However, it is the responsibility of each academic program to prepare faculty to take steps to build KT capacity.
Occupational therapy educators are encouraged to integrate into their curricula courses and activities that teach students how to effectively conduct a systematic literature search, critically appraise peer-reviewed articles, determine the extent to which research findings should be translated into practice, and identify barriers and facilitators that influence evidence implementation (Kemp et al., 2021). Moreover, academic fieldwork coordinators (AFWCs) can play a key role in fostering KT. AFWCs can select sites that ideally model the use of evidence in practice, and if a site lacks KT expertise, AFWCs have the opportunity to foster the relationship by offering KT training for both occupational therapists and occupational therapy assistants—the latter of whom are the primary occupational therapy service providers in the long-term-care and skilled nursing settings (AOTA, 2019).
Considerations for Practitioners
In this time of value-based payment, there is an urgent need for practitioners to not only recognize, articulate, and advocate for occupational therapy’s distinct value but also to implement the most effective and efficient evidence-based services. To support practitioners’ ability to provide these evidence-based services, AOTA has developed an extensive collection of resources that facilitate the translation of knowledge into practice, leading to improvements in the quality of care provided to client populations (AOTA, 2021b, 2021c, 2021d). Practitioners may also consider participating in quality improvement teams to iteratively improve health care services, which can be a valuable endeavor. Occupational therapy practitioners can excel as key members of these teams, providing their unique and valuable perspective regarding occupation, activity analysis, and client-centered care.
Resources to Support Knowledge Translation in Practice Settings
Professional organizations are a prime resource for practitioners to find the tools to communicate their distinct value and effectively translate evidence into practice. For instance, AOTA’s Evidence-Based Practice Department provides several easily accessible and understandable resources for AOTA members. A full list of resources can be found on AOTA’s website (https://www.aota.org/Practice/Researchers.aspx). Some of these resources include but are not limited to Critically Appraised Topics, the Evidence-Based Practice Resource Directory, the Journal Club Guide, AOTA’s Choosing Wisely® campaign, the KT Toolkit, Occupational Therapy Practice Guidelines, the American Journal of Occupational Therapy, and several peer association occupational therapy journals (Table 1).
Resources for Providing Value-Based Care and Translating Evidence Into Practice
Note. AOTA = American Occupational Therapy Association; AOTF = American Occupational Therapy Foundation; CMS = Centers for Medicare & Medicaid Services; KT = knowledge translation; OT = occupational therapy; PDSA = Plan-Do-Study-Act; QI = quality improvement.
Role in Monitoring Quality
It is of utmost importance that practitioners and administrators keep current on quality payment and reporting programs. Many of these programs track patient and system-level outcomes, and occupational therapy services can be vital to optimize outcomes, reduce admissions, and improve organizations’ quality reporting scores. AOTA Evaluation Checklists for the skilled nursing, home health, and Medicare Part B practice settings can complement facilities’ standard occupational therapy evaluation process and provide information about the CMS quality measures being tracked as a part of quality and payment programs. For instance, AOTA’s (2021d) Skilled Nursing Facility Evaluation Checklist alerts practitioners to several quality measures that affect value-based reimbursement. Examples of these quality measures include the percentage of residents experiencing one or more falls with major injury and new or worsened pressure ulcers. Occupational therapy practitioners are encouraged to collaborate with their administrators to determine how their facility can optimize these quality measures through the translation of evidence-based interventions and programs into practice.
Considerations for Researchers
Conceptually, the provision of EBP should lead to improved client outcomes. As defined by Sackett et al. (1996), the core components of EBP are client values, clinical expertise, and the best available evidence. The development and advancement of the latter component is primarily the responsibility of occupational therapy researchers and their investigative team members. The profession relies on these researchers to develop and test interventions and programs that are effective in promoting clients’ participation in meaningful daily occupations.
Translation of Evidence-Based Interventions
Although the body of intervention research in occupational therapy has grown dramatically over the past decade, much remains to be learned about the interventions and programs that consistently lead to improved client outcomes. Traditionally, intervention effectiveness has been established through the empirical testing of interventions in randomized controlled trials (RCTs; Deaton & Cartwright, 2018). However, prior work in the KT field has indicated that practitioners do not or are not able to implement these rigorously tested interventions under the same conditions in which the intervention was deemed effective (Piller et al., 2021; Wiltsey Stirman et al., 2019). Unfortunately, this mismatch between empirical evidence (e.g., RCTs) and clinical practice is all too common, suggesting the need for innovative research approaches that establish intervention effectiveness and the utility of these interventions in practice.
Implementation Research in Occupational Therapy
With the continued emergence of intervention research in occupational therapy and growing interest in expediting the use of effective interventions in practice, interventionists may find great benefit in collaborating with implementation scientists to examine the degree to which interventions and programs can be translated to occupational therapy care. Such collaborations may take form through hybrid effectiveness–implementation trials (Landes et al., 2019) in which data representing both client outcomes (e.g., pain, stress levels) and implementation outcomes (e.g., feasibility, appropriateness, acceptability) are collected and analyzed (Proctor et al., 2011). Rigorous research using these hybrid design approaches has great potential to build the occupational therapy field’s knowledge of effective interventions, and it also allows investigators to assess the barriers, facilitators, and strategies that may affect the real-world implementation of these interventions in occupational therapy settings (Curran et al., 2012).
Conclusion
In his 2007 Eleanor Clark Slagle Lecture, the late Jim Hinojosa stated, “We live in a time of hyperchange—rapid, dramatic, complex, and unpredictable change” (p. 629)—words that are as true today as they were then. The field of occupational therapy is challenged by continuously evolving health care models and payment structures; ever-expanding populations with diverse needs; and new issues, practice areas, and technologies (Tyminski et al., 2019). Nearly 15 yr ago, Dr. Hinojosa challenged the profession by asking what occupational therapy educators, practitioners, and researchers can do to shape the future of occupational therapy. Given shifts in payment models and the continual need to confirm occupational therapy’s value, all occupational therapy stakeholders must play an active role in optimizing the future of the profession. Educators must shape future practitioners by encouraging students to advocate for the critical importance of occupational therapy and by honing their skills in the application of EBP; practitioners must evaluate their own abilities and routinely identify strategies to translate the best available evidence into practice; and researchers must develop and test interventions that can be implemented in real-world settings to improve client outcomes. Collaboration across all three of these stakeholder groups will be imperative to further establish the profession’s value and the overall benefit of occupational therapy services to clients as well as payers.
Footnotes
Acknowledgments
The authors have no conflicts of interest to disclose.