Abstract
This is the first study to examine potential disparities in access to outpatient occupational therapy services among Veterans recently discharged from Veterans Health Administration inpatient psychiatric care.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA; 2012), recovery-oriented psychiatric care shifts the focus away from symptom management, emphasizing instead the support of recipients “in a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (p. 3). As the largest integrated mental health care system in the United States, the Veterans Health Administration (VHA) has embraced the tenets of recovery-oriented services across the continuum of care (National Academies of Sciences, Engineering, and Medicine, 2018). With respect to the acute setting, the VHA strives to deliver recovery-oriented inpatient psychiatric care by working with hospitalized Veterans to stabilize symptoms and facilitate a transition to the independent performance of valued activities upon discharge, thereby aligning with a major dimension of recovery-oriented services: supporting a self- directed and purposeful life through engagement in meaningful activity (SAMHSA, 2012; U.S. Department of Veterans Affairs, 2013). Unfortunately, Veterans who are hospitalized for psychiatric conditions are at risk for limited engagement in meaningful activity (e.g., community-based activities) after discharge (Chen et al., 2022).
Occupational therapy practitioners are uniquely equipped to promote participation in self-directed and meaningful activity and are therefore integral to the delivery of recovery-oriented services to Veterans after they are discharged from inpatient psychiatric care (American Occupational Therapy Association, 2017; Synovec, 2015). Occupational therapy practitioners are skilled at collaborating with clients to select personally meaningful and health-promoting activities and at systematically addressing barriers to successful performance (Eakman, 2014). Indeed, community-based occupational therapy interventions have been shown to improve engagement in a variety of activities among persons with mental health conditions, including activities of daily living (ADLs; e.g., bathing), instrumental activities of daily living (e.g., financial management), social activities, and others (e.g., employment; leisure; D’Amico et al., 2018; Ikiugu et al., 2017; Noyes et al., 2018). Therefore, it is critical that outpatient occupational therapy services are equitably distributed to Veterans upon discharge from a psychiatric hospitalization.
Equitable access occurs when patient need (e.g., occupational performance challenges) dictates receipt of services (e.g., occupational therapy). Potential disparities in access occur when factors unrelated to clinical need drive utilization, such as patient-level (e.g., sociodemographic characteristics) or organization-level forces (e.g., facility resources; Anderson et al., 2014). Prior research indicates that among Veterans receiving inpatient psychiatric care, sociodemographic characteristics (e.g., Black race) and facility-level factors (e.g., measures of care quality) are associated with reduced access to occupational therapy services (Kinney et al., 2024b). With respect to the outpatient VHA setting, among Veterans with a history of traumatic brain injury (TBI), those who receive care at facilities with fewer resources are more likely to have an unmet need for occupational therapy (Kinney et al., 2023). However, little is known regarding whether outpatient occupational therapy services are equitably distributed to Veterans upon discharge from inpatient psychiatric care in the VHA. Investigating the potential presence of such disparities is the first step in the development of strategies aimed at promoting equitable access to these beneficial services among Veterans in need.
This study had three main objectives. First, we investigated whether a direct measure of occupational therapy need—ADL limitations—was associated with outpatient occupational therapy utilization among Veterans recently discharged from VHA inpatient psychiatric care. Second, we examined whether patient-level (e.g., sociodemographic factors) and facility-level characteristics (e.g., facility complexity) were associated with outpatient occupational therapy utilization after adjusting for ADL limitations, indicating potential disparities in access to these beneficial services. Last, we examined whether the relationship between ADL limitations and outpatient occupational therapy utilization differed according to facility-level characteristics.
Method
Participants and Procedures
This study consisted of a secondary analysis of administrative data for Veterans admitted to a VHA inpatient psychiatric unit between January 1, 2015, and January 1, 2020. Data were gathered from the Veterans Affairs Corporate Data Warehouse (CDW), which stores VHA electronic medical records data. Study procedures have been described in detail elsewhere (Kinney et al., 2024b). This study was approved by local regulatory bodies.
Inclusion criteria for this analysis included (1) admission to a VHA inpatient psychiatric unit with occupational therapy services available, (2) documented ADL performance, (3) discharge to a home- or community-based setting, and (4) survival at least 90 days after discharge. For Veterans with multiple admissions during the study’s time frame, the first hospital stay was analyzed. Among the 118,974 Veterans who met inclusion criteria, 1,295 (1.1%) were removed because of missing predictors, leaving 117,679 eligible for analyses. See Figure 1 for details regarding the application of inclusion criteria.
Detailed summary of the application of inclusion criteria.
Measures
ADL Status
To measure ADL performance, we leveraged our validated algorithm by which ADL information (independent vs. limited) is extracted from unstructured narrative portions of inpatient psychiatric nursing assessments documented within 24 hr of admission (Kinney et al., 2024b). Nursing assessments during this time frame were targeted because it represents a window during which ADL limitations are more frequently documented given that the information is used to inform care planning. Eligible ADLs consisted of bathing or showering, dressing, personal hygiene and grooming (e.g., brushing teeth), toileting, and feeding. Limitations in ADLs was defined as requiring physical assistance, supervision, or setup from another person to complete one or more activities. When validated against manual chart reviews, the algorithm identifies ADL limitations with .93 sensitivity (95% confidence interval [CI] [.90, .96]) and .91 specificity (95% CI [.89, .94]).
Outpatient Occupational Therapy Utilization
Outpatient occupational therapy utilization (yes vs. no) was defined as at least one of the following conditions within 90 days after discharge from the inpatient psychiatric hospitalization, associated with outpatient care records: (1) occupational therapy–specific Current Procedural Terminology ® (CPT ®) codes 1 (97003, 97165, 97166, 97167, 97004, 97168), (2) an occupational therapy–specific 500 series Decision Support System Identifier in the primary or secondary position (U.S. Department of Veterans Affairs, 2000), and (3) provider information reflecting an occupational therapy practitioner. Consistent with prior studies that have measured outpatient occupational therapy utilization in the VHA, these particular CPT codes were selected because they are unique to occupational therapy, whereas other CPT codes (e.g., therapeutic exercise) are eligible for utilization by other rehabilitation disciplines, and therefore their inclusion would introduce potential measurement bias (Kinney et al., 2023). Decision Support System Identifier codes are used to track workload and productivity for specific clinical services in the VHA. This method was inclusive of occupational therapy services delivered in person and virtually.
Facility Characteristics
We obtained the following characteristics of facilities to which each Veteran had been admitted: facility complexity, psychiatric bed supply, and psychiatric care quality. These characteristics corresponded to facility conditions at the time of admission. Facility complexity (low, medium, high) is a composite index reflecting factors such as patient mix (e.g., clinical risk) and diversity of services provided (Veterans Health Administration Office of Productivity and Staffing, 2020). Psychiatric bed supply was defined as the number of operational inpatient psychiatric beds at the time of admission. Tertile values for the distribution of bed supply were used to identify a low, moderate, or high bed supply. Psychiatric care quality was measured using the Hospital Based Inpatient Psychiatric Services indicator, a VHA composite measure of two rates calculated from the proportion of Veterans who were (1) screened with respect to risk to self or others, substance use disorder, trauma, and, strengths, and (2) discharged with two or more antipsychotic drugs using appropriate justification (Joint Commission, 2016). Tertile values were used to identify low, moderate, and high care quality.
Sociodemographic Characteristics
The following sociodemographic characteristics were abstracted from the CDW for each Veteran at the time of admission: age (years), sex assigned in the medical record (male or female), race/ethnicity (White, non-Hispanic; Black, non-Hispanic; American Indian/Alaskan Native, non-Hispanic; Asian American, non-Hispanic; Native Hawaiian/Pacific Islander, non-Hispanic; Hispanic; unknown), and marital status (married or unmarried).
Clinical Characteristics
Data regarding primary diagnosis, history of TBI, comorbidity burden, and length of stay were gathered from the CDW. Primary diagnosis was the diagnosis documented as the reason for admission, identified using codes from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD–9–CM; World Health Organization, 1979), and the ICD, 10th Edition (ICD–10; World Health Organization, 2015; major depressive disorder, posttraumatic stress disorder, alcohol use disorder, schizophrenia or schizoaffective disorder, bipolar disorder, other substance use disorder, other disorder). History of TBI (no vs. yes) was identified by ICD–9–CM or ICD–10 codes indicating a TBI documented at any time prior to admission (Adams et al., 2022). Comorbidity burden was measured using the Charlson Comorbidity Index and was calculated on the basis of data gathered the year before admission (Quan et al., 2005). Inpatient psychiatric occupational therapy utilization (yes or no) was defined using criteria identical to those used to detect outpatient occupational therapy utilization but corresponded to inpatient psychiatric encounters. Length of stay was the total number of days spent on the inpatient psychiatric unit.
Data Analysis
A descriptive analysis of the total sample was conducted and stratified by outpatient occupational therapy utilization. To examine whether ADL status or sociodemographic characteristics were associated with outpatient occupational therapy utilization after discharge, we used modified Poisson regression to model outpatient occupational therapy utilization (yes vs. no) as a function of ADL status, facility characteristics, sociodemographic characteristics, and clinical characteristics (Zou, 2004). We used a clustered sandwich estimator to account for clustering of Veterans within VHA facilities (Zeileis et al., 2019). To investigate whether the relationship between ADL status and occupational therapy utilization differed across facility characteristics, we tested statistical interactions between ADL status and each facility characteristic separately. We visually probed statistically significant interactions. R (Version 4.3.1) was used to conduct all analyses (R Core Team, 2023). Statistical significance was evaluated at α = .05.
Results
Most Veterans were White, non-Hispanic (60%), and 88% were male. The most common reason for admission was major depressive disorder (26%). Thirteen percent received outpatient occupational therapy within 90 days of discharge from inpatient psychiatric care. Approximately 8% had a documented ADL limitation; a similar proportion of Veterans with limitations was observed among those who received outpatient occupational therapy (9%) and among those who did not (7%; Table 1).
Characteristics of Veterans Receiving Inpatient Psychiatric Care (N = 117,679)
Note. Percentages are based on the column sample size. ADL = activities of daily living; OT = occupational therapy; PTSD = posttraumatic stress disorder; ref. = reference category; TBI = traumatic brain injury.
Model Explaining Occupational Therapy Utilization Without Interactions
There was no statistical evidence that Veterans with ADL limitations were more likely to receive outpatient occupational therapy within 90 days of discharge from inpatient psychiatric care. With respect to facility characteristics, Veterans who received care at facilities of higher complexity (medium and high vs. low complexity) were less likely to receive outpatient occupational therapy. Conversely, Veterans who received care at facilities with higher inpatient psychiatric care quality (moderate and high vs. low) and a moderate (vs. low) bed supply were more likely to receive outpatient occupational therapy.
With respect to sociodemographic characteristics, Black and Hispanic Veterans (vs. White, non-Hispanic) were less likely to receive outpatient occupational therapy services. Married Veterans were also less likely to receive such services. Female Veterans were more likely to receive outpatient occupational therapy compared with male Veterans, and older age was similarly associated with an increased likelihood of service utilization.
Clinical characteristics associated with an increased likelihood of outpatient occupational therapy utilization included a primary diagnosis of alcohol use disorder or other substance use disorder (vs. major depressive disorder), a history of TBI, greater comorbidity burden, receipt of inpatient psychiatric occupational therapy; and shorter length of stay (Table 2).
Parameter Estimates for the Model Explaining Occupational Therapy Utilization Without Statistical Interactions (N = 117,679)
Note. ADL = activities of daily living; 95% CI = 95% confidence interval for risk ratio (RR); OT = occupational therapy; PTSD = posttraumatic stress disorder; ref. = reference category; TBI = traumatic brain injury.
Models That Included Interactions Between ADL Status and Facility Characteristics
The interactions between ADL status and both facility complexity and bed supply were not statistically significant (p > .05). We observed a statistically significant interaction between ADL status and inpatient psychiatric care quality. The relationship between ADL status and outpatient occupational therapy utilization tended to be weaker among Veterans who received care in facilities with moderate care quality (risk ratio [RR] = 0.86, 95% CI [0.751, 0.991], p = .037) and high care quality (RR = 0.87, 95% CI [0.757, 0.999], p = .049) relative to Veterans who received care in facilities with low care quality. Figure 2 illustrates that in facilities with low care quality, those with ADL limitations were more likely to access outpatient occupational therapy. This was not evident in facilities with moderate to high care quality.
Predicted probability of outpatient occupational therapy utilization versus inpatient psychiatric care quality by ADL status.
Discussion
This is the first study to investigate potential disparities in access to outpatient occupational therapy services after discharge from VHA inpatient psychiatric care. Our findings suggest a potentially unmet need for these beneficial services in this population. First, only 13% received outpatient occupational therapy within 90 days of discharge. Second, ADL limitations, a potential indicator of need for occupational therapy services, was not associated with utilization of outpatient occupational therapy. Last, nonclinical factors, such as racial/ethnic identity and facility characteristics (e.g., measured care quality), were associated with access to occupational therapy, suggesting potentially disparate access to these beneficial services. This study lays the foundation for scientific, clinical, and policy efforts aimed at promoting equitable access to outpatient occupational therapy services among Veterans in need, ensuring successful occupational performance and overall well-being among all members of this high-risk population.
Only 13% of our sample received outpatient occupational therapy within 90 days of discharge from inpatient psychiatric care. This proportion is relatively low compared with observed rates of inpatient occupational therapy utilization among Veterans with psychiatric conditions (25%), as well as outpatient occupational therapy services among Veterans with TBI (24%; Kinney et al., 2023, 2024b). Although the specific reasons for relatively low utilization of outpatient occupational therapy services after discharge from a psychiatric hospitalization are unclear, it may reflect a disproportionate focus on connecting Veterans with mental health services. To be clear, access to mental health services after discharge is critically important; such treatment aligns with the preferences of recently hospitalized Veterans and has been linked to reduced risk for psychiatric readmission (Kim et al., 2011; Pfeiffer et al., 2016). Nonetheless, as the VHA continues to strive for consistent delivery of recovery-oriented psychiatric services, occupational therapy should more frequently be considered as a part of necessary care to facilitate the transition from inpatient psychiatric care to the community. Evidence suggests that during this transition, Veterans experience a high risk for psychiatric readmission and suicide-related outcomes; Veterans with activity limitations are at particular risk for such adverse outcomes (Kinney, Stephenson, et al., 2022; Kinney et al., 2024a, Kinney, Reis et al., 2025; Valenstein et al., 2009). Given occupational therapy practitioners’ specialized expertise in promoting engagement in meaningful and health-promoting activity, occupational therapy services may help promote recovery and prevent such adverse outcomes upon discharge (American Occupational Therapy Association, 2017). Thus, modifiable barriers to incorporating outpatient occupational therapy services into transitional services for Veterans receiving inpatient psychiatric care should be clarified and targeted by scientific and policy efforts (e.g., testing the effect of implementation strategies; Powell et al., 2015).
ADL limitations, an indicator of need for occupational therapy services, were not associated with outpatient occupational therapy utilization upon discharge. This finding stands in contrast to those of other studies in both inpatient (Kinney, Graham, et al., 2022; Kinney et al., 2024b) and outpatient settings (Kinney et al., 2023), which indicated the tendency for occupational therapy services to be allocated to Veterans in need (i.e., those with activity limitations). On the one hand, this finding may indicate an unmet need for outpatient occupational therapy in this population, a claim substantiated by the relatively low utilization of these services discussed in detail earlier. On the other hand, this finding may be explained by important methodological limitations that warrant discussion. First, data regarding ADL performance were gathered at admission and thus may not reflect Veterans’ functional status at discharge, the point at which referral decisions for outpatient occupational therapy services presumably occurs. Second, ADL limitations are a narrow indicator of need for outpatient occupational therapy services. Although VHA providers and administrators consider ADLs a critical target of occupational therapy services among Veterans with psychiatric conditions, they perceive ADL limitations as insufficient to encompass the breadth of the occupational therapy scope of practice in this setting (e.g., personally meaningful activity; Kinney et al., 2025). As such, future research should examine access to outpatient occupational therapy services using indicators of need that more comprehensively depict treatment targets in this population (e.g., social activities).
Veterans who identified as Black and Hispanic were less likely to receive outpatient occupational therapy services relative to White, non-Hispanic Veterans. Evidence regarding racial/ethnic disparities in access to occupational therapy services in the VHA has been mixed. Our findings are consistent with those of previous research suggesting that Black Veterans are less likely to receive inpatient psychiatric occupational therapy services relative to their White counterparts, but they contradict the results of a study of outpatient occupational therapy utilization among Veterans with TBI that revealed no association with racial/ethnic identity (Kinney et al., 2023, 2024b). The discrepancy of our findings relative to Kinney et al.’s (2023) study of Veterans with TBI may be due to the fact that Kinney et al. (2023) focused on the VHA’s Polytrauma/TBI System of Care (PSC), a national network of integrated, interdisciplinary teams with expertise in TBI rehabilitation, versus inpatient mental health services. These care settings differ in a number of important ways, with potential implications for occupational therapy access. For example, the tightly woven interdisciplinary teams comprising the PSC, whose work with Veterans and their family may extend over weeks and months, may facilitate enhanced communication about the need for outpatient occupational therapy, thereby leading occupational therapy utilization to be driven more by clinical need than by nonclinical factors, such as race/ethnicity.
The present study is the first to document a potential racial/ethnic disparity in access to outpatient occupational therapy services among Veterans who were recently hospitalized for psychiatric reasons. The accurate measurement of clinical need is requisite for investigations of inequitable access to health care; given the aforementioned limitations of using ADL performance to identify need for occupational therapy in this setting, future research should attempt to replicate our findings using other measures of activity performance that are more proximal to discharge (Anderson et al., 2014). Should the findings be replicated, future research should aim to determine the specific mechanisms by which these potential disparities occur. Given documented disparities in mental health outcomes among Veterans in underrepresented racial/ethnic groups, efforts aimed at promoting equitable access to occupational therapy and other mental health services may be indicated (Merians et al., 2023).
Veterans who were discharged from facilities that had higher inpatient psychiatric care quality were more likely to receive outpatient occupational therapy. Moreover, statistical interactions indicated that ADL limitations were a weaker driver of access to occupational therapy services among those who received care in facilities with higher care quality, suggesting that the perceptions of the need for occupational therapy may differ in such facilities. Our findings are consistent with those of prior research indicating that Veterans who receive care at facilities with higher care quality are more likely to receive occupational therapy in the inpatient psychiatric setting (Kinney et al., 2024b). The present study extends this finding by revealing that care quality similarly shapes access to services after discharge. VHA providers and administrators have suggested that higher performance on indicators of inpatient psychiatric care quality reflects a shared commitment to evidence-based and interdisciplinary psychiatric care (Kinney et al., 2025). Such a shared commitment may lead to increased awareness of the distinct value of occupational therapy within interdisciplinary mental health teams, thereby increasing rates of referrals to outpatient services upon discharge. Strategies aimed at promoting a shared commitment to psychiatric care that values the distinct contribution of occupational therapy practitioners (e.g., identifying and preparing champions) may help increase access to outpatient occupational therapy services among Veterans in need (Powell et al., 2015; Shea, 2021).
Study Limitations
To measure ADL performance, we used a validated algorithm to extract unstructured data regarding performance from nursing assessments, but we were unable to account for the reliability with which performance was evaluated. In addition, as previously mentioned, ADL performance at the time of inpatient psychiatric admission has limitations as an indicator of the need for outpatient occupational therapy services, including the fact that it represents only a narrow conceptualization of treatment targets. Future research should attempt to replicate this study’s findings using standardized assessments of occupational performance at inpatient psychiatric discharge to reflect the potential need for outpatient occupational therapy services. We were unable to measure occupational therapy encounters that were primarily focused on mental health–related barriers to occupational performance. Although focusing on a sample of Veterans who were recently hospitalized for psychiatric conditions increases the likelihood that post-discharge occupational therapy services had a mental health focus, it is possible that our study overestimated mental health– specific occupational therapy utilization. Last, we were unable to identify occupational therapy visits delivered to eligible Veterans outside the VHA system; future research should leverage community care claims to achieve a more comprehensive depiction of occupational therapy utilization in this population.
Implications for Occupational Therapy Practice
Our findings have the following implications for occupational therapy practice: ▪ Outpatient occupational therapy utilization after discharge from VHA inpatient psychiatric care is relatively low and may be driven in part by nonclinical factors (e.g., race/ethnicity, facility characteristics); therefore, researchers, practitioners, and policymakers must be aware of potential disparities in access. ▪ Our findings lay the foundation for future research aimed at understanding modifiable factors that shape access to outpatient occupational therapy in this setting, thereby informing practice and policy efforts that promote equitable access to these beneficial services.
Conclusions
Before the present study, little was known about potential disparities in access to post-discharge outpatient occupational therapy services among Veterans hospitalized for psychiatric conditions. We found that access to outpatient occupational therapy was relatively low in this population and that nonclinical factors (e.g., race/ethnicity) were associated with occupational therapy service utilization. Our findings suggest a potentially unmet need for these beneficial services in this high-risk population and can inform scientific, clinical, and policy efforts aimed at promoting equitable access to outpatient occupational therapy services among Veterans in need.
Footnotes
1 CPT ® is a registered trademark of the American Medical Association. All rights reserved.
Acknowledgments
This work was supported by a Health Services Research Grant to Adam R. Kinney from the American Occupational Therapy Foundation. Jeri E. Forster reports grants from the U.S. Department of Veterans Affairs (VA), the U.S. Department of Defense (DoD), the National Institutes of Health (NIH), and the State of Colorado. Lisa A. Brenner reports grants from the VA, DoD, NIH, and the State of Colorado; editorial remuneration from Wolters Kluwer and the Rand Corporation; and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her affiliation with the University of Colorado. This work does not necessarily represent the views of the VA or of the U.S. government.