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. Each article in this series summarizes the evidence from published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision-making. In this Evidence Connection article, we provide a case report of a caregiver of a patient who had experienced a stroke. The occupational therapy evaluation and intervention process is described.
This Evidence Connection article provides a case report for a caregiver of a patient who had experienced a stroke and describes the occupational therapy evaluation and intervention process.
Stroke is a leading cause of disability in adults and thus frequently requires family and friends to take on the role of caregiver (Tsao et al., 2023). These informal caregivers are ill-equipped to perform many of the daily living activities and medical tasks that may be necessary (Family Caregiver Alliance, 2006 ; Miller et al., 2010). The burden of caregiving often leads to poorer physical and emotional health for the caregiver (Family Caregiver Alliance, 2006; Loh et al., 2017). It may also be harmful to the care recipient who has had a stroke, resulting in a greater incidence of institutionalization, more frequent hospitalizations, and poorer outcomes overall (Bakas et al., 2014). Stroke rehabilitation guidelines and the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; American Occupational Therapy Association [AOTA], 2020) instruct occupational therapy practitioners to treat the caregiver not only as an essential part of the rehabilitation team but also as a client (Winstein et al., 2016).
This case study exemplifies the findings of our systematic review on the effectiveness of interventions that are within the scope of occupational therapy practice for caregivers of people who have had a stroke to facilitate maintaining the caregiver role (Mack & Hildebrand, 2023). In this case, we illustrate how to weave evidence-based interventions for the caregiver into the treatment of the person who has had a stroke in one setting in the stroke continuum of care: acute inpatient rehabilitation.
Case Study
Rachel (she/her), age 72, experienced a right middle cerebral artery stroke 6 days ago, resulting in left-sided weakness and sensory impairments. Her husband David, age 71, found her lying on the floor of their bathroom, confused, with left facial drooping and an inability to move her left upper extremity. He immediately called 911, and Rachel was transported via ambulance to a local acute care hospital, where she was medically stabilized and provided treatment. She was then transferred to an acute inpatient rehabilitation hospital.
Occupational Therapy Evaluation
Emilia (she/her), a staff occupational therapist at the acute inpatient rehabilitation hospital, completed a full initial evaluation with Rachel, including a brief occupational profile using AOTA’s (2022) Occupational Profile Template. As part of the occupational profile and analysis of occupational performance with Rachel, Emilia included David and asked him about his ability to physically assist Rachel and about his daily routines and roles at home.
Rachel and David have three adult children and six grandchildren. One daughter and her family live locally but are unable to provide much support given their family commitments. Rachel is a retired public librarian, and David is a retired accountant. They are involved in their local synagogue and enjoy spending time with their grandchildren and attending their sports games. On occasion, they help transport grandchildren to and from activities. While Rachel spends her free time at home, reading or gardening, David is often outside the home, having coffee with friends, exercising at the Jewish Community Center, or volunteering at a local food bank. David, notably, has a history of chronic back pain from an injury, although it is currently well controlled. Both Rachel and David value their independence and largely share household responsibilities.
Rachel and David live in an urban area on the ground floor of a multifamily home. There are three steps to enter the home, with bilateral railings. The primary bathroom is spacious but has a tub shower without grab bars. Given the home setup, David anticipates he will physically need to assist Rachel with entering and exiting the home and with showering.
The results of the analysis of occupational performance revealed that Rachel had weakness and decreased coordination on her left side, with her upper extremity more affected than her lower extremity. She had deficits in functional cognition, including safety and judgment deficits and impaired sequencing as well as minor impulsivity during functional mobility and toileting. There was evidence of mild left neglect affecting her functional abilities. She required maximum physical assistance for dressing, bathing, and toileting and minimum assistance for seated grooming. She also required moderate verbal cueing for safety, sequencing, and problem solving during functional tasks. Further assessment of her cognition was indicated, although she was oriented and able to follow multistep directions.
During Rachel’s evaluation, Emilia also had David complete the Preparedness for Caregiving Scale, a short, eight-item tool that examines how the caregiver rates their confidence in delivering care in different domains (Archbold et al., 1990; Zwicker, 2021). He scored a mean of 1.75, falling between “Not too well prepared” and “Not at all prepared.” Emilia noted that he felt least prepared to meet Rachel’s physical needs, to make caregiving activities pleasant, and to handle emergencies. When asked for further information, David stated that he was nervous about hurting his back and Rachel getting hurt during daily activities, in particular while showering. He stated they both wanted him to provide the majority of Rachel’s personal care, but he did not feel confident in his ability to do so at this time (Table 1).
Initial Evaluation: Caregiver Assessment Results
At the conclusion of the evaluation, Emilia asked both David and Rachel for their goals, and David identified three that were important to him: Rachel must be able to shower in the tub shower safely. They need to minimize the amount of outside help required. He wants Rachel to be able to stay at home while maintaining his own physical and emotional health.
Occupational Therapy Intervention
On the basis of the assessment findings from the Preparedness for Caregiving Scale, the occupational profile, and the goal-setting conversation, Emilia, Rachel, and David decided that it would be beneficial for David to learn skills to support Rachel in addition to interventions focused primarily on Rachel’s stroke recovery. David wanted to be able to remain in the position of caregiver for as long as needed. Emilia reviewed the evidence presented in the systematic review (Mack & Hildebrand, 2023) and found the following information: ▪ There is strong evidence for the use of problem-solving therapy, a cognitive–behavioral therapy technique, when combined with stroke education. ▪ There is strong evidence for one-on-one caregiver education and support interventions. ▪ Multimodal interventions (interventions with many different parts addressing different aspects of the caregiver and client experience) have moderate strength of evidence. ▪ Occupational therapy practitioners should provide a combination of interventions such as problem-solving techniques, customized support for each caregiver, and individualized education in the care of the stroke survivor.
There was a limited number of studies in the systematic review, and few described interventions in sufficient detail to adequately guide her; therefore, Emilia decided to also look for other sources, including the OTPF–4 and additional information on problem-solving therapy techniques (Dobson & Dozois, 2021; D’Zurilla & Nezu, 2006). The OTPF–4 provided information on the role of occupational therapy in facilitating work with caregivers and a framework for understanding how caregiving is a co-occupation between the caregiver and the recipient of care. Resources on cognitive–behavioral therapy and problem-solving therapy provided guidance and information on how to best use problem-solving therapy techniques.
With the information from the systematic review and other sources, her clinical expertise, and input from Rachel and David, Emilia developed a plan of care for addressing David’s goals in addition to goals focused primarily on Rachel’s function. During Rachel’s stay in inpatient rehabilitation, she participated in two daily 45-min occupational therapy sessions; David joined for three 45-min sessions/wk. For David, targeted outcomes in caregiving tasks included increased self-efficacy, independence, and safety in supporting Rachel during daily activities of daily living routines.
Intervention 1: Introduction to Problem-Solving Techniques
After the initial evaluation, Emilia introduced problem-solving techniques in a session with both Rachel and David. To ensure understanding and carryover, Emilia used a variety of educational methods: clear verbal instructions, written instruction via a worksheet, and links to related videos. Emilia also practiced the teach-back method to ensure their understanding.
Emilia introduced the following steps of ADAPT (D’Zurilla & Nezu, 2006), a problem-solving technique, during one of the first sessions: ▪ Attitude: Adopt a positive attitude to problem-solving ▪ Define: State what the problem is and discuss potential obstacles ▪ Alternatives: Identify a variety of alternative solutions to what has been tried ▪ Predict: Predict the success of each alternative, and choose the one most likely to succeed ▪ Try out: Try out the solution and decide whether it was successful or if the process must be repeated
Emilia billed for the session using the CPT® code 97129: Therapeutic interventions that focus on cognitive function and compensatory strategies to manage the performance of an activity. This portion of the intervention lasted <15 min, so an additional code was not needed.
Intervention 2: Implementation of Problem-Solving Techniques
During the next session, Emilia had David use the ADAPT problem-solving technique with Rachel during a challenging dressing task: donning socks and shoes. Emilia reviewed the ADAPT steps and supported David and Rachel with defining the problem, identifying alternative solutions, and predicting which solution would work best. While Emilia provided guidance to David, he collaborated with Rachel to predict that they could best don socks by assisting Rachel with crossing one leg over the other. David and Rachel together tried the solution and determined that it was successful.
They also tried donning shoes in the same manner but were unsuccessful on their first attempt. Emilia coached David and Rachel through the ADAPT steps again, and they identified a possible alternative method to donning shoes: loosening the laces as much as possible. On the second attempt, Rachel was able to don shoes with moderate assistance. During this activity, Rachel practiced and gained confidence in lower body dressing, and David used the ADAPT problem-solving technique to determine how to best support her. Emilia billed for the session using CPT code 97535: Self-care/home management training.
Emilia continued to implement the ADAPT problem-solving technique during each daily occupational therapy session. She introduced increasingly difficult tasks, starting with seated and less complex tasks (e.g., brushing teeth) and progressing to more complex tasks, including tub shower transfers and bathing.
Intervention 3: Stroke Education
During the initial assessment, Emilia noted that both David and Rachel had limited knowledge about the cause of stroke or the functional implications. Emilia gave them handouts and resources from the American Stroke Association (n.d.) to provide appropriate and timely education to David as Rachel’s rehabilitation stay progressed. Because David participated in rehabilitation sessions 3×/wk, Emilia provided education throughout Rachel’s stay instead of in only one session before her discharge. They also discussed functional implications of the stroke as problems arose naturally during functional activities. For example, Emilia educated David about functional cognition deficits and appropriate cueing strategies to support sequencing during a meal planning task that Rachel was completing (CPT codes 97129 and 97130: Therapeutic interventions that focus on cognitive function and Compensatory strategies to manage the performance of an activity, respectively).
Emilia used a variety of educational methods, including verbal education, printed handouts, and links to educational videos. The rehabilitation department at the hospital had these resources readily available for use with stroke survivors and caregivers. However, to ensure individualized support she provided only relevant materials to the family.
Intervention 4: Connection With Interdisciplinary and Community Supports
From her review of the evidence, Emilia knew that, to better meet David’s goals, there must be customized (and ideally one-on-one) long-term education and support available. Because time spent exclusively with David would not be reimbursed, she partnered with other members of the interdisciplinary team in the rehabilitation hospital to ensure adequate support. In this case, she connected with the facility’s social worker, chaplain, and case manager. During interdisciplinary rounds, Emilia communicated her plan of care with the team, including the use of problem-solving techniques with David to promote a successful discharge for Rachel and well-being for himself.
The social worker scheduled sessions with Rachel and David to provide counseling and reinforce the problem-solving therapy techniques Emilia had introduced and connected David with a social worker in the community to provide continued counseling after discharge. The case manager consulted with Emilia to develop a list of resources for David about respite options, support groups, and equipment-lending closets. The chaplain provided spiritual guidance to David through supportive listening and prayer.
Occupational Therapy Outcomes
Rachel was discharged to home with David as her primary caregiver after 13 days in the acute inpatient rehabilitation facility. Given the short timeframe, Emilia knew that ongoing support and education would be essential for David and Rachel’s continued success. Therefore, before Rachel was discharged, she did the following: ▪ documented clearly in the discharge paperwork the ongoing involvement of David as caregiver and the use of the ADAPT problem-solving technique; ▪ consulted with the interdisciplinary team to ensure that community resources were in place for ongoing education and support of both Rachel and David, including appropriate occupational therapy home care services; ▪ provided David with two summary sheets of the techniques used during their time together, including information on the ADAPT problem-solving technique, and instructed David to share this information with the occupational therapist who would be providing home care; ▪ provided contact information in the discharge paperwork to allow for a “warm hand-off” if the home care therapist wanted further information; and ▪ had David complete the Preparedness for Caregiving Scale (Table 2).
Discharge: Caregiver Assessment Results
Note. ADAPT = Attitude, Define, Alternatives, Predict, Try Out.
Applying the Evidence to Your Own Practice
Occupational therapy practitioners have the opportunity and obligation to work toward increased participation in meaningful occupations and improved quality of life not only for the person with stroke but also for the caregiver. Caregivers benefit from personalized, multifaceted interventions that can be incorporated into existing models of care for the person with stroke in all care settings, in particular in those that are postacute. Incorporating caregivers into multiple treatment sessions and providing training in problem-solving techniques prepares them to successfully analyze and meet future challenges when the patient is no longer receiving therapy. Appropriate and timely information on the effects of stroke, along with education and training on rehabilitation techniques, will meet the caregivers’ needs both in the moment and in the future. Finally, ensuring follow-up with counseling, a support group, and other community resources is essential for maintaining the well-being of the caregiver. These evidence-based interventions will facilitate caregivers’ ability to flourish in that role long after the occupational therapy services have ended and ensure better outcomes for the patient who has had a stroke.