The global trend towards preventative care creates an opportunity for occupational therapy (OT) to integrate into interprofessional primary care teams. Barriers to integrating OT practitioners into primary care include limited stakeholder buy-in, the lack of established administrative and billing procedures for OT services in this setting, and limited clinical precedence. This document serves to facilitate overcoming these barriers by presenting citations and annotations on the most relevant literature, grouped into three main categories, which are further divided into sections and subsections.

Category One addresses stakeholder buy-in by supporting readers’ general knowledge of primary care OT with the Role and Value section, and communication skills to share that knowledge with the Being an Advocate section. The Role and Value section consists of documents outlining the fit between OT and primary care practice, and the benefit that including OT on an interprofessional primary care team can bring. The following section, Being an Advocate, supports readers in communicating with stakeholders and being leaders in this emerging practice area.

Category Two addresses administrative barriers by educating the reader on the external legislative influences in the Healthcare Policy section, presenting options for primary care OT delivery and how to get one's foot in the door in Integration Strategies, and finally presenting the Cost-Efficacy of primary care OT. Understanding national and state Healthcare Policy is essential in realizing the specific immutable opportunities and barriers, and also opportunities for continued legislative advocacy. Integration Strategies is an overview of the various angles through which an OT practitioner could initiate involvement in primary care settings. Finally, an important administrative consideration is the funding of any OT service provided in primary care. The Cost-Efficacy section of this document arms readers with clear data that supports the integration of OT from a fiscal perspective.

Category Three is intended to support provision of OT services, from an individual perspective, both administratively and clincialy. The sections include General Practice literature on the role and scope of a primary care OT and assessment tools, and is followed by multiple sections of specific conditions that a primary care OT is likely to address in primary care settings, including research into the clinical efficacy of interventions.

This document is searchable via the Table of Contents. Find the category, section, subsection, or article of interest, and click on it to be taken to that part of the document, where the full citation and a summary are available.

Acronyms Key:
ACA….. ADL…... ACO…... AOTA… CBT…... CDC…... CCO…... CMS…... EMR….. IADL…. MI…….. OT…….. PCP…… PCMH… PT…….. QOL…... RTC….... WHO….	Affordable Care Act Activities of Daily Living Accountable Care Organization American Occupational Therapy Association Cognitive Behavioral Therapy Centers for Disease Control and Prevention Coordinated Care Organization Centers for Medicare & Medicaid Services Electronic Medical Record Instrumental Activities of Daily Living Motivational Interviewing Occupational Therapy/Occupational Therapy Practitioner Primary Care Provider (includes MD, DO, PA, NP) Patient Centered Medical Home Physical Therapy/Physical Therapy Practitioner Quality of Life Randomized Control Trial World Health Organization

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Category One

Role and Value

AOTA. (n.d.). Primary care.

Retrieved from https://www.aota.org/practice/manage/primary-care.aspx

AOTA website of current primary care resources, including articles and updates on the primary care and OT movement.

AOTA. (2013, Dec 24). AOTA engaged in ongoing effort to promote role of OT in primary care.

News from AOTA. Retrieved from https://www.aota.org/Publications-News/AOTANews/2013/Primary-Care-Promote.aspx

This website news post describes the commissioned Environmental Scan: Review of New Models of Primary Care Delivery, the AOTA Forum on Interprofessional Team-Based Care, and Action Items to follow up on
- Environmental Scan: Review of New Models of Primary Care Delivery
  - AOTA (2013). Review of New Models of Primary Care Delivery. Retrieved from https://www.aota.org/~/media/Corporate/Files/Secure/Advocacy/Health-Care-Reform/commissioned-report.PDF
  - Environmental scan of current conditions, trends and challenges within the changes, including the potential for OT involvement
  - Top illness-related diagnoses reported for outpatient:
    - Hypertension, acute upper respiratory infections, diabetes, hyperlipidemia, arthritis, depression
    - 50% of visits are from patients with one or more chronic condition
  - History
    - Health Maintenance Organizations (HMO) were developed in early 70s: prepaid health plans that enroll members and arranged for their care from a designated provider network.
      - Capitation is a form of managed care
      - Intended to create new incentives for primary care by increasing income, status and reputation of PCPs, as well as promote comprehensive and cost-effective care.
        However, it was difficult for PCPs to manage care under capitation financing
        
        Most HMOs and preferred provider organizations (PPOs) paid PCPs discounted fee-for-service, not capitated rates.
        Care didn’t improve. This resulted in for-profit care and other unprogressive practices
  - Currently
    - Triple Aim
      - Improve health through evidence-based interventions to address behavioral, social, and environmental determinants of health
      - Deliver higher quality care
      - Deliver affordable care
    - ACOs
      - New payment mechanism to increase provider collaboration, save money by avoiding unnecessary tests and procedures
      - A group of providers voluntarily come together to be held jointly accountable for the health of a defined population of Medicare beneficiaries. If the care is high quality and low cost, they keep the surplus funding
      - Emphasis on primary care, integration and coordination of care across providers, reducing duplication of services, preventing medical errors and managing chronic diseases.
      - The increased accountability for the health of a population has inspired most ACOs to base their model on the PCMH
    - Patient Centered Medical Home (PCMH)
      - Model of care delivery focusing on population health, coordination of care, performance measurement to drive quality improvement, incentives in the care delivery system, and patient engagement to support self-management of care.
        Information systems, EMRs, that enable quality monitoring
        Systematic preventative services
        
        Utilization monitoring
        
        Population health tracking
        
        Team-based care for whole person and community. Focus on outcomes, access to care, appropriate reimbursement.
        Continuous, accessible, high-quality, patient-oriented care
        
        Alternative scheduling, such as same-day
    - In addition to PCMHs and ACOs, the ACA changes also call for the integration of primary and behavioral care, increased home and community based services, and new delivery sites, such as retail clinics.
      - The Center for Integrated Health Solutions (CIHS) promotes the integration of behavioral and primary care.
        CIHS is a partnership between the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA, a branch of the US Department of Health and Human Services)
- AOTA Forum on Interprofessional Team-Based Care
  - Forum in June 2013 on assessing how OT can be involved in primary care, described in two summary documents, one by Ted McKenna, and one is the official AOTA summary
  - McKenna, T. (2013, Jun 26). AOTA forum on on interprofessional team-based care: Identifying new roles for OT in primary care [News]. Retrieved from https://www.aota.org/Advocacy-Policy/Health-Care-Reform/News/2013/PrimaryCareForum.aspx
    - Describes the interprofessional nature and structure of the forum
    - Key factors influencing healthcare changes:
      - Aging population, rapid rise of chronic conditions such as diabetes, technology for service delivery such as telehealth, patients’ gaining health literacy as a priority for self-management of health, competitions between health professionals for space on primary care teams, growing demand for research related to the efficacy of the various primary care team providers.
    - Barriers for integrating OT
      - Generalist education, outcomes-based research, complex and changing reimbursement systems, difficulty in articulating and promoting the value of OT to all stakeholders
  - AOTA (2013). AOTA forum on interprofessional team-based care. Retrieved from https://www.aota.org/~/media/Corporate/Files/Secure/Advocacy/Health-Care-Reform/forum-report.PDF
    - Goal: create a better understanding of the present and future state of interprofessional team-based care, and what OT can do on those teams
    - Current environment:
      - High cost of care, aging population, growth of chronic conditions, inadequate access to care, fragmented structure for delivering and paying for care, lack of coordination of care between settings, issues with quality of care particularly with chronic conditions and continuity of care, poor reimbursement, physician dissatisfaction, high workload, workforce shortages, and burnout of PCPs
      - The Triple Aim guides the changes to create solutions to the above issues
        Solutions include: ACOs, PCMHs, team-based care, integrated behavioral health, increased home and community services, care for dual-eligibles (Medicare and Medicaid), new delivery models such as retail sites.
    - Potential roles for OTs:
      - Prevention/wellness, pre-birth, healthcare navigation, transition and adaptation, patient activation and self-management, lifestyle changes, cognitive and neurosensory issues, team management, therapeutic groups
      - Start with chronic conditions, work on self-management, and the aging population
      - Capitated funding models may be the best payment arrangement for OTs on interprofessional teams
    - Barriers:
      - Articulating and demonstrating the value of OT, using evidence in practice, clear delineation of scope of practice, reimbursement, referral chain, how to measure quality of OT services, standardized assessments, creating research on efficacy of OT in primary care, staying informed of primary care delivery systems
    - Next steps:
      - Define what an OT will do in primary care
        Requires understanding of scope of practice, primary care patient populations, evidence-based interventions, knowledge of billing practices, evidence of cost-efficacy, systems to track efficacy, expense, and cost savings
      - Marketing materials
        Targeted to a variety of stakeholders. Should include case examples of how OT helps the team, the conditions that OT will see the most, and that OT has its roots in primary care.
      - Educate OTs to meet the needs of primary care
      - Support outcomes research on OT involvement in primary care
        First case studies, to inform the directions of future bigger studies.
        
        Funding for research can come from the Patient Centered Outcomes Research Institute and AOTF
        
        Research should align with the Centennial Vision of AOTA, the Healthy People 2020, the Triple Aim, CMS Innovation projects, Institute of Medicine recommendations for primary care and team-based care, etc.
        
        Measurement can include patient no-show rate, FIM scores, patient satisfaction, QOL, community engagement, National Outcome Measurement System.
      - Increase advocacy on reimbursement and other issues
        OT scope of practice and licensure varies by state, and so do the specifics of primary care.
- Action Items
  - Retrieved from: https://www.aota.org/~/media/Corporate/Files/Advocacy/Health-Care-Reform/action-items.PDF?la=en
  - To-do list based on the Review of New Models of Primary Care Delivery, and AOTA’s Forum on Interprofessional Team-Based Care
    - Find out how OT working in primary care help their team
    - Gather existing research on OT in primary care, and explore new opportunities for research and publication
    - Pull a list of experts who spoke at the AOTA conference about primary care
    - Ask the Representative Assembly Coordinating Committee to create official documents on the role of OT in primary care
    - Stay abreast of the changes happening in primary care, and build relationships with PCPs and other stakeholders
    - Spread the word about the distinct value of OT
    - Get OT education programs on board, develop more continuing education on primary care
    - Possibly develop a Special Interests Section on primary care

AOTA. (2014a). The occupational therapy practice framework: Domain and process.

American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. doi:10.5014/ajot.2014.682006

The essential document defining the domain and scope of OT practice
- Includes prevention and health promotion in the scope of OT practice
  - “Create/promote” (health promotion) approach, designed to enhance strengths and performance for everyone within authentic contexts
  - “Prevent” (disability prevention) approach designed to prevent barriers to performance through focus on contextual supports and challenges, activity demands, or client needs regardless of their state of health or disability
- OTs can recognize and address the impact of habits and routines on the management of chronic conditions and the development of healthy lifestyle.

AOTA. (2014b). The role of occupational therapy in primary care

[Position Paper]. American Journal of Occupational Therapy, 68(Suppl. 3), S25-S33. doi:10.5014/ajot.2014.686S06

Official AOTA position paper saying OT is well-suited for primary care teams, especially in caring for patients with one or more chronic conditions
- According to the CDC (2009), approximately one-fourth of people diagnosed with a chronic condition
- OT can recognize and address the impact of habits and routines on the management of chronic conditions and the development of healthy lifestyles
Suggested interventions:
- Self-management of chronic conditions and prevention of secondary complications
- Health promotion and lifestyle modification to prevent chronic conditions
- Self-management of psychiatric conditions and promotion of mental health,  
- Management of musculoskeletal conditions including pain management,  
- Safety and falls prevention within the home and community environments,  
- Promoting and ensuring access to community resources for social participation and community integration,  
- Palliative and end-of-life care to allow for QOL,  
- Driving and community mobility resources for older adults,  
- Redesign of physical environments to support participation in valued activities,
- Family and caregiver assistance and support (Canadian Association of Occupational Therapists, 2013; Metzler et al., 2012).

AOTA (2015a). Occupational therapy’s role in health promotion

[AOTA fact sheet]. Retrieved from http://www.aota.org/-/media/Corporate/Files/Practice/Health/Tools/FactSheet_HealthPromotion.pdf

Health is more than the absence of disease, it is about participating in your life.
OTs help people organize their occupations into daily routines that prevent and minimize dysfunction, promote and develop healthy lifestyles, and facilitate adaptation and recovery from injury, disease, or developmental challenges
OTs can perform health risk assessments, and facilitate success by matching a person’s skills to the demands of the activity, utilizing environmental supports and minimizing environmental barriers, and by offering solutions to the challenges associated with changing habits and routines.

AOTA (2015b). The role of occupational therapy in chronic disease management

[AOTA fact sheet]. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/FactSheet_ChronicDiseaseManagement.pdf?la=en

75% of healthcare dollars go to managing chronic diseases, which are largely preventable
OT can work on self-management skills, help clients manage daily activities and responsibilities, and also help modify thinking and behaviors related to health maintenance
- Address occupational deficits due to chronic conditions, to sustain or improve functional status
- Energy conservation or activity modification to manage the fatigue that often accompanies chronic conditions
- Individually adapt health management tasks
- Incorporate health management tasks into daily routines
- Develop coping strategies, behaviors, habits, routines, and lifestyle adaptations to support physical and psychosocial health and wellbeing

AOTA (2016). Wellness & prevention: Occupational therapy’s opportunity in the era of health care reform

[AOTA fact sheet]. Retrieved from http://www.aota.org/~/media/Corporate/Files/Advocacy/Health-Care-Reform/Ad-Hoc/Wellness%20Draft%202_with%20edits-cjed.pdf?la=en

Aligning OT with the values of wellness & prevention in the ACA
Suggestions for wellness promotion and prevention for OT
- Lymphedema management, self-management with chronic conditions, falls prevention, CarFit, caregiver training and support
- Backpack awareness, healthy tech use, bullying awareness, obesity prevention
- Home assessments and modifications, injury prevention, emotional wellbeing through occupational balance, occupational body mechanics, depression screening

CAOT (2013). CAOT position statement: Occupational therapy in primary care.

Retrieved from https://caot.in1touch.org/document/3710/O%20-%20OT%20in%20Primary%20Care.pdf

Canadian Association of Occupational Therapists’ position paper articulating the role and value of OT in primary care in Canada

Dahl-Popolizio, S., Doyle, S., & Wade, S. (2018): The role of primary health care in achieving global healthcare goals: Highlighting the potential contribution of occupational therapy,

World Federation of Occupational Therapists Bulletin, DOI: 10.1080/14473828.2018.1433770

Describes the role of OT in helping address the WHO global health goals of managing, and reducing the risk of developing non-communicable or chronic diseases by practicing in primary care settings
- Draws upon a 2008 WHO report on the need for primary care services
- Describes the global health trends and measurable goals of the international community with respect to non-communicable or chronic diseases
- Describes primary care, per the proposed WHO model as central to achieving the goals.
- Describes the role of OT in addressing non-communicable diseases and meeting WHO goals
  - Discusses commonalities between national and regional OT position statements on OT in primary care, for chronic conditions

Dahl-Popolizio, S., Muir, S., Davis, K., Stuart, K., Wade, S., & Voysey, R. (2017). Occupational therapy in primary care: Determining the receptiveness of occupational therapists and primary care providers.

The Open Journal of Occupational Therapy, 5(4), article 10. https://doi.org/10.15453/2168-6408.1372

Participants were provided with a brief paragraph describing the potential OT contribution to a primary care team, then asked to answer a survey to determine their receptiveness to OT in primary care
- Results: 94% to 99% of OTs and 82% to 97% of PCPs indicated possibly or yes to the inclusion of OT on the primary care team
PCP receptiveness to OT inclusion is a potential barrier, but PCPs and OTs are generally supportive of integrating OT into primary care settings, indicating the barriers are other than attitudinal

Devereaux, E. B., & Walker, R. B. (1995). The role of occupational therapy in primary health care.

American Journal of Occupational Therapy, 49(5), 391-396. doi:10.5014/ajot.49.5.391

Forward thinking article from 1995, that is relevant today.
- Changes were already beginning at this time, and allied health, including OT, were planning on being a part of it
  - Shifting the focus to health and away from illness, and away from acute and towards chronic treatments “from cure to care”
OT is well suited to be a part of this healthcare transition
- We are generalists, just like PCPs. Generalizing becomes our specialty in primary care
- OT will notice other things that the PCPs may not notice
- OT thinks in systems, not in strict cause and effect.

DHS. (2018). 2020 LHI topics.

Retrieved from https://www.healthypeople.gov/2020/leading-health-indicators/2020-LHI-Topics

Sets goals for the health of our nation
- Based on leading health indicators
  - Access to health services, clinical preventive services, environmental quality, injury and violence, maternal infant and child health, mental health, nutrition and physical activity and obesity, oral health, reproductive and sexual health, social determinants, substance abuse, tobacco
Updated every 10 years

Killian, C., Fisher, G., & Muir, S. (2015). Primary care: A new context for the scholarship of practice model.

Occupational Therapy in Health Care, 29(4), 383-396. http://dx.doi.org/10.3109/ 07380577.2015.1050713

Describes OT’s role in primary care while suggesting improved coordination of care, outcomes and cost savings.
- The changing health climate, due partly to the ACA, is an opportune time to advocate for OT services in primary care.
- The Scholarship of Practice Model, wherein the OT uses research to inform practice, and uses practice to guide future research questions, can guide primary care OT practice.
- Describes application of OT models of practice in the primary care setting (Model of Human Occupation, Canadian Model of Occupational Performance and Engagement, and Person-Environment-Occupation-Performance Model), as well as use of related assessment tools

Muir, S. (2012). Occupational therapy in primary health care: We should be there

[Health Policy Perspectives]. American Journal of Occupational Therapy, 66, 506–510. Retrieved from http://dx.doi.org/10.5014/ajot.2012.665001

As the US healthcare system evolves to provide quality healthcare with positive outcomes, primary care must change to make best use of healthcare dollars.
- OT could be facilitators in the transition towards a value-based system, including transitioning to ACOs and PCMHs
The current healthcare system is fragmented
- Since OTs are broadly trained in human development, health promotion, disease process intervention, activity analysis and behavior modification, lifestyle intervention, as well as the use of adaptive equipment, the profession could be fundamental to reducing fragmentation in healthcare.
The ACA service provision models PCMH and ACO are attempting to facilitate the kind of contextual, holistic, and coordinated care that is at the core of OT.
Primary care OT isn’t for everyone, certain characteristics are needed.
- Generalist
- Be able to intervene instantaneously, in a brief, single session.
- Self-advocate, educate the PCPs, and understand the other team members’ roles, and professional boundaries.
  - We need to articulate our value
  - “Intrusionary OT,” be in the room with the PCPs, show them, don’t tell them, what OT can do, in the moment, with the patient.
OT has a unique, holistic and client-centered approach. In the new pay-for-value system, OT should be in primary care to improve outcomes and add save money

Pizzi, M. A., & Richards, L. G. (2017). Guest Editorial—Promoting health, well-being, and quality of life in occupational therapy: A commitment to a paradigm shift for the next 100 years.

American Journal of Occupational Therapy, 71, 7104170010. https://doi.org/10.5014/ajot.2017.028456

Supports OT in promoting health and wellness, emphasizing participation over performance, and optimizing wellbeing and health in individuals, communities, and populations
Describes the connection between occupation and health
Pizzi Health and Wellness Assessment (PHWA): a reliable and valid assessment tool that links occupational performance to health. Focuses on client’s perceived abilities, level of health related to daily occupations, and readiness for change.
Environment-Health-Occupation-Well-Being (E-HOW) Model: guides practice with wellbeing and QOL as the outcome of focus.

Reitz, S. M. (1992). A historical review of occupational therapy's role in preventative health and wellness.

American Journal of Occupational Therapy, 46(1), 50-55. doi:10.5014/ajot.46.1.50

This article outlines OT’s long history of involvement in prevention and wellness.

Scaffa, M. E., Van Slyke, N., & Brownson, C. A. (2008). Occupational therapy services in the promotion of health and the prevention of disease and disability.

American Journal of Occupational Therapy, 62(6), 694-703. Retrieved from http://ajot.aota.org/article.aspx?articleid=1867125

Describes OTs contribution to health promotion and prevention, for internal and external audiences
Health promotion and prevention are national health goals:
- WHO, 1986 in the Ottawa Charter for Health Promotion
  - Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, and social wellbeing, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment.
  - Health is a resource for everyday life, not the objective of living.
  - Health emphasizes social and personal resources, and physical capacities.
- Goals of Healthy People 2010 include increasing quality years of life, and decreasing health disparities.
- Prevention is part of health promotion
  - Primary: Education/health promotion strategies to help people avoid the onset and reduce the incidence of unhealthy conditions, diseases, or injuries. Identifies and eliminates risk factors.
  - Secondary: Early detection and intervention after disease occurs. Prevents/disrupts disability
  - Tertiary: Arrests the progression of condition, prevent further disability, & promote social opportunity
Health promotion and prevention as OT
- The potential range of what people can do, be, and strive to become is the primary concern, and health is a by-product. A varied and full occupational lifestyle will maintain and improve health and wellbeing
- Health enables occupation, which provides the meaning that supports wellbeing.
- Occupational engagement is the means and the goal of OT intervention
  - OT can implement the guidelines of the nutritionist, the PT, etc., to incorporate healthy patterns, integrating the expertise of multiple professions into practical situations
- Health management and maintenance is an IADL, health promotion and prevention are OT intervention approaches
- Occupational imbalance, deprivation or alienation are risk factors for poor health, and poor health is a risk factor for these occupational issues
- OT can work with health promotion and prevention on an individual or population basis

WHO (1978). Declaration of the Alma-Ata.

Retrieved from http://www.who.int/publications/almaata_declaration_en.pdf

Re-defines global health and health priorities in a way that indicates a trend towards holistic health and prevention, which is relevant to OT and primary care
- Health is not merely the absence of disease
- Health inequities are a major problem
- Governments have a responsibility to the health of their people
- Primary care is a priority
  - Culturally relevant
  - Across the full lifespan and healthspan
  - Connected to community resources
  - Evidence-based

Being an Advocate

AOTA. (in press). The importance of primary care education in occupational therapy curricula.

American Journal of Occupational Therapy, 72.

Advocates for educational content that prepares OT practitioners to work in primary care.
Includes a discussion on OT in primary care, relevant ACOTE standards, and resources for incorporation into OT curricula

Doll, J. (2017, September 25). Promoting OT’s role in ambulatory care primary care teams.

OT Practice, 22(17). Retrieved from https://www.aota.org/Publications-News/otp.aspx

Points to consider when designing and implementing OT services in an ambulatory primary care setting:
- Know your organization: Consider the culture, mission, and vision. Consider timing - is the organization currently engaged in other complex changes?
- Learn your business: know the financial structure for reimbursement, and how OT services will fit in
- Say the same thing to many people, many times: Educate providers and administrators about the role, value, and benefits of OT
- Get to know the EMR: Allows for sharing care plans, communicating with primary care team, demonstrating patient outcomes
- Experiment and expect change: no two organizations will be exactly alike, try new models and see what works.
- Build relationships: find champions for your cause, build relationships with providers and administrators
- Seek feedback: from patients, care team members, and administrators
- Build in metrics: consider aligning metric selection with outcome goals of the clinic
- Disseminate outcomes: share stories of success and challenges to allow others to succeed too

Donnelly, C., Letts, L. (2013). 10 tips to integrate occupational therapy in primary care teams.

Occupational Therapy Now, 15(5), 7 - 8.

Educate primary care stakeholders as to the role of OT in primary care
Work interprofessionally (for example, co-create a pain management course)
Co-treat with other professionals
Connect with other OTs working towards primary care practice
Expand OTs reach by having a student
Go to inservices and host inservices
Socially connect with team members
Join a work task committee at your clinic
Document in the EMR where other team members can see your documentation
Practice in close proximity to other team members, be right in the midst of the action

Lamb, A. (2016, Nov 9). Demonstrating our distinct value in your daily practice.

Celebrate AOTA Member Appreciation Webinar Series. Retrieved from https://aota.adobeconnect.com/p6l6uyl470b?launcher=false&fcsContent=true&pbMode=normal

Webinar explaining what a distinct value means, what our distinct value is, and how and why to articulate it in practice.
How do we define value in healthcare these days?
- The Triple Aim
  - Enhance the quality of care
    - OT is client-centered, always has been. Promote client-centered practice across professions.
    - Use evidence-based interventions and standardized assessments to show effectiveness, as well as client-centered outcomes
    - Strive for appropriate utilization of care based on client needs
  - Enhance the efficiency of the system
    - Incorporate wellness and prevention into every aspect of practice
    - Develop treatment protocols for at-risk populations
    - Lead care transitions, discharge, care coordination, etc.
  - Reduce healthcare costs
    - Self-management approach for chronic conditions. Our distinct value is that our self-management skills are anchored in daily habits and routines
    - Collect cost-effectiveness data in everyone’s practice
    - Make interprofessional collaborations to increase access to care and save PCP time

The distinct value statement
- “OT’s distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary and familiar activities of everyday life. OT is client-centered, achieves positive outcomes and is cost-effective.”
  - Video on the distinct value: www.aota.org/otdistinctvalue
Represent distinct value in practice
- Types of OT interventions include Occupations, Activities, Preparatory methods and tasks
- We need to focus on occupation as intervention. That is our distinct value
  - Make sure other interventions clearly connect to the actual occupations, the things clients need to do, want to do and have to do.

Metzler, C. A. (2016). A new year, a new way to promote OT.

OT Practice, 21(21). p. 7.

Use billing and coding to demonstrate the value of OT
The new Current Procedural Terminology (CPT) codes as of Jan 2017 promotes OT’s distinct value
- Focuses on performance in occupations, in addition to client factors
- Face to face time with the client and family is included for evals
- Low, medium, and high eval codes, underscoring the clinical decision making

Patel, P. (2015). The role of occupational therapy in primary care.

Occupational Therapy Doctorate Capstone Projects. Paper 2. Retrieved from http://encompass.eku.edu/otdcapstones/2/

A student capstone project focused on communicating the value of OT to other professionals
Case for Integration of OT in primary care
In-service for PCPs
- Overview of ACA, the triple aim and primary care
- Definition of OT
- Scope of OT
- How OT can be a significant contributor in a primary care team
- Examples from the 3/21 Federally Qualified Health Centers (FQHCs) that already have OTs, from the AOTA (2013) Review of New Models of Primary Care
PCPs asked about OT education, OT scope, future models of primary care that might include OT, difference between OT and PT, difference between OT and behavioral health (OT is more inclusive of daily routines, habits, and taking into account the context), referral processes for different diagnoses, and showed interest in adaptive tech

Sample, J. M. (2016, August 22). Planning a successful state OT on the hill day.

OT Practice, 21(15), 12-16. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Advocacy is an important part of OT
Know who you will be speaking with on hill day,
- Including how many representatives, what their districts are, what their term limits are, what committees they are assigned to, party affiliations, who the leaders are, and who you can count on to champion OT
Keep your local community of OT and OT advocates informed
- Increase membership and involvement in state OT associations
Focus on key topics
Create a team of volunteers to organize the hill day planning

Leadership

AOTA (2016). Emerging leaders development program.

[website]. Retrieved from http://goo.gl/rcs8hb

AOTA's program to foster new AOTA service leaders
Candidates must be in school or within first 5 years of practice
- Applications are accepted every spring

AOTA. (2018). Leadership Development Toolkit.

[website]. Retrieved from https://www.aota.org/Practice/OT-Assistants/OTA-Leadership.aspx

A website with resources to build leadership skills, including links to articles and podcasts

Ellie, E., Grady, A., & Nielson, C. (2011). Mentoring leaders: The power of storytelling for building leadership in health care and education.

Bethesda, MD: AOTA Press.

A textbook guide for mentors for inspiring leadership, including a workbook on self-reflection and growth, community building, enacting leadership practices, building followership, leading for the future.

Fleming-Castaldy, R. P. & Patro, J. (2012). Leadership in occupational therapy: Self-perceptions of occupational therapy managers.

Occupational therapy in health care, 26(2), 187-202. doi: 10.3109/07380577.2012.697256.

This study examines leadership in OT by looking at clinic managers
Developing leaders, including the Emerging Leaders Development Program, is a key aspect of the AOTA Centennial Vision
Leadership theories
- Leadership is not an inborn quality, and good leadership in one situation doesn’t mean it will work in every situation
  - Contingency leadership
    - Task-oriented with a focus on goal attainment
    - Relationship-oriented with a focus on successful social dynamics
- Leadership Challenge Model
  - Five important characteristics
    - Model the way, inspire a shared vision, challenge the process, enable others to act, encourage the heart
- Leadership Practices Inventory
  - Based on the Leadership Challenge Model. Assesses leadership skills
Leadership in OT
- Disproportionately male.
- OT managers rate themselves highly according to the Leadership Practice Inventory
- Additional research is needed for OT leaders who aren’t specifically in management positions.
- Future leaders should develop the 5 skills of the Leadership Challenge Model (Visionary Leader in Phipps, 2015) in order to influence the future of OT

Hobbs, M. & Lamb, A. J. (2016). A mindful path to leadership series module 3: Mentoring and leadership.

Bethesda, MD: AOTA Press.

An online Continuing Ed course exploring mentor/mentee roles, including strategies for finding a mentor

OTCommunityofLeaders. (2016). OT Leadership Live Podcast.

Retrieved from www.talkshoe.com/tc/139040

Ongoing podcast series on various topics of leadership in OT

Phipps, S. (2015, August). Transformational and visionary leadership in occupational therapy management and administration

[Continuing education article]. In OT practice, 12(15), CE1-CE8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

OT as a transformational leader during times of change
- Relevant for OT within or outside of management positions
Leaders vs. Managers
- Managers are internally focused, short term, control and direct people and operations, strategy, structure and systems
- Leaders are externally focused, long term, inspire and empower people, style, skills, goals
- Both are needed. Anyone can be a leader.
Visionary leaders:
- Model the way: actions speak louder than words. Bear the burden you expect your team to take as well
- Inspire a shared vision: listen to others, and communicate the importance of your vision and how it impacts them, let them see why the change is needed
- Challenge the process: encourage risk taking, resiliency and internal locus of control
  - Resistance to change is natural, change is threatening. Be sensitive.
  - Treat a problem like a challenge and an opportunity
- Enable others to act: foster trust & collaboration, disperse the power. Their ideas and actions are part of the needed solution
- Encourage the heart: clear standards and detailed feedback, reinforce desired culture
Developing a vision
- Start with an achievable end in mind
- Make sure all stakeholders share the vision
Communicating a vision
- Be consistent in your message
- Network and get feedback from all stakeholders
  - Use various means of communication, social media, etc.
Implementing a vision
- Develop clear goals based on stakeholder feedback and vision
- Budget, organizational systems, specific plans for each department involved, use coaching and training as needed
Sustaining a vision
- Foster accountability, spread the responsibility and the power, and the rewards.
- Review progress and revisit goals frequently
- Identify barriers and problem-solve

Primary Care Progress (n.d.). Homepage.

Retrieved from http://www.primarycareprogress.org/home

The website for a free to join interprofessional group of leaders, focused on transforming primary care.

Rogers, P., Killian, C., Hudgins, E., & Pollard, T. (2016, May). Transitioning from clinician to manager.

SIS Quarterly Practice Connections, 1(2), 17-19. Retrieved from https://www.aota.org/Publications-News/SISQuarterly/entire-issue-pdf.aspx

Article in Administration & Management Special Interest Section (SIS) about OTs becoming managers
- Management opportunities exist in primary care
- Essential skills include enhanced knowledge of service area, reimbursement systems, budget planning, and people management skills
- Being a manager makes OT more visible, allows for more advocacy and the ability to influence bigger decisions.
- Resources
  - Administration & Management SIS (AMSIS) at www.aota.org/AMSIS
  - OT Connections discussion at http://aota.org/sis_forums/f/10.aspx. There are management and administration forums here
  - American Management Association (2009) provides seminars to build and improve management skills
  - AOTA Volunteer Leadership Development Committee
  - The Occupational Therapy Manager (Jacobs & McCormack, 2010)

Sweetman, M. M. (2016, July). Authentic leadership in occupational therapy.

[Continuing education article]. In OT Practice, 21(13). p. CE1-CE8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Authentic leadership is an ideal fit for OTs
- Authentic leaders are true to core values, and demonstrate sincerity. Authentic leadership is evidence-based.
- Four primary components of authentic leadership: self awareness, internalized moral perspective, balanced processing, and relational transparency
- Authentic leadership can be employed in various relationships, including clients

Waite, A. (2016, September 26). Alert the media: Tips for talking with reporters about occupational therapy.

OT Practice, 21(17), 17-19. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Speaking or writing about OT in the media is one of the most effective and efficient ways to advocate for OT
- Enthusiasm about OT is most important.
- Be careful and concise, repeat the main points you want to communicate
- Request interview questions in advance
- Check your facts and avoid jargon

Category Two

Healthcare Policy

AOTA (2012). Accountable care organizations and medical homes

[AOTA ACOs PCMHs Fact Sheet]. Retrieved from https://www.aota.org/-/media/Corporate/Files/Advocacy/Health-Care-Reform/ACO/ACOs%20%20Medical%20Homes%20Fact%20Sheet%202012%20combined%20%20rev%2022012.pdf

AOTA Fact Sheet on ACOs and PCMHs
OT in ACOs:
- Focus on QOL, home safety, ADLS & IADLS, participation, vision, ergonomics, driving, fall risk, swallowing, pediatric, mental health
Steps to get involved
- Gather effectiveness materials to advocate for inclusion with chronic conditions
- Get involved in local ACO & PCMH planning and management teams
- Develop collaborative relationships with providers, especially in peds, rehab, stroke, brain injury, and autism
- Consider additional certification, low vision, driving, home safety, etc.
- Become familiar with the Medicare Health Risk Assessment (HRA), which is part of the Annual Wellness Visit (AWV) for Medicaid beneficiaries. It contains ADL and IADL, and might influence changes
- Get to know your organization’s EMR, and make sure it has OT language options

AOTA. (2018). Individual measures for occupational therapists.

Retrieved from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare/MACRA/individual-measures.aspx

How to report on MACRA and MIPS measures, with clear descriptions of measures and standardized assessment tools that can be used to inform the data reported.
- MIPS: Merit-based Incentive Payment Program
OTs are eligible to voluntarily report quality data under MACRA and MIPS on 12 measures with OT CPT codes

Braveman, B., & Metzler, C. A. (2012). Health care reform implementation and occupational therapy

[Health Policy Perspectives]. American Journal of Occupational Therapy, 66, 11–14. http://dx.doi.org/ 10.5014/ajot.2012.661001

Overview of the ACA changes, focusing on insurance changes, new payment structures, and new delivery systems
These changes present both opportunities and challenges to OT
- Opportunities
  - A member of an integrated primary care team in an ACO or PCMH
  - Preventative risk assessments, safety screening
  - “Rehabilitation and habilitation” is a required category in the mandatory benefits package
  - Integrated Behavioral Health is also a required category in the mandatory benefits package
- Challenges
  - Decreased direct reimbursement
  - Exclusion from development of key implementation strategies
  - Other disciplines establishing themselves as key players
AOTA’s response to the ACA
- Focus on QOL and self-management, not just disease status
- Advocate to CMS to include measures on fall prevention, etc., to create a specific reason to include OT
- Many issues are happening at the state level.
- Ad Hoc committee on Health Care Reform Implementation subgroups on Health benefits/medical necessity, ACOs/PCMHs, Chronic care/self-management, Mental health, Tele-health, Prevention and wellness, Long term care
  - http://www.aota.org/advocacy-policy/health-care-reform.aspx

Halle, A. D., Mroz, T. M., Fogelberg, D. J., & Leland, N. E. (2018). Occupational therapy and primary care: Updates and trends

[Health Policy Perspectives]. American Journal of Occupational Therapy, 72, 7203090010. https://doi.org/ 10.5014/ajot.2018.723001

An update to the 2012 Health Policy Perspectives article on primary care.
Models of Service Delivery: Alternative Payment Models
- Comprehensive Primary Care Plus (CPC+): a 5-year, multi-payer initiative to improve primary care that will target 20 U.S. geographic regions and 20,000 doctors and practitioners
- Next Generation ACO: provides greater opportunities for shared savings to create increased incentives for experienced ACOs
- Federally Qualified Health Center (FQHC): a reimbursement designation from CMS for safety net providers who provide comprehensive services to a medically underserved area or population and have ongoing quality assurance programs
- PCMH: a care delivery model focused on reducing costs by providing care that is comprehensive, patient and family centered, coordinated, accessible, and accountable
  - Within the PCMH model, OTs have been able to include a portion of their salary under the health education component of the medical home services.
There are many barriers, including reimbursement, and lack of adequate preparation for articulation/demonstration of primary care OT in schools. A white paper on primary care education is in press now.
Look to international models of primary care OT to see the value and role
Now is the time to act, despite constant uncertainty

Lamb, A. J., & Metzler, C. A. (2014). Defining the value of occupational therapy: A health policy lens on research and practice.

American Journal of Occupational Therapy, 68(1), 9-14.

The 2010 ACA is greatly altering the health policy landscape in which the practice of OT exists and as a result there is a needed for greater consensus on what constitutes value in healthcare, and how to measure and increase that value.
- ACA created Center for Medicare and Medicaid Innovation (CMMI) tests innovative payment and service delivery models to reduce program expenditures while maintaining or improving quality of care for those who receive benefits from Medicare, Medicaid, or the Children’s Health Insurance Program.
- Some CCMI created models explained in the article include The Independence at Home (IAH), which works to use home based primary care teams, and the ACA and Comprehensive Primary Care Initiative which work to improve coordination of care.
- All of these models influence how consumers and professionals perceive “value”. Therefore, OT’s possibilities must be used as the basis for assertive and focused actions to ensure that any new system and all its components (models) fully use the skills and benefits of OT.

Leland N. E., Crum K, Phipps S, Roberts P, & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery.

American Journal of Occupational Therapy, 69(1), 69010900101-69010900107.

Healthcare system shifting from a volume-based reimbursement system to a value-based, high quality care, evidence-based practices, and patient-centered care.
- The authors of this article examine healthcare quality and patient outcomes while describing the healthcare context that is driving the need for quality measurement in OT.
- This will assist in the discussion of how OT can define high-quality care processes to increase outcomes and maintain a “viable” future for the profession.

Leland, N. E., Fogelberg, D. J., Halle, A. D., & Mroz, T. M. (2017). Occupational therapy and

management of multiple chronic conditions in the context of health care reform

[Health Policy Perspectives]. American Journal of Occupational Therapy, 71, 7101090010. https://doi.org/10.5014/ajot.2017.711001

The prevalence of multiple chronic conditions is on the rise. This population has high rates of healthcare utilization yet poor outcomes.
There are multiple recent policies that are designed to help those with multiple chronic conditions, which offer opportunities for OTs to contribute to addressing chronic conditions, including within primary care settings

Metzler, C. A., Hartmann, K. D., & Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy

[Health Policy Perspectives]. American Journal of Occupational Therapy, 66, 266–270. http://dx.doi.org/10.5014/ajot.2010.663001

Defining primary care since the implementation of the ACA
- PCPs include MDs, PAs and NPs. OT is “supplemental”
  - Loan reimbursement and incentive programs are limited to PCP
    - Section 3502 of the ACA:
      - Grants to coordinate primary, acute, behavioral and long term services for Medicare and Medicaid population
- The last part of this article breaks apart the definition of primary care according to the ACA and links it to OT

Parsons, H. (March 2017). Promoting OT’s role in mental and behavioral health services.

OT Practice, 22(4), 7. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Describes legislation and legislative advocacy to bolster OT’s role in mental and behavioral health, including 21st Century Cures Act

Parsons, H & Hooper, L. (2018, April). Health care reform update.

Presentation at AOTA National Conference, Salt Lake City, UT.

Discussion of recent federal legislative changes including executive orders, and the process that resulted in 2017 repeal of health insurance individual mandate effective January 1st, 2019, and the subsequent impact on healthcare
- Healthcare feels tenuous at this point, but the changes created by the ACA are largely still influencing US healthcare delivery and payment, but now with more variability between the states
  - Including EHBs, work requirements, premiums, individual mandates, and more.
    - Oregon approved a tax on hospitals and insurance companies to help fund the state portion of Medicaid funding
    - Oregon also obtained a 1332 Waiver, which is created to allow states the ability to develop alternative means of meeting coverage goals. Oregon’s waiver is for reinsurance, which means the government pays for some high-cost claims from enrollees with expensive conditions, lowering insurance companies costs which results in lower premiums.

Willmarth, C. & Hooper, L. (2016, Nov 10). Health care reform update

[Webinar]. In Celebrate AOTA Member Appreciation Webinar Series. Retrieved from https://www.aota.org/Conference-Events/member-appreciation/webinar-library/Advocacy.aspx

This Webinar on healthcare reform updates.
Essential Health Benefits (EHBs)
- ACA established a provision of 10 essential health benefits
  - Victory in OT advocacy, to include the Rehabilitation and Habilitation, but there wasn’t a consistent definition, so states varied
    - Now, thanks to AOTA advocacy, there is a standard definition of what states need to provide.
- Summary of benefits and coverage (SBC): An easy to read document for consumers to know their benefits, including OT in rehabilitation and habilitation
Delivery system reform
- Center for Medicare & Medicaid Innovation (CMMI)
  - CMMI tests new payment and delivery models, and promotes successful ones
    - Including ACOs, PCMHs, Bundled payments, and chronic care management
AOTA and primary care
- AOTA Primary Care Website: www.aota.org/primarycare
- Environmental Scan: Review of New Models of Primary Care Delivery
- AOTA Forum on Interprofessional Team-Based Care

Integration Strategies

McColl, M. A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O’Brien, P., & Donnelly, C. (2009). Models for integrating rehabilitation and primary care: A scoping study.

Archives of Physical Medicine and Rehabilitation, 90(9), 1523-1531. https://doi.org/10.1016/j.apmr.2009.03.017

The objective of the study was to describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services.
- Based on decided criteria 38 articles pertaining to both primary care and rehabilitation were selected for use; it was determined that there were 6 different models for providing primary healthcare and rehabilitation services in an integrated approach:
  - clinic, outreach, self-management, community-based rehabilitation, shared care, and case management.
- In addition, a number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings:
  - team approach, interprofessional trust, leadership, communication, compensation, accountability, referrals, and population-based approach.

Behavioral Health

AOTA (n.d.). Occupational therapy practitioners: A key member of the Community Behavioral Health team.

Retrieved from https://www.aota.org/Advocacy-Policy/State-Policy/Issue-Campaign-Mental-Behavioral-Health.aspx

The profession of OT began in mental health settings
OTs address mental health and cognitive impairments, including the social, emotional, psychological, functional, and environmental aspects of these conditions
Certified Community Behavioral Health Centers (CCBHC) offer integrated, coordinated care for the whole person
- OT is an excellent fit, and focuses on daily functioning with a strengths-based approach
National Alliance on Mental Illness (NAMI) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for Assertive Community Services Teams include OT

Dahl-Popolizio, S., Manson, L., Muir, S., & Rogers, O. (2016). Enhancing the value of occupational therapy in primary care: The role of occupational therapy.

Families, Systems, and Health, 34(3), 270 - 280. http://dx.doi.org/10.1037/fsh0000208

A comparison of OT training and the core competencies of behavioral health in primary care.
OT is very qualified to deliver primary care behavioral health services.

Lute, R. M. & Manson, L. (2015). Integrated Care and Specialty Behavioral Health Care in the Patient-Centered Medical Home.

In W. O’Donohue & A. Maragakis (Eds.) Integrated Primary and Behavioral Care (pp. 19-38). Switzerland: Springer International Publishing. Retrieved from http://www.springer.com/cda/content/document/cda_downloaddocument/9783319190358-c1.pdf?SGWID=0-0-45-1531068-p177384817‬‬‬‬‬‬‬‬‬‬‬‬‬‬.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬

Behavioral health in primary care
- Focus
  - Mind-body-behavior connection
  - Consultation, health promotion, symptom mitigation, and functional improvement
    - Consultation can be for the physician, care team, and/or patient. Can be individual or group
  - Skill development for management of medications, or behavioral/emotional difficulties
  - Behavioral health providers need skills of flexibility, rapidity, and generalizability
  - Health and wellness with the PCP’s medical concerns in context
- Intervention
  - Provide brief, solution-focused assessment and intervention. 30-min session, 1-4 sessions
  - Behavior change plans, lifestyle modification, resource building, and targeted person-centered, culturally competent, brief interventions
  - CBT, solution-focused therapy, problem-solving therapy, goal setting, MI, mindfulness, relaxation training, biofeedback, Rational Emotive Behavioral Therapy, ACT, behavioral analysis
  - 5A’s of behavioral change in PC: assess, advise, agree, assist, and arrange
    - Assess patient’s knowledge about illness and ability to self-manage
    - Advise by building on what the patient knows about their health, wellness, and condition
    - Agree on target risks, health promotion behaviors, and adherence using the patient’s own verbiage, avoid jargon. Joint goal setting and action plans are created with the patient’s strengths, confidence, conviction, priorities, and preferences in mind. Utilizing rating scales for assessing importance and confidence in ability to accomplish the plans improves likelihood of accomplishment
    - Assist by facilitating discussions identifying and problem-solving solutions to barriers, and identifying supportive resources and people.
    - Arrange by setting follow-up communication with PCP, care team, and/or return with behavioral health, identifying time frame for achieving action plans or goals, and specific support planning

Care Coordination

Fader, J., Goldstein, D., & Vause-Earland, T. (2016, November 7) Hotspotting collaborative student efforts to identify and intervene with emergency service “super-utilizers.”

OT Practice, 21(20). p. 13-16. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Hotspotting includes identifying patients who overuse healthcare (“super-utilizers”), preparing targeted interventions, and reshaping ineffective utilization patterns.
- Hotspotting is care coordinating, advocating for, educating and empowering super-utilizers.
- The role of OT in hotspotting is similar to the role of OT in primary care
  - “assess functional cognition, performance, habits, roles, and routines that impact health and wellbeing, then collaborate with the client to identify ways to navigate the healthcare system to address personal health needs. A strong knowledge of physical, social, and cultural environments makes an OT well suited to working with the complex patients”
- OT students can get involved in the national, 6-month program called Interprofessional Student Hotspotting Learning Collaborative.
  - https://www.aamc.org/initiatives/hotspotter/
  - an OT program must participate with an AAMC-registered medical college in order to get involved.

Moore, K. (2013). Wellness navigator: An innovative role in primary health care for occupational therapists.

Occupational Therapy Now, 15(5), 20-21.

Highlights the role of OTs as wellness navigators within Community Health Teams (CHTs) in Canada and how OTs are well suited to perform this role.
- In public community locations, CHTs use a community health model to promote health and wellness by helping citizens build knowledge, confidence, and skills to make changes in their daily lives to live healthier, and prevent and manage common risk factors for chronic health conditions.
- Wellness navigators collaborate with family physicians and other health providers to assist citizens with health conditions, mental health concerns, emotional health, as well as services for individuals, families, and community groups.
- Wellness navigator is an innovative role in primary healthcare that is effective in preventing citizens from “falling between the cracks” of systems.

Moyers, P. A., & Metzler, C. A. (2014). Interprofessional collaborative practice in care coordination

[Health Policy Perspectives]. American Journal of Occupational Therapy, 68(5), 500-505. doi:10.5014/ajot.2014.685002

OT is well-suited for effective team management and the implementation of care coordination
The hierarchy of PCPs in PCMHs needs to be reworked to put OT in the administrative and gate-keeper roles.
OTs have a holistic and collaborative view that would benefit care-coordinating leadership roles.
There is a similarity between National Committee for Quality Assurance goals for PCMH and ACOTE standards for OT education
This supports the use of OTs as prepared and appropriately educated leaders and care coordinators.
OTs must translate occupation to clearly link it to disease management, population health, lifestyle and behavioral change, self-management, and reducing caregiver burden.

Robinson, M., Fisher, T. F., & Broussard, K. (2016). Role of occupational therapy in case management and care coordination for clients with complex conditions

[Health Policy Perspectives]. American Journal of Occupational Therapy, 70(2), 7002090010p1-7002090010p6.

OT is well suited to the emerging roles of case management and care coordination
Patient engagement is part of patient satisfaction and thus the Triple Aim, and it also affects health outcomes
- Care coordination throughout the system needs to promote maximum patient self-management
OT can also take into account all of the complex factors that impact a patient with a complex condition, including social, environmental, medical, structural, etc.
OTs are educated to be providers of health education and promotion and case management and coordination for clients with chronic diseases
- The article sites several ACOTE standards that directly relate to case management and care coordination
The Commission for Case Manager Certification has an exam for case manager credentialing. Many expectations are already covered in OT education. OT could be a case manager for complex chronic conditions, specifically.
Case managers are typically nursing or social work positions, and aren’t paid as well as typical OT positions.
- Perhaps OT as a consultant to case managers instead
- In some settings, you can’t be both a case manager and a provider
OT could also manage care transitions throughout the care continuum.
- OT can see what would encourage someone to be more independent, and how they can be successful
- Knowledge of stages of change
OT is adept at connecting between providers and community resources

Models in Action

Benthall, D. (2017, February 20). Out of the physician’s office and into the home: Exploring OT’s role on a home-based primary care team.

OT Practice, 22(3), 8 - 13. Retrieved from https://www.aota.org/Publications-News/otp.aspx

The Veterans Health Administration (VHA) developed a program called Home Based Primary Care (HBPC), providing interdisciplinary services (including OT) to veterans with complex medical conditions
- Veterans in this program are frail, chronically ill, and at high risk for hospitalization. Routine clinic-based care is ineffective for these clients.
- Goals are to reduce hospitalization, optimize function and QOL, promote aging in place
- Interdisciplinary team includes: physician, physician assistant/nurse practitioner, social worker, dietician, pharmacist, OT and PT, clinical psychologist, access to chaplain services
- OT is provided using a consultation model. Assess functional status, ensure access to equipment and home modifications to support occupational performance, implementation of lifestyle modifications
  - Education and training of self-management tasks are more relevant when performed in client’s natural context
  - OTs serve as generalists, intervene in many areas including falls prevention, dementia family caregiver training, home safety, driving and community mobility, wheelchair seating and positioning, chronic pain, vision impairment, mental health, palliative and end of life care.
  - OT consults with the veteran in their home a minimum of 4 to 8 times per year – a long-term approach to care

Brown, C., & Diamond-Burchuk, L. (2013). Occupational therapists providing interprofessional education and enhancing health within a teaching primary care centre.

Occupational Therapy Now, 15(5), 14-16.

This article explores the role of OT in the interprofessional primary care team at Northern Connection Medical Center, in Canada.
Describes the experiences of working OTs as they engage in the dual role within the primary care center as both interprofessional educators and direct service providers.
- OTs provide opportunities to teach both residents and family physicians at the center about the role and scope of OT by allowing them to observe OT assessments and interventions, provide informal consultations, and provide feedback on the results of OT assessments and interventions of clients
- Describes some challenges and potential solutions to clarifying the OT’s unique role in this setting and how developing this role in a teaching environment has provided the opportunity to re-realize and teach the strengths OT can bring to the primary care role.

Donnelly, C., Brenchley, C., Crawford, C., & Letts, L. (2013). The integration of occupational therapy into primary care: A multiple case study design.

Bio Med Central Family Practice, 14(60), 1-12.

In 2010, the province of Ontario, Canada provided funding to include OTs as members of Family Health Teams, an interprofessional model of primary care. A multiple case study design was used to provide an in depth description of the integration of OT.
- The study found that explicit strategies and structures are required to facilitate the integration of a new professional group. An understanding of professional roles, trust and communication are foundations for interprofessional collaborative practice.
  - Specific strategies that support integration of OT into primary care:
    - Educate team members of professional role of OT
    - Ensure OT has full access to EMR, for formal documentation and informal messaging
    - Involve OT students through fieldwork placements, to increase to reach of the OT
    - Participate in educating students from other disciplines
    - Develop a role within pre-existing interprofessional programs and structures (such as a pain management course)
    - Build relationships with team members by attending networking events, social functions, meetings, inservices, etc.

Donnelly, C. A., Leclair, L. L., Werner, P. F., Hand, C. L., & Letts, L. J. (2016). Occupational therapy in primary care: Results for a national survey.

Canadian Journal of Occupational Therapy, 83(3), 135 0 142. doi: 10.1177/0008417416637186.

Respondents (n 52) were almost exclusively working on interprofessional teams.
Intervention was provided most frequently to individual clients, and services were provided both within the home/community and in the clinic.
OTs offered a range of health promotion and prevention services, predominantly to adults and older adults.
- The top three practice areas were the provision of equipment, fall prevention, and chronic disease management
A number of supports and barriers to the integration of OT are identified

Duddy, K. J., (2016). Primary care occupational therapy: An occupation-based approach for veterans with chronic conditions

[doctoral project]. Retrieved from https://hdl.handle.net/2144/14582

The author developed and implemented OT services at a VA primary care clinic, to help veterans who experience chronic conditions, called VA Everyday Matters
- Includes: a review of chronic conditions, literature for OT in primary care, a description of the proposed program, and an evaluation of the program including funding and dissemination plan

Eichler, J., Royeen, L. (2016). Occupational therapy in primary health care clinic: Experiences of two clinicians.

Families, Systems, & Health, 34(3), 289 - 291. doi: 10.1037/fsh0000226.

Describes the process and experience of two OTs who provided services in primary care settings. Includes case examples, and discussion of benefits and challenges.

Garvey, J., Connolly, D., Boland, F., & Smith, S. M. (2015). OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: a randomized controlled trial.

BMC family practice, 16(1), 59.

OPTIMAL is an OT-led 6-week self-management program.
Results indicate improvements in activity participation and performance, self-efficacy, health related QOL, and goal attainment
The intervention group also had increased frequency of engagement in IADL, including household chores and meal preparation.

Koverman, B., Royeen, L., & Stoykov, MA., (2017). Occupational Therapy in Primary Care: Structures and Processes that Support Integration.

The Open Journal of Occupational Therapy, 5(3). Retrieved from http://scholarworks.wmich.edu/ojot/vol5/iss3/12/

Describes the implementation of OT services in a primary care setting, applying the Basic Logic Model to inform planning and implementation
- Model offers guidance for program development in a primary care setting

Krpalek, D., Javaherian-Dysinger, H., & Hewitt, L. (2016). Designing occupational therapy services in a primary care setting: Successful strategies and lessons learned

[Powerpoint]. Retrieved from https://s3.amazonaws.com/v3-app_crowdc/assets/7/7c/7cdc720a6105b04c/Primary_Care_AOTA_Handout.original.1458676010.pdf

Describes the process of integrating into a primary care setting:
Part One: Scoping out the land
- Vision: have a vision for OT in primary care, how it fulfills the mission of the organisation, how it will impact health and current healthcare system
- Collaboration: Identify collaborators, network
- Know the needs: Identify common diagnoses and describe patient panel
- Advocate: sell yourself and your idea
Part Two: Structural Design
- Planning OT intervention
  - How does the organization run? Identify administrative/workflow processes
  - How could OT services fit it? Identify the role of OT, logistics like referral processes
  - What resources are needed? Including space, documentation, materials, supports, and funding
Part Three: Testing the model
- Will require persistence, and will be a back and forth process
- Success story: Partnered with a Family Medicine Practice at Loma Linda University

Lang, J. (2016, February 9). Pacific University clinic offers affordable primary care and much much more.

Retrieved from http://www.pacificu.edu/about-us/news-events/pacific-university-clinic-offers-affordable-primary-care-and-much-more

One-stop suite of health services at clinic locations in downtown Portland (1411 SW Morrison, Ste. 310), and Hillsboro (222 SE 8th Ave., Ste. 212)
Integrated psych, PT, OT, SLP, Primary western and alternative medicine, particularly for low-income clients

Murphy, A. D., Griffith, V. M., Mroz, T. M., & Jirikowic, T. L. (2017). Primary care for underserved population: Navigating policy to incorporate occupational therapy into federally qualified health centers

[Health Policy Perspectives]. American Journal of Occupational Therapy, 71(2): 7102090010p1-7102090010p5. doi: 10.5014/ajot.2017.712001.

Federally Qualified Health Centers (FQHCs) offer primary and preventative health services to medically underserved populations or areas (homeless, low income, migrant workers, marginalized cultural/ethnic groups)
Social Justice and Occupational Justice: incorporation into FQHCs can support both
Funding and reimbursement in FQHCs
- Provide services to patients covered my Medicaid, Medicare, and private insurance
- Medicaid reimbursement varies by state, and includes prospective payment, cost based payments, negotiated fee-for services schedules, and combinations.
  - Prospective payment system: clinic receives a set amount of money for each face-to-face visit between a patient and an FQHC provider. At this time, OT isn’t considered an FQHC provider.
- OTs can typically bill “incidental to” when providing services with a qualified provider
- Overall, OT billing in an FQHC is highly complicated, and due to the variety of payment models (many of which OT cannot participate in), may not enable full reimbursement for overhead costs
Case examples: Current models of OT in primary care
- University of Southern California: Eisner Pediatric and Family Medical Center. A full-time OT was integrated into this FQHC.
  - Funding: Clinic negotiated a higher encounter rate to cover additional costs associated with retaining an OT and providing OT services.
- Saint Louis University (SLU) Model: OT and OT student provided services in a primary care clinic.
  - Funding: The OT was employed by SLU, and had 6 months leave from teaching duties. Students provided services with appropriate supervision
Independent billing model
- A potential option would be to have an OT contract clinic space, and see clients referred by PCPs

Rogers, O., Heck, A., Kohnert, L., Paode, P., & Harrell, L. (2017). Occupational therapy’s role in an interprofessional student-run free clinic: Challenges and opportunities identified.

The Open Journal of Occupational Therapy, 5(3), Article 7. https://doi.org/10.15453/2168-6408.1387

Describes a student-run free clinic (SRFC) in Arizona, where students of 9 professions, including OT, from 3 universities provide interprofessional care
Role of OT: “upper-extremity impairment, musculoskeletal pain, medication management, fall prevention, and behavioral health issues, among many others”
- Address the habits and routines that led to the condition, or that are required to manage the condition. Because the population served (those experiencing homelessness) may not be able to follow up, focusing on self-management is crucial.
- Workflow with other professions and the role and value of OT is described, providing a model for integrated primary care OT services
SRFC as an opportunity for students to learn, share the value of OT with other professions, and provide care for underserved population
Challenges include recruiting and retaining volunteers, limited understanding of role of OT in other professions

Serfas, K. L. (2016, October 10). Pediatrics in primary care: Insights and experiences from one faculty practice model.

OT Practice, 21(18), 12-17. https://www.aota.org/Publications-News/otp.aspx

AOTA has prioritized finding and profiling existing models of primary care that use OT. This is an account from a primary care pediatric OT
- She began by volunteering, with students
  - They accompanied the PCPs into exam rooms, conduct occupational profiles, and developmental screenings (Ages and Stages)
The screen is conducted immediately, and if results indicate further evaluations are needed, referrals are made
PCPs could do the screen. But time constraints, lack of training, and limited knowledge on community resources impair that ability.
- Challenges: continually communicating the OT role, logistics of one OT with multiple PCPs seeing multiple patients simultaneously, and reimbursement
- Benefits: increasing caregiver efficacy by educating on child’s performance and suggesting ways to continue behavior or skill development at home, promoting effective parent/child interactions, and cultivating positive relationships.

Population/Public Health

Braveman, B. (2015, December). Population health and occupational therapy

[Health Policy Perspectives]. American Journal of Occupational Therapy, 70, 7001090010p1-7001090010p6. doi: 10.5014/ajot.2016.701002

Population health is an aspect of the Triple Aim, and not much has been written about OT and population health
- OT can start by integrating population needs into clinical care, or address individual needs on a policy or systems level
  - Primary care OT is a great way to begin with individual patients, and have an impact on larger populations
- Health determinants are largely outside of the healthcare professional's domain, including public health agencies, community organizations, schools, businesses etc.
  - OT is familiar working in all of these settings, and thus could help healthcare partner with them to achieve the population health aims
- Recommendations for the future
  - Articulate the success of OT in population health, and OT’s competency with working at the population level in general
  - Identify specific competencies for population health work, and include them in our Framework
  - Make population health part of our OT and OTA curriculum. Currently it only exists at the doctoral level
  - Celebrate OTs who don’t do direct patient care, but practice OT at the population level

Marval, R., & Townsend, E. (2013). Homelessness: Enabling solutions in primary health-care occupational therapy.

Occupational Therapy Now, 15(5), 17-19.

Currently OT services are underutilized within primary health centers with regard to people experiencing homelessness, a population that is disproportionately exposed to preventable acute and chronic health conditions.
- OTs, recognizing the impact homelessness plays on an individual’s balance of meaningful occupations, can target both individual impairments as well as environmental obstacles that create this imbalance.
  - One such solution is the Mobile Outreach Street Health (MOSH) service, which offers contextually relevant primary care to people who are homeless, street-involved, or at risk of homelessness.
  - This service provided by nurses and a part-time OT, is a population-level approach to realizing equitable health and participation has shown potential to broadly impact both individual MOSH clients and the community as a whole.

Scaffa, M. E., Desmond, S., & Brownson, C. A. (2001). Public health, community health, and occupational therapy.

In M. E. Scaffa (Ed.), Occupational therapy in community-based practice settings (pp. 35–50). Philadelphia: F. A. Davis.

A book on OT in public health, and community based practice settings.

Wood, R., Fortune, T., & McKinstry, C. (2013). Perspectives of occupational therapists working in primary health promotion.

Australian Occupational Therapy Journal, 60(3), 161-170.

This qualitative study explores and describes the primary health promotion practice of community health workers with an OT background working at a community or population (macro) level, rather than at the client service (micro) level, and explores related enablers and barriers to this practice.
- Although some practitioners with an OT background perform primary health promotion, the findings indicate that a number of barriers deter OT from engaging in this type of practice, including lack of funding, preparation and limited understanding of the role of OT in health promotion.
- Enablers to engagement included undertaking further education, gaining clinical experience and establishing a professional identity.

Rural

Health Resources and Service Administration. (2018). HPSA Find

[searchable database]. Retrieved from https://datawarehouse.hrsa.gov/tools/analyzers/HpsaFindResults.aspx

Searchable of Health Professional Shortage areas (HPSAs) in the USA, can search Oregon specifically
- HPSA score (1-26) indicates the priority (26 is highest priority)
Similar information available at http://www.ohsu.edu/xd/outreach/oregon-rural-health/data/health-care-shortage.cfm

Oregon Health Authority. (2013, Jan). 5-year strategic plan for primary care provider recruitment in Oregon.

Oregon Health Policy Board, Oregon Healthcare Workforce Committee. Retrieved from http://library.state.or.us/repository/2013/201302041527201/

HB 2366, in 2011, tasked OHA with creating a strategic plan to recruit more PCPs into Oregon
- Three goals for Oregon’s recruitment plan
  - Produce more PCPs within Oregon
  - Increase effectiveness of external recruitment
  - Support rural and underserved communities in their own efforts to recruit and retain PCPs
Relevance for OT
- Oregon, especially in rural areas, is in need of PCPs. OT integration into primary care in rural areas may be more impactful, and perhaps better received
- This article also has information on loan repayment incentives, which OT can use to advocate for inclusion
- Target Health Professional Shortage Areas, as indicated by maps

Team Based Care

Ghorob, A., & Bodenheimer, T. (2012). Sharing the care to improve access to primary care.

New England Journal of Medicine, 366(21), 1955-1957. doi:10.1056/NEJMp1202775.

Access to primary care services is limited
To improve access, empower the interprofessional team to share the care, not merely follow direct PCP orders
- Prescription refills could be pre-approved and have standing orders
- Non-PCPs can do counseling on lifestyle for chronic conditions
- Panel managers can survey the registry on the whole panel, and see where the gaps are in routine/preventable services
The most significant barrier is the discomfort that many PCPs feel about giving up decisions regarding preventive and chronic care, which, though seemingly routine, are often complicated by patients' various coexisting conditions, preferences, and goals. Also, ensuring that the non-PCP services are billable.

Johnson, C. E. (June 2017). Understanding interprofessional collaboration: An essential skill for all practitioners.

OT Practice, 22(11), CE1 - CE8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

A continuing education article that describes OT’s role in supporting interprofessional collaboration (IPC). Discusses the principles and importance of IPC, offers case examples and strategies for implementing IPC principles.

Leclair, L. (2013). Occupational therapists in primary health care and primary care: Important contributors to the interprofessional team.

Occupational Therapy Now, 15(5), 3-4.

Despite the provided opportunities for OTs to integrate into primary care settings, through the emphasis on interprofessional collaborative care teams, many PCPs still have limited exposure to OT and their scope of practice.
Authors suggest building partnerships with and educating PCPs, policy makers, and the broader public on ways OT can ease the workload and support practice.
- This includes addressing falls and mobility issues, promoting health and wellness, facilitating return to work, providing support and education to caregivers, as well as assisting with chronic pain and chronic disease management.

Loria, K. (2015). Innovative models of care delivery.

PT In Motion, 7(8): 25-30. Retrieved from http://www.apta.org/PTinMotion/2015/9/Feature/InnovativeModels/

APTA is funding new PT care delivery models, and will publish the outcomes
- Childhood obesity in a PCMH
  - This trial will generate cost-effectiveness data, using a 12-month RCT
  - Studying the clinical and cost effectiveness
- Chronic back pain in ACOs
  - This trial will see if conservative PT intervention can reduce utilization of more costly MRIs, surgery, etc.
  - Evaluate the role of early access to PT in reducing cost of care and improving client outcomes
www.apta.org/innovation2/
- Initiative aimed at improving PTs role in innovative healthcare models.

Cost Effectiveness

Dahl-Popolizio, S., Rogers, O., Muir, S., Carroll, J. K., & Manson, L. (2017). Interprofessional primary care: The value of occupational therapy.

The Open Journal of Occupational Therapy, 5(3), article 11, 1-10. doi: 10.15453/2168-6408.1363.

Overview of OT education and the cost/benefit of integrating OT into primary care from a fiscal perspective
Includes typical day with CPT charges, and revenue due to PCPs treating more medically oriented cases, having deferred chronic health/lifestyle patients to OT

Hart, E. C. & Parsons, H. (2015). Cost-Effective Solutions for a Changing Health System

[AOTA PDF]. Retrieved from http://www.aota.org/about-occupational-therapy/professionals/ebp/cost-effective-health-care-reform.aspx

OT has shown effectiveness in the following arenas:
- Age-Related Decline
  - OTs can provide effective and economical activity-based interventions that maximize independence and enhance functioning for older adults.
- Falls Prevention
  - OT interventions save money by reducing fall risk and mortality in older adults through environmental modifications and person factors
- Alzheimer's Disease and Related Dementia
  - OT reduces need for care and saves money by improving health status and QOL for patients and caregivers while decreasing admissions, through environmental modification, evaluation of daily routines, wellness-promoting activities, restoring physical skills, education and training
- Chronic Pain
  - Identify pain triggers, teach techniques to decrease the frequency and duration of pain, and recommend adaptive strategies to decrease pain during tasks
  - Cost savings by improving function, increasing return-to-work rates, reducing disability claims, and decreasing dependence on prescription medications

Hay, J., LaBree, L., Luo, R., Clark, F., Carlson, M., Mandel, D., … & Azen, S. P. (2002). Cost-effectiveness of preventive occupational therapy for independent-living older adults.

Journal of the American Geriatrics Society, 50(8), 1381–1388. doi:10.1046/j.1532-5415.2002.50359.x

A RCT (n 163) demonstrating the cost-effectiveness of the OT program used in the Well Elderly study (see Clark et al, 1997)
Preventative OT demonstrated cost effectiveness in conjunction with a trend towards decreased health expenditures, when compared to a “social activity” control group

Nagayama, H., Tomori, K., Ohno, K., Takahaski, K., & Yamauchi, K. (2015). Cost-effectiveness of occupational therapy in older people: Systematic review of randomized controlled trials.

Occupational Therapy International, 23(2), p. 103. doi: 10.1002/oti.1408

Review of five RCTs of high-quality economic evaluation of OT services for older adults: two on falls prevention, two on preventative OT services, and one on OT services for people with dementia.
Conclusion: Two of the five studies found significant clinical effect and cost effectiveness

Rexe, K., McGibbon Lammi, B., & von Zweck, C. (2013). Occupational therapy: Cost-effective solutions for changing health system needs.

Healthcare Quarterly, 16(1), 69-75.

This article aligns the Canadian health reforms with the cost-effectiveness of OT.
- OT is cost-effective in treating or preventing injury and improving health outcomes in falls preventions, musculoskeletal injury, stroke rehab, early intervention in developmental disabilities, respiratory rehab, & home care
- OT can be beneficial in chronic disease, pain management, mental health, dementia, end-of-life or palliative care, Case management, injury prevention, caregiver education, prevent hospitalization, reduce hospital stay length
Canada’s healthcare system is facing similar challenges and undergoing similar reforms in philosophy as the USA
- High cost, aging population, and chronic conditions. vs. Team-based care, value driven, and cost-effectiveness.
Based on the literature, these are cost-effective opportunities for OT in the new reforms
- Shortening length of hospital stays
  - There aren’t enough beds and longer stays are expensive.
- Increased effectiveness of community-based services
  - Hospitalization is expensive
  - This is the point to support preventative, primary care.
- Reducing costs of pharmaceutical intervention Specifically for mental health issues
  - Drugs are expensive
- End of life care
  - Dying is expensive.

Richardson, J., Letts, L., Chan, D., Stratford, P., Hand, C., Price, D., & Law, M. (2010). Rehabilitation in primary care setting for persons with chronic illness: A randomized controlled trial.

Primary Health Care Research and Development, 11, 382-395. doi:10.1017/S1463423610000113.

RCT of six-week self-management workshop led by PT and OT for adults with chronic illness in a primary care setting
- Suggests cost-effectiveness of OT and PT in primary care as decreasing inpatient days. But no reduction of emergency department visits or health status.

Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates.

Medical Care Research and Review 74(6), 668-686. doi 10.1177/1077558716666981

“OT is the only spending category where additional spending has a statistically significant association with lower readmission rates” in a hospital setting, for three health conditions: heart failure, pneumonia, and acute myocardial infarction
Six specific OT interventions to lower readmissions
- Provide recommendations and training for caregivers
- Determine whether patients can safely live independently, or need further rehab or nursing care
- Address existing disabilities with assistive devices, so patients can safely do ADLs
- Perform home safety assessments before discharge and suggest modifications
- Assess cognition and ability to physically manipulate daily objects, and provide training when necessary
- Work with PT to increase rehab intensity

Category Three

General Practice

American Psychological Association. (2016). A curriculum for an interprofessional seminar on integrated primary care.

Retrieved from http://www.apa.org/education/grad/curriculum-seminar.aspx

Provides a series of 8 curricular modules designed to foster the competencies necessary for working in integrated primary care settings.
Designed to be implemented in a education setting for students, and taught by an interprofessional group of instructors

Baily, (2017, July 10). Putting goals into action for health behavior change.

OT Practice, 22(12), 19-21. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Health Management and Maintenance IADL includes promoting healthy routines, which are important to health promotion and disease prevention
Help clients to identify barriers to healthy occupations, and the contexts that contribute to unhealthy behaviors
Develop goals: performance vs mastery goals, approach vs avoidance goals, challenging vs easy goals
Develop action and coping plans
- Action plans: Specify where, when and how a specific behavior will be performed
- Coping plans Identify barriers that might derail an action plan, and pre-plan alternative options
Help clients to self-monitor: may use activity trackers, phone apps, food diaries
Enlist social supports

Bracken, A. (2017, May 8). Engaging challenging clients through motivational interviewing.

OT Practice, 22(8), 20-22. Retrieved from https://www.aota.org/Publications-News/otp.aspx

MI is a useful strategy for use with clients who are reluctant or ambivalent about actively addressing their condition
When using MI:
- Ask open-ended questions: “What are your goals?” “How do you feel about the plan we created?”
- Identify client’s readiness to change: Do they believe change is needed? Are they ready to select and make changes? Ask them to identify pros/cons of change
- Use reflective listening: paraphrase responses, summarize
- Be optimistic about positive change: Believe in client’s ability to change
- Serve as a collaborator: promote client’s active participation and ownership of their problems
- Recognize the emotions of change: expect an ebb and flow of progress/change
- Offer feedback: ask permission to give feedback, give non-judgmental feedback, ask for client’s input regarding the feedback
- Give clients options: Give variety of choices so client can pick what works for them, empowering them to make choices
- Invite decision making: Ask them what they’re going to do next, invite them to problem solve

Bristow, H. (2017). Apps for health promotion and occupational engagement.

Administration and Management Special Interest Section Quarterly, 2(4), 13 - 15. Retrieved from https://www.aota.org/Publications-News/SISQuarterly/Administration-Management/11-17-behavioral-change.aspx

Article suggests apps that may help clients to implement lifestyle changes to promote health and wellness
- Diabetes care: mySugr app, mySugr Logbook app
- Medication management: Medisafe app
- Exercise: RunKeeper app, Noom app
- Patient compliance related to reading and understanding handouts and instructions: Voice Dream Reader app

Burson, K. & Synovec, C. (2016). The OT generalist: The why and how to

[Powerpoint]. Presentation at AOTA National Conference, Chicago, IL. Retrieved from https://s3.amazonaws.com/v3-app_crowdc/assets/c/c5/c57ecaa151f45147/The_OT_Generalist_-_Final.original.1459822266.pdf

Identify population needs: diabetes, COPD, asthma, arthritis/pain, hypertension, heart disease, cancer, acquired brain injury, mental illness, and substance use
- Describe each in terms of prevalence, impact
- Discuss occupational performance and its potential impact on social determinants of health
- Modifiable risk factors: health behaviors
Discuss policy trends that support OT in primary care, and the impact OT could have in primary care
How to be an OT generalist
- OT’s distinct value: grounded in occupation, promotes full participation in life, which promotes mental and physical health
- Describes our distinct value in assessment and intervention
- Activity analysis: As a generalist, consider ALL components and factors, use the OTPF to guide
- Discuss how to get started in an organization: evaluate setting, identify areas of need that OT can fill, identify service provision model (how to deliver care)
- Global assessments: COPM, MOHOST
- Describe evaluation methods, strategies and adaptations for: cognition, physical rehabilitation, mental health
- This section is somewhat long and seemingly valuable
- Billing: the key is to tie whatever you are doing to medical necessity. Know insurance source and allowable services/encounter data

Chromiak, S.B., Scaffa, M.E., & Norris, S. (2014). Occupational Therapy in Primary Health Care Settings.

Chapter 27 in Scaffa, M.E. & Reitz, S.M. (Eds.). Occupational Therapy in Community-Based Settings (2nd Ed.). Philadelphia: FA Davis.

Describes OT contributions and strategies in primary care related to:
- Health promotion assessments and interventions across the lifespan
- Prevention
- Intervention in weight loss, smoking cessation, low back pain, domestic violence, and mental health conditions
- Medication management, health literacy interventions, and self-management of chronic conditions
- Health risk appraisals, patient education, and caregiver services

Clark, F. A., Blanchard, J., Sleight, A., Cogan, A., Florindez, L., Gleason, S.,… Vigen, C. (2015). Lifestyle Redesign: The intervention tested in the USC Well Elderly Studies

(2nd ed.). AOTA Press. Retrieved from https://myaota.aota.org/shop_aota/prodview.aspx?TYPE=D&PID=247034959&SKU=900359

This is the manual for how to incorporate the famously effective Well Elderly (see Clark et al., 1997, 2012) techniques into practice.
They also have a webcase continuing education series, https://myaota.aota.org/shop_aota/prodview.aspx?TYPE=K&KID=Lifestyle+Redesign

Dahl-Popolizio, S. (2015). Occupational Therapists Treating the 'Whole Person' in Primary Care: How do we do that?

[Powerpoint]. Retrieved from OccupationalTherapy.com

A discussion of the role of and need for OT in primary care
- Statistics and citations on chronic conditions, cost of care, and other factors relevant to primary care OT
A list of several assessments that are relevant for primary care, and a website where many assessments can be found: http://www.rehabmeasures.org/default.aspx, and a discussion of the evaluation process in primary care
- MMAS (Morisky Medication Adherence Scale)
- COPM (Canadian Occupational Performance Measure)
- FOTO (Focus On Therapeutic Outcomes – specific body part assessment related to function)
- PHQ-9 (Patient Health Questionnaire -9)
- GAD-7 (General Anxiety Disorder – 7)
- The DUKE (General Health Profile)
Examples of primary care OT interventions for conditions including COPD, diabetes, irritable bowel syndrome, cardiovascular disease, and musculoskeletal issues.

DeRosa, J. (2013, September 23). Providing Self-Management Support to People Living with Chronic Conditions.

OT Practice, 18(17), CE1 - CE8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Discusses factors contributing to health reform, the ACA and subsequent reimbursement changes, intrinsic motivation and behavior change, and self-management techniques
- CMS sets reimbursement standards that other payers follow, including pay-for-performance, which incentivizes coordinated care and improved quality metrics. OT needs to clearly deliver value in order to be a part of this new paradigm.
- OTs can work with patients to help manage chronic conditions to improve patient satisfaction and health outcomes.
  - Nurture internal motivation through building a sense of competence, self-determination, and investment in change
  - Use motivational interviewing techniques including asking open ended questions, offer affirmation and empathy, use reflective listening, develop discrepancy, roll with resistance, and summarize
  - Home Health Quality National Improvement Campaign best practice for self-management includes establishing a clear focus, educate client at a graded level, develop shared goals, create a clear action plan, and use a problem-solving approach.

Donnelly, C. A., Brenchley, C. L., Crawford, C. N., & Letts, L. J. (2014). The emerging role of occupational therapy in primary care:

Le nouveau role de l'ergotherapie dans les soins primaires. Canadian Journal of Occupational Therapy, 81(1), 51-61. doi:10.1177/0008417414520683

A multiple case study on the roles of OT in the Family Health Teams model of interprofessional primary care
Authors describe six themes of OT in primary care
- OT as generalist
  - Across the lifespan, wide array of interventions. Eg. Older adults (cognition, falls prevention, home safety), Complex chronic conditions, Chronic pain
- Focus on function
  - This is the common thread across the diverse caseload, unique to OT on the primary care team, and valuable
- Challenge of managing caseloads
  - OT will be underutilized if the PCPs don’t understand their role
  - Focus on team priorities: Don’t do everything, do what your team needs
  - Consider group interventions
- Enhancing access to OT
  - Depending on the client’s insurance, they might not otherwise be able to see an OT
  - Connection to community resources, like the focus on function, were more unique to OT
- Multiple influences shape the OT role
  - Personal factors: Clinical experiences and interests influence the clients they work with
  - Organizational and Community factors: Fit your organization, fit your community
- Outcomes and assessments
  - It is difficult to assess if OT is effective in this setting, because you can’t and shouldn’t separate it from the team
  - OTs need to more accurately assess effectiveness with standard measures.
  - Assessments OTs used in primary care, arranged from most to least used
    - Pediatric
      - Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI)
      - Sensory Processing Measure
      - Sensory Profile
      - Behaviour Rating Inventory of Executive Function (BRIEF)
      - Alberta Infant Motor-Scale
      - Children’s Handwriting Evaluation Scale (CHES)
      - Developmental COordination Disorder Questionnaire
      - Goodenough-Harris Draw-a-person Test
      - Movement ABC
      - Peabody Developmental Motor Scales
      - Test of Visual-Perceptual Skills
    - Older Adult
      - Berg Balance Scale
      - Brief Pain Inventory
      - Canadian Occupational Performance Measure (COPM)
      - Clock Drawing
      - Montreal Cognitive Assessment (MoCA)
      - Timed Up and Go (TUGS)
      - Trails A & B
      - Cognitive Linguistic Quick Test (CLQT)
      - Safety Assessment of Function and Environment for Rehabilitation (SAFER)
      - 6 Minute Walk Test
      - ABC Balance Confidence Scale
      - Assessment of Motor and Process Skills
      - McGill Pain Questionnaire
      - Motor Free Visual Perceptual Test

Donnelly, C., O’Neil, C., Bauer, M., & Letts, L. (2017). Canadian Occupational Performance Measure (COPM) in primary care: A profile of practice.

American Journal of Occupational Therapy, 71, 7106265010. https://doi.org/10.5014/ajot.2017.020008

There is no published research on outcomes of OT intervention in primary care
COPM is a good fit for primary care due to its focus on occupation and function rather than medical symptoms
- Home management (n = 101), functional mobility (n = 91), and active leisure (n = 83), were the top three issues reported by primary care OTs in Canada
- COPM is a valuable tool for assessment and goal-setting, but there was a challenge in finding an opportunity to reassess with the tool.

Fisher, G., & Friesema, J. (2013). Implications of the Affordable Care Act for occupational therapy practitioners providing services to Medicare recipients

[Health Policy Perspectives]. American Journal of Occupational Therapy, 67(5), 502-506. doi:10.5014/ajot.2013.675002

Medicare population is on the rise, and other reimbursers often follow Medicare’s suit. Understand the changes to Medicare and the ACA, and find the opportunities
- Develop evidence-based, interprofessional, site-specific best practice protocols
- Model client-centeredness to your team, to improve patient satisfaction
OT helps prevent hospital acquired injuries, and also help prevent readmission
- Develop protocols to make sure that patients can safely manage their ADLs and IADLs
  - Educate patients and family members about which warning signs that warrant a hospital visit, and what does not
  - Work on self-management: medication management, cognitive, sensory or physical accommodations
  - Assess for fall risk, and environmental hazards
  - Engage client in therapeutic occupations that will build strength, endurance, cognitive, and functional capacities.
- Work with your team to ensure that everyone understands how health literacy affects outcomes

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel.

Washington, D.C.: Interprofessional Education Collaborative. Retrieved from https://ipecollaborative.org

Interprofessional goals in education, to create a cohesive, client-centered healthcare workforce
- Four competency domains
  - Values/Ethics for interprofessional practice
  - Roles/Responsibilities
  - Interprofessional Communication
  - Teams & Teamwork

Muir, S. & Dahl Popolizio, S. (2016). Enhancing efficiency and value of the integrated primary care team: Occupational therapy.

[PowerPoint]. 2016 Integrated Healthcare Conference, Tempe, AZ.

Roles of OT in primary care:
- Behavioral health roles: care managers, behavioral health consultants, behavioralists, etc.
- Intervention foci: chronic conditions, roles, habits and routines, patient activation and chronic care self-management, pediatrics, upper extremity, mental/behavioral health, compensatory techniques and equipment
Efficiency and effectiveness enhances by integrating OT
- OT can see patients who have functional needs, and not medical needs. This frees up the PCP to see more acute and medically-oriented cases.
- Metrics: prevention, cost savings by reduced utilization, patient satisfaction, provider satisfaction, increased access to care, time efficiency
OT and population health
- Group interventions, stratified for risk
The Muir Model of OT in Primary care
- Who is a primary care OT:
  - Able to work at the Top of the License
  - A true generalist, able to work across the lifespan and support mental, behavioral, and physical health.
  - OTs in specialized and advanced practices
  - Knowledgeable about the domain and process, practices by the Code of Ethics
  - Independent, critical, creative, and able to act as a self-advocate
- Roles of a primary care OT:
  - Initial contact or main provider for some issues
  - Case management
  - Health promotion, disease prevention
  - Screenings
  - Chronic disease/mental or behavioral health management
- Value of OT in primary care:
  - Prevent complications and hospitalizations
  - Cost savings
  - Patient and provider satisfaction
  - Increased efficiency and access
- Essential components of primary care OT:
  - Top of the license principle
  - Contextualized, client-centered assessments
  - Brief direct interventions, with contact over a lifetime
  - Screening and prevention, home safety, wellness promotion
  - Chronic disease management
  - “Intrusionary OT”

Muir, S., Henderson-Kalb, J., Eichler, J., Serfas, K., and Jennison, C. (2014, August 25). Occupational therapy in primary care: an emerging area of practice

[Continuing education article]. OT Practice, 19(15), CE1-CE-8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Describes the issues surrounding healthcare, and the ACA’s attempts to ameliorate them
- Primary care as defined by the ACA: integrated, accessible, sustained relationship, within the context of community
  - Includes family practice, pediatrics, geriatric, and internal medicine
  - PCPs include MDs, DOs and mid-levels
- ACOs, PCMHs, Federally Qualified Health Centers (FQHCs)
Primary care health conditions
- This is not the intensive therapy that would be appropriate for outpatient rehab. Focus on education and home exercise programs, emphasizing self-efficacy and patient responsibility. Bridge the PCPs recommendations and client compliance
Opportunities for OT and primary care
- OT is by nature holistic, across the lifespan, client-centered, function focused, generalist
- Occupational participation is a determinant of health
- Interventions vary for each client, but focus on remediation, prevention, health promotion, and establishment of healthy occupational routines.
Funding options for OT in primary care
- The lack of a clear mechanism for funding OT services in primary care is a major barrier.
- Bundled payments allow for a fixed dollar amount to cover a set of services for a specific issue, defined as an episode of care, for a set time period.
- A first step would be to get a National Provider Identifier (apply at https://nppes.cms.hhs.gov)
- Credentialing agencies, that are needed to establish the employee as a billable provider, may not credential OTs.
  - But, the medical practice can contact each insurance provider to determine whether OT services can be billed as a separate provider under the general provider number of the department or practice, or “incident to” the physician’s services.
    - That means we would bill under the PCPs number
      - The PCP would need to do the initial visit, but then OT could do follow-up visits, without the PCP, and still use their number
    - OT would need to write a treatment encounter note for each session.
- Some state practice acts require a referral from PCPs before OT can be provided.
  - Treatment requirements are separate from referral requirements established by a payer
- Understand Medicare guidelines, as many private insurers follow their lead.
- Be sure to document clearly, using language that clearly describes deficits and how they impact functioning.
  - Goals must be measurable and achievable in one or two sessions.

Murphy-Turliuk, A. (2013). Ontario occupational therapists’ experience of integrating into family health teams.

Occupational Therapy Now, 15(5), 9-11.

Explores the role of 22 OTs in primary care practice at community-based clinics, known as Family Health Teams (FHTs) in Ontario.
- Describes the methods used, formation of strategic partnerships, activities undertaken, resources developed, and support provided to both members and teams that provided the foundation for integration of OTs into FHTs throughout Ontario.
- Recommendations
  - Conduct a needs assessment of the patient list) using EMRs to identify common intervention needs
  - Inventory existing OT services in the area to assist with triaging referrals and avoiding duplication of service.
  - Establish communication with the local home health OT agencies to enhance referrals to each other
  - Identify high utilizers that may benefit from OT intervention. However, avoid duplicating already available services
  - Don’t try to be all things to all people, i.e.,state what your scope of practice includes/excludes and make referrals accordingly.
- Themes:
  - Demand for service varies, sometimes there is a waiting list, and sometimes OT is underutilized due to PCPs limited knowledge of OT role.
  - It is a challenge to use the OT effectively when there are multiple sites to serve
  - Communication is a challenge where there are multiple EMRs.
  - There is a need for both workload measurement tools and outcome measures to be used uniformly.
  - Devote some time to indirect service for the team as a consultant for system navigation of local healthcare resources.
  - There is a consistent need for service due to the aging demographic.
  - OTs need to constantly educate the team and promote occupational therapy services to ensure the flow of referrals and build a case for future growth

Naumann, D. N. (2013). Occupational therapists as knowledge brokers: Leading knowledge translation in primary care.

Occupational Therapy Now, 15(5), 29-30.

Knowledge translation (KT) is emerging as an important competency for Canadian OTs; this involves applying emerging research findings to clinical environments in order to provide health-care services that support current best practice.
However, the complex and busy primary care environment contains many barriers to the utilization of KT.
- The authors continue by arguing that OTs are in an ideal position to lead KT in primary care, as the field’s unique skill sets and education prepares OT with the tools and knowledge required to understanding the learning needs of an interprofessional audience.
- As knowledge brokers in primary care practice, OTs can offer innovative client-centered approaches to KT that consider the clinician (person), occupation, and environmental factors preventing KT’s full utilization in primary care.

Schwartz, J. K., Grogan, K. A., Mutch, M. J., Nowicki, E. B., Seidel, E. A., Woelfel, S. A., & Smith, R. O. (2017). Intervention to improve medication management: Qualitative outcomes from a Phase I randomized controlled trial.

American Journal of Occupational Therapy, 71, 7106240010. https://doi.org/10.5014/ajot.2017.021691

OT is effective in increasing medication management skills and can lead to self-perceived improvements and the adoption of new medication management behaviors.
Manualized 30-min OT intervention, the Integrative Medication Self-Management Intervention (IMedS), developed by an OT on the basis of theory, current practice, and best evidence. The intervention manual is available by request.
- Three-step process: 1) review of 2-week medication diary and medication adherence questionnaire. 2) client makes a medication goal 3) develop strategies to meet the goal
- IMedS protocol prompts the OT to have the client consider strategies in the following six areas: (1) altering the activity, (2) advocacy, (3) education, (4) assistive technology, (5) environmental modifications, and (6) securing timely refills.

Schwartz, J. K., & Smith, R. O. (2017). Integration of medication management into occupational therapy practice

[The Issue Is]. American Journal of Occupational Therapy, 71, 7104360010. https://doi.org/10.5014/ajot.2017.015032

Describes the unique role and qualifications of OTs to address medication management, with consideration for impact and implication of healthcare reform

Defines medication management, compares OT to other professions’ job skills relevant to medication management, describes factors related to medication adherence, relates medication management to current healthcare priorities and reform, recommends more pharmacology education for OTs

Evidence-Based Practice

AOTA (n.d.) Evidence-based practice & research

[Website]. Retrieved from http://www.aota.org/Practice/Researchers.aspx

The AOTA collection of resources for OTs looking to support their practice with evidence
- Including Evidence-Based Practice (EBP) Resource Directory
  - An online service that links users to web based EBP resources

Bennett, S., Hoffman, T., McClusky, A., McKenna, K., Strong, J., & Tooth, L. (2003). Introducing OTseeker

(occupational therapy systematic evaluation of evidence): A new evidence database for occupational therapists. American Journal of Occupational Therapy, 57(3), 635-38. doi:10.5014/ajot.57.6.635

Free service for OTs to increase access to research to support clinical decisions
www.otseeker.com

Health Measures (2018). PROMIS®.

Retrieved from http://www.healthmeasures.net/explore-measurement-systems/promis

PROMIS® (Patient-Reported Outcome Measurement Information System): A collection of free, person-centered, validated self-report measures assessing physical, mental and social health in adults and children. Available in many languages.

Diabetes, Fatigue, & Other Chronic Conditions

AOTA. (2011). AOTA fact sheet: Occupational therapy’s role in diabetes self-management.

Retrieved from https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/Diabetes%20fact%20sheet.pdf

OTs can play a strong role in diabetes education and self-management for individuals with or at risk for diabetes by providing education and training to modify habits and routines and develop new ones to promote healthier lifestyle and minimize disease progression
- Help clients develop simple, concrete, measurable and achievable self-management goals consistent with the seven behaviors advocated by the American Association of Diabetes Educators (AADE) (healthy eating, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risk)
Offers specific intervention suggestions for OTs working with patients experiencing diabetes

AOTA (2017, August 21). OT news: Medicare diabetes prevention program expanded model.

OT Practice, 22(15), 3. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Organizations can classify as Medicare Diabetes Prevention Program “suppliers” if they meet the CDC requirements
- All providers involved, including the OTs, would need to be a certified diabetes educator, and submit their active NPI numbers
- The program developed would need to consist of 16 core sessions of a CDC-approved, 6-month group curriculum, and follow up sessions
- The primary goal is 5% weight loss
- Services would be billed by the “supplier” organization, and not by the individual clinician.
- CMS has a fact sheet about this new model: https://goo.gl/7Thvad

Cahill, S. M., Polo, K. M., Egan, B. E., & Marasti, N. (2016). Interventions to promote diabetes self-management in children and youth: A scoping review.

American Journal of Occupational Therapy, 70(5). 7005180020p1-7005180020p8. doi: 10.5014/ajot.2016.021618.

Exploration on the literature surrounding self-management interventions for youth with diabetes.
The ACA supports diabetes self-management through a variety of programs and provisions
Daily occupations and routines provide a natural framework in which to embed disease self-management skills and behaviors
- Address self-management readiness skills in children younger than age 14
- Provide self-management education to children older than 14
- Involve parents, and consider integrating technology

Connolly D., O'Toole L., Redmond P., Smith S. M. (2013). Managing fatigue in patients with chronic conditions in primary care.

Family Practice, 30(2), 123-124.

Discusses a systematic review and other research to apply to primary care OT intervention for fatigue
- Systematic review: OT-led fatigue management interventions are a promising approach to fatigue management.
  - Intervention goals: Increase understanding of fatigue; assist in identifying factors that exacerbate fatigue; facilitate fatigue management strategies
  - Process: Analysis of daily activity energy requirements; education on pacing/planning/prioritizing, work simplification, body mechanics, adaptive equipment, and environmental modification; addressing related factors including sleep, anxiety, nutrition, and problem solving skills
- 6-week group-based energy management program for patients with multiple sclerosis resulted in decreased impact of fatigue, increased self-efficacy, improved QOL and continued implementation of fatigue management strategies at 1-year follow-up period.
Predictors of response to self-management interventions include ‘readiness to change’, willingness to adopt new behaviours and higher baseline of self-efficacy, as well as higher socio-economic and functional status. Increasing age may be associated with decreased motivation to adopt new behaviors.

Cornforth, A. (2010). The management of asthma in primary care.

Nurse Prescribing, 8(11), 520- 524. https://doi.org/10.12968/npre.2010.8.11.79785

This article discusses the management of asthma in a primary care setting.
- Important interventions include patient education, medication management, and developing personalized action plans.

Hand, C., Law, M., & McColl, M. A. (2011). Occupational Therapy Interventions for Chronic Diseases: A Scoping Review.

American Journal of Occupational Therapy, 65(4), 428-436. doi:10.5014/ajot.2011.002071

Review of 16 outcome studies involving OT intervention (alone or within a multidisciplinary team) addressing chronic diseases.
Authors conclude that, while conflicting evidence does exist, OT intervention can improve occupational outcomes for adults with chronic diseases.
Authors describe focus and outcomes of various studies related to areas of occupation, physical and mental health, and group and individual interventions

Hart, E. (October, 2015). The key to managing a chronic condition

[podcast]. Everyday Evidence Podcast Series. Retrieved from http://www.aota.org/Practice/Researchers/Evidence-Podcast.aspx

Much of managing a chronic condition is self-management, including meds, and behaviors
- OT intervention is valuable for helping patients know what changes are needed, and strategizing and implementing changes into existing routines and habits
  - It isn’t just one solution to one problem, OT teaches the clients a process that empowers the client to identify challenges and problem solve
  - Energy conservation and prioritizing are key

Hughes, J. L. (2009). Chronic fatigue syndrome and occupational disruption in primary care: Is there a role for occupational therapy?

British Journal of Occupational Therapy, 72(1), 2-10.

A great degree of occupational disruption caused by chronic fatigue syndrome (CFS) and myalgic encephalomyelitis (ME) is reported in primary care, especially in self-care and productivity. Occupational disruption is not managed adequately by PCPs, and could be addressed by OTs to prevent occupational dysfunction
- Patients value acknowledging the condition and its implications, graded exercise therapy, CBT, energy conservation and information on CFS/ME
- Focus on impact of occupational disruption on personal causation, self-efficacy, habits, roles, interests and values to prevent inappropriate adjustment to chronic illness, role constriction and imbalance, which may lead to secondary disability, poor QOL and social isolation associated with occupational dysfunction, including support in coping with the economic, political and legal implications of CFS/ME and the subsequent stigma and controversy.

Malcolm, M. P. (2018, April). Role of occupational therapy in diabetes care: Identifying intervention targets through research.

Presentation at AOTA National Conference, Salt Lake City, UT.

A discussion of four research studies examining the interrelated risk factors for poor self-management of diabetes.
- 1. Malcolm et al., Relating Activity and Participation Levels to Glycemic Control, Emergency Department Use, and Hospitalizations in Individuals With Type 2 Diabetes:
  - More time spent in occupations in the home is associated with higher A1c
  - Hospitalization and ED use rates increased with lower overall activity, more sedentary behavior, and more in-home socialization
  - Patients who are younger, are minorities, and have comorbidities are at an increased risk of ED use, and hospital
- 2. Grimm et al., Fall Risk Factors for Individuals with Type 2 Diabetes Mellitus Younger than 65
  - Of adults aged 65 or younger with type II diabetes, increased falls are associated with increased anxiety, depression, fear of falling, and more medications, and obesity, visual deficits and neuropathy factor into those falls
- 3. Alter et al., The Relationship between Quality of Life, Activity, and Participation Among People with Type 2 Diabetes Mellitus
  - QOL in people with type II diabetes is significantly predicted by fear of falling, age, and depression
- 4. Schmid et al. Yoga Improves Quality of Life and Fall Risk-Factors in a Sample of People With Chronic Pain and Type 2 Diabetes
  - Yoga improves QOL and fall risk factors in a sample of people with chronic pain and type II diabetes

O’Toole, L., Connolly, D. & Smith, S. (2013). Impact of an occupation-based self-management programme on chronic disease management.

Australian Occupational Therapy Journal, 60(1), 30-38. doi:10.1111/1440- 1630.12008

This pilot study with 16 participants aimed to assess the feasibility and potential impact of an occupation-based self-management programme for community living individuals with multiple chronic conditions.
- Six weekly group sessions were provided by an OT with support from interprofessional team. Each session included education and goal-setting. Topics included activity and health, fatigue management, mental wellbeing, physical activity, medication management and communication with health professionals
- Significant differences were found, including frequency of activity participation, self-perceptions of occupational performance, and satisfaction with occupational performance
The results support the feasibility of such a program.

Patel, H. N., Freeman, A. M., & Williams, K. A. (2017). Diabetes: An opportunity to have a lasting impact on health through lifestyle modification.

American Journal of Managed Care, 23(4), COV1, SP144 - SP146. Retrieved from http://www.ajmc.com/journals/evidence-based-diabetes-management/2017/march-2017/Diabetes-an-opportunity-to-have-a-lasting-impact-on-health-through-lifestyle-modification

A review of evidence of lifestyle modification for diabetes management or remission
- Research supports multicomponent interventions, targeting emotional, social, or family processes involved in diabetes management
- Evidence-based lifestyle modifications include: physical activity, adopting healthier eating practices, managing stress, and using social-environmental support to initiate and sustain health-related behaviors.
  - Effective lifestyle modification requires patient knowledge, problem-solving skills, motivation, environmental support and effective coping skills
- Lifestyle modification is an evidence-based, effective, and economical way to treat type 2 diabetes, but is under-utilized by medical professionals, despite strong evidence.
  - Diabetes-related care accounts for more than $1 of every $5 spent on healthcare in the US

Pyatak, E. A. (2011). The role of occupational therapy in diabetes self-management interventions.

OTJR Occupation, Participation and Health, 31(2), 89–96.

Systematic review. Key findings:
- OT-led intervention for diabetes self-management should incorporate personal and contextual factors while providing long-term support.
- Interventions must include aspects of skill building and education with customization and self-tailoring to adapt interventions for individual needs.
- OT intervention can also address secondary complications of diabetes such as sensation loss and low vision.

Pyatak, E. A., Carandang, K., Vigen, C. L., Blanchard, J., Diaz, J., Concha-Chavez, A., ... & Peters, A. L. (2018). Occupational therapy intervention improves glycemic control and quality of life among young adults with diabetes: The Resilient, Empowered, Active Living With Diabetes (REAL Diabetes) randomized controlled trial.

Diabetes Care, dc171634. https://doi.org/10.2337/dc17-1634

RCT evaluating a manualized OT intervention (REAL Diabetes Intervention) for young adults with diabetes.
- Methods: Intervention group attended bi-weekly sessions guided by manual with seven content modules; control group got bi-weekly phone calls and standardized education materials
- Results: Intervention group showed improvement in HbA1c (blood sugar), diabetes related QOL, and habit strength for checking blood sugar
- Conclusion: “The REAL diabetes intervention improved blood glucose control and diabetes related QOL among a typically hard-to-reach population, providing evidence that a structured OT intervention may be beneficial in improving both clinical and psychosocial outcomes among individuals with diabetes”
REAL diabetes intervention is modeled after Lifestyle Redesign OT intervention framework
- Modules: Assessment and goal setting; living with diabetes (basic self-management knowledge and skills); access and advocacy (accessing healthcare and self-advocacy in healthcare and community settings); activity and health (establishing and maintaining health promoting habits and routines); social support (receiving desired support from family and friends and connecting to the diabetes community); emotional wellbeing (managing stress and coping with diabetes-related burn-out); long-term health (reflecting on progress and planning for the future)
- OT performs assessment, then picks relevant topics from the remaining six modules based on the client’s goals and needs. Manual is conceptualized as a “menu” of possible treatment goals and activities.

Rao, A. K. (2014). Occupational therapy in chronic progressive disorders: Enhancing function and modifying disease.

American Journal of Occupational Therapy, 68(3), 251-253. doi:10.5014/ajot.2014.012120

Reviews meta-analysis published by the British Medical Journal on exercise vs. drugs on mortality outcomes in chronic disorders, and applies the findings to OT
- No difference between drugs or exercise in terms of mortality, on preventing coronary heart disease or prediabetes.
  - Physical exercise was more effective than drugs for stroke patients
- Physical activity is a disease modifier for dementias, and evidence is emerging for Parkinson’s as well

Van Heest, K. N. L., Mogush, A. R., & Mathiowetz, V. G. (2017). Effects of a one-to-one fatigue management course for people with chronic conditions and fatigue

[Centennial Topics]. American Journal of Occupational Therapy, 71, 7104100020. https://doi.org/10.5014/ajot.2017.023440

One-to-one fatigue management course run by OTs is effective at decreasing fatigue, increasing self-efficacy, supporting many aspects of QOL, and increasing the implementation of energy conservation strategies for people with chronic conditions and moderate to severe fatigue, especially people with MS.
Introduces fatigue and describes course:
- Five modules: (1) Basics of Fatigue, (2) Communication and Fatigue, (3) Body Mechanics and Making the Most of Your Environment, (4) Analyzing and Modifying Activities, and (5) Living a Balanced Lifestyle.
- 4-6 sessions, 1-2 hrs each
- Education was provided and homework was assigned at each session.

Musculoskeletal

Andrade, J. A., Brandao, M. B., Pinto, M. R. C., & Lanna, C. C. D. (2016). Factors associated with activity limitations in people with rheumatoid arthritis.

American Journal of Occupational Therapy, 70(4), 7004290030p1-7004290030p7. doi:10.5014/ajot.2016.017467.

Handgrip strength and hand ROM deficits limit activity the most for people with rheumatoid arthritis, followed by decreased dexterity and impaired vitality

AOTA (2017). AOTA Critically Appraised Topics and Papers Series: Musculoskeletal disorders.

Administration and Management Special Interest Section Quarterly, 2(4), 13 - 15. Retrieved from https://www.aota.org/Publications-News/SISQuarterly/Administration-Management/11-17-behavioral-change.aspx

Reviews evidence on effectiveness of exercise and work-related interventions to prevent musculoskeletal pain among current workers to facilitate an immediate and sustainable return to work (RTW) for sick-listed injured workers
Clinical scenario: Pain results in lost work days, increased consumption of medical interventions, and decreased QOL
Implications for findings in practice:
- Daily Activities
  - OT interventions less than 12 weeks after injury are more cost effective
  - Intervention should focus on reengagement in ADLs and IADLs, along with specific goals related to return to work
  - CBT alone is not supported by evidence
- Exercise
  - Incorporate exercise that engages the worker in active participation at home, re-engage him/her in daily activities and work
  - Lifting training alone not supported
- Workplace interventions
  - Ergonomics interventions increase work comfort, reduce lost days, pain prevalence and intensity, and injury rate
  - Changes in workplace design, equipment and organization
Focus on strengthening and relaxation exercises, customized for the worker’s unique job requirements and environments
For other critically appraised topics (CATs) on topics including musculoskeletal disorders visit https://www.aota.org/Practice/Rehabilitation-Disability/Evidence-Based.aspx#Musculo

AOTA (2018). AOTA Critically Appraised Topic Series: Rheumatic diseases and conditions.

Retrieved from https://www.aota.org/Practice/Rehabilitation-Disability/Evidence-Based/CAT-Arthritis-Fibro-multi.aspx

Review of high level research reveals strong evidence on the effectiveness of multidisciplinary interventions within the OT scope on occupational performance, pain, fatigue, depression, and sleep for patients with fibromyalgia. Inconclusive evidence for the impact of those interventions on sleep.

Dorsey, J., Bradshaw, M. (2017). Effectiveness of occupational therapy interventions for lower-extremity musculoskeletal disorders: A systematic review.

American Journal of Occupational Therapy, 71, 7101180030p1 - 7101180030p11. https://doi.org/10.5014/ajot.2017.023028

Systematic review on OT interventions for lower extremity (LE) musculoskeletal disorders (MSDs) including: hip fracture, LE joint replacement, LE amputation or limb loss, and non-surgical osteoarthritis pain.
Results support strong role for OT in treating clients with LE MSDs
- Activity pacing found to be effective for nonsurgical LE MSDs
- Multidisciplinary rehabilitation is effective for LE joint replacement and amputation

Lockwood, O., Preston, W., Luu, O., McGuire, O., & Skaria, O. (2015). Back in the saddle: A systematic review of occupational therapy interventions that facilitate return-to-work.

Retrieved from http://jdc.jefferson.edu/cgi/viewcontent.cgi?filename=0&article=1038&context=createday&type=additional

Systematic review on the interventions within the scope of OT to best facilitate return-to-work for adults with musculoskeletal disorders on workers compensation
- Psychosocial interventions (moderate effects), patient education (strong), interdisciplinary (strong), and mode of delivery of services (mixed).

Loveland, J. D. (2017, May 8). Hands down: Upper extremity challenges that can occur in individuals with diabetes.

OT Practice, 22(8), 8 - 13. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Impact of diabetes on hands and upper extremities (UE) may be under-addressed in primary care.
UE Complications from diabetes include: Dupuytren's disease, trigger finger, limited joint mobility (stiff hands), Carpal Tunnel Syndrome, peripheral neuropathy, frozen shoulder (adhesive capsulitis), reduced grip/pinch strength, hand infections, hand ulcers, rotator cuff injury, De Quervain’s Tenosynovitis, shoulder osteoarthritis
Orthopedic assessments for the UE in individuals with diabetes
- Suspected rotator cuff injury: Empty can (supraspinatus) test, Drop Arm Test
- Suspected Glenoid Labrum (SLAP) Tear: Apley’s Scratch Test, Hawkins-Kennedy Impingement Test, Grind Test, Clunk Test, O’Brien Test
- Suspected frozen shoulder (Adhesive capsulitis): Apley’s scratch Test, Loss of PROM & AROM External Rotation > Flexion & Abduction > Internal Rotation
- Wrist and Hand: Tinel’s sign, Finklestein test, Phalen test, Froment’s sign

Marik, T. L., & Roll, S. C. (2017). Effectiveness of occupational therapy interventions for musculoskeletal shoulder conditions: A systematic review.

American Journal of Occupational Therapy, 71, 7101180020. https://doi.org/10.5014/ajot.2017.023127

Literature review found strong evidence supporting range of motion, strengthening exercises, and joint mobilizations for improving function and decreasing pain in people with musculoskeletal disorders of the shoulder.
Moderate to mixed evidence supporting physical agent modalities (depending on the specific shoulder disorder)

Porcheret, M., Jordan, K., & Croft, P. (2007). Treatment of knee pain in older adults in primary care: Development of an evidence-based model of care.

Rheumatology, 46(4), 638-648. doi: 10.1093/rheumatology/kel340

Evidence-based guidelines for knee pain are reviewed and adapted for use in primary care.
- Four steps of intervention, from general to ongoing, treatment-resistant pain.
  - Step one: weight loss, education, sleep advice, exercise, heat modalities
  - Step two: walking aids, group education, analgesics
  - Step three: CBT, OT, TENS, medication and injection
  - Step four: surgery

Roll, S. C., & Hardison, M. E. (2017). Effectiveness of occupational therapy interventions for adults with musculoskeletal conditions of the forearm, wrist, and hand: A systematic review.

American Journal of Occupational Therapy, 71, 7101180010. https://doi.org/10.5014/ajot.2017.023234

59 articles are reviewed to reveal the best evidence for OT treatment for adults with musculoskeletal conditions of the forearm, wrist, and hand.
“The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions.”
A limited number of studies included occupation-based interventions

Siegel, P., Tencza, M., Apodaca, B., & Poole, J. L. (2017). Effectiveness of occupational therapy interventions for adults with rheumatoid arthritis: A systematic review.

American Journal of Occupational Therapy, 71, 7101180050.https://doi.org/10.5014/ajot.2017.023176

Strong evidence to support the use of physical activity and psychoeducational interventions to improve function, pain, fatigue, depression, self-efficacy, and disease symptoms in people with rheumatoid arthritis.
- The majority of the studies in this review were not created or completed by OTs, and are thus not occupation-based
Implications for OT practice:
Be mindful of disease process and plan around both flare-ups and stable periods to make the most of interventions
Strong evidence supports aerobic, resistive, and aquatic exercise for pain, QOL, and independence.
Use components of Tai Chi, yoga, or dynamic exercise programs for fatigue, depression, and vitality, or recommend community-based programs
Use a variety of psychoeducational interventions such as general patient education, self- management, CBT, and individualized joint protection to improve function, pain, fatigue, depression, and self-efficacy.
Improvements in self-efficacy may have positive effects on psychological status, function, and overall wellbeing, despite lack of strong evidence for this

Snodgrass, J., & Amini, D. (2017). Occupational Therapy Practice Guidelines for Adults with Musculoskeletal Conditions.

Bethesda, MD. AOTA Press. Retrieved from https://myaota.aota.org/shop_aota/prodview.aspx?TYPE=D&PID=326598462&SKU=900439U

Return to work
- Workplace modifications promote return to work, increase comfort, reduce days lost and pain intensity, and lower pain and injury for people on the job.
- CBT can reduce job loss prevalence, injury rate, pain, and sick leave for people remaining on the job.
- Specific resistance training, physical exercise, and clinic-based therapy paired with reengagement in daily activities reduces pain and promotes return to work
Chronic Pain
- Multidisciplinary pain management programs can reduce pain and improve function.
- A full graded motor imagery program can reduce pain and increase function in patient-selected tasks.
- Internet-delivered CBT can decrease severity of depression, generalized anxiety, and disability and increase ability to cope with pain.
- Mirror therapy can reduce pain, and mind-body therapy can reduce pain and depression and increase health and function.
- Mindfulness-based interventions can decrease pain and depressive symptoms.
- Resistance training can increase muscle strength, functional ability, and QOL for people with chronic or acute MSCs.
- Education addressing the neurophysiology of pain can reduce pain ratings, improve function, and help clients develop strategies to cope with pain.
- Multicomponent education on self-management can reduce pain and depressive symptoms and increase global health, physical function, and self-efficacy.
- Lifestyle interventions can increase global health and physical function (but not decrease depression) for those with chronic pain.
Spine
- CBT can increase physical capacity and addressing illness perceptions can improve engagement in patient-relevant activity after a back injury.
- Reminders, return-to-work strategies, job coaching, energy conservation, and joint protection can treat and prevent back injury, pain, and disability.
- A multidisciplinary program for low back pain including CBT and exercise can reduce disability, fear-avoidance beliefs, and pain, enhance QOL
- Aerobic exercise, especially walking, can improve strength for people with low back pain.
- Continuous low-level heat wrap therapy can prevent and treat the early phase of delayed-onset muscle soreness in the lower back.
Shoulder
- Resistive exercise can increase function and decrease pain for neck and shoulder pain.
- Preparatory activities combined with resistive exercise can reduce pain and improve function of or shoulder pain.
- Exercise, physical agent modalities, neuromuscular reeducation, and mobilizations reduce pain and improve functional outcome for subacromial impingement.
Elbow
- Resistive exercise, manual techniques, and multimodal therapy interventions can improve function, grip strength, and pain for lateral epicondylitis.
- Short-term forearm orthosis use and eccentric exercises in a multimodal therapy program can reduce pain and improve function for lateral epicondylitis.
- Core strengthening can decrease compensatory movements for subacute elbow injury.
Forearm, Wrist and Hand
- Strengthening and stretching versus education can improve hand functioning for people with rheumatoid arthritis
- Radial nerve mobilization can improve pinch (but not pain sensitivity) for people with thumb carpometacarpal osteoarthritis
- Mobilization and exercise interventions can improve symptoms and function for people with carpal tunnel syndrome

Older Adults

AOTA (2012). Occupational therapy and the prevention of falls

[Fact Sheet]. Retrieved from http://www.aota.org/-/media/corporate/files/aboutot/professionals/whatisot/pa/falls.pdf

Fear of falling leads to limiting physical activity, which leads to falls.
Focus on the client’s individual, specific fears.
Falls prevention is well-researched, and very reimbursable
- Since addressing inactivity is a big part of falls prevention, this could help to generalize that OT is good at addressing inactivity.

AOTA (2014). Focus On Falls Prevention and Home Modification.

Retrieved from https://www.aota.org/~/media/Corporate/Files/Practice/Aging/Resources/Focus-On-Falls-Prevention-Home-Mod-Booklet.pdf

A collection of AOTA publications on falls prevention and home modifications, including fact sheets, how-to guides, and links to evidence

Bone and Joint Initiative. (2018) Fit to a T program.

Retrieved from http://www.usbji.org/programs/public-education-programs/fit-to-t

US Bone and Joint Initiative’s free public education program geared towards clients on fracture prevention, bone health, and osteoporosis. In English and Spanish.
Created in response to the Surgeon General’s first ever report on bone health and osteoporosis

Callahan, C. M., Boustani, M. A., Unverzagt, F. W., Austron, M. G., Damush, T. M., Perkins, A. J., … & Hendrie, H. C. (2006). Effectiveness of collaborative care for older adults with alzheimer disease in primary care.

Journal of the American Medical Association, 295(18), 2148 - 2157. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/202837

Research article that supports interprofessional primary care services for addressing the needs of clients with alzheimer disease.
Patients and caregivers received education on communication skills; caregiver coping skills; legal and financial advice; patient exercise guidelines with a guidebook and videotape; and a caregiver guide provided by the local chapter of the Alzheimer’s Association; as well as other individualized and behavioral interventions
- Behavioral interventions included: personal care, repetitive behavior, mobility, sleep disturbances, depression, agitation or aggression, delusions or hallucinations, and caregiver’s physical health
- Pharmacological intervention was also used as appropriate, and adherence was supported by interprofessional team

Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D., ... & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial.

Journal of the American Medical Association, 278(16), 1321-1326. doi: 10.1001/jama.1997.03550160041036.

Preventative health programs based on OT may mitigate against the health risks of older adulthood
- 9-month treatment (n 361) for healthy, community dwelling adults aged 60 and older compared OT-based lifestyle intervention group was compared to a social activity control group, and a non-treatment control group
- Outcomes assessed via self-administered questionnaires on physical and social function, health, life satisfaction, and depression
  - Benefits in health, function, and QOL were found with OT group. Both control groups generally declined
- Author’s proposed reasons why the OT intervention was more effective:
  - Activities were chosen based on principle that occupation is linked to health. Subjects created meaningful and therefore health-promoting routines
  - OT intervention was highly individualized, even though it was conducted in a group setting
  - OT intervention included specific instruction on how to overcome barriers to everyday living
“The most effective test to date of the effectiveness of OT”

Clark, F., Jackson, J., Carlson, M., Chau, C., Cherry, B. J., Jordan-Marsh, M.,… Azen, S. P. (2012). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the Well Elderly 2 Randomised Controlled Trial.

Journal of Epidemiology and Community Health, 66, 782–790. http://dx.doi.org/10.1136/jech.2009.099754

Report on efficacy and cost efficacy of the Well Elderly II Trial (Jackson, Mandel, Blanchard et al, 2009), which repeated the methodology of Clark et al (1997) with a larger and ethnically diverse population
OT intervention improved bodily pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction, and depressive symptomatology
Intervention found to be cost effective

Fry, D., Fox, B., & Donnelly, C. (2013). Traveling a new road: A driving cessation group in primary care.

Occupational Therapy Now, 15(5), 25 - 26. Retrieved from https://www.aota.org/Publications-News/otp.aspx

OTs in primary care typically focus on screening and assessment for driving skills and safety, but they also have an important role in guiding driving cessation
Loss of driving impacts independence, leisure engagement, socialization and overall health and wellbeing
This article describes a psycho-educational group designed for clients with dementia and their spouses. Provided clients with strategies and resources to remain independent and engaged; opportunity to discuss and normalize feelings of loss; a place to address grief associated with loss of driver’s license.

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S.E. (2012). Interventions for preventing falls in older people living in the community (Review).

The Cochrane Library, 9. doi: 10.1002/14651858.CD007146.pub3

Cochrane review of effects of interventions designed to reduce incidence of falls in older people living in the community
- Group and home-based exercise programs, and home safety interventions reduce rate and risk of falls
- Multifactoral assessment and intervention programs reduce rate of falls, but not risk of falling; Tai Chi reduces risk of falling
- Home safety interventions found more effective when delivered by an OT. Home safety interventions also found to be cost-effective
- No evidence for cognitive behavioral interventions on rate of falls
- Interventions to increase knowledge/educate about falls alone didn’t significantly reduce rate/risk of falls

Hunkleler, E. M., Katon, W., Tang, L., Williams, J. W., Kroenke, K., Lin, E. H. B. L., … Unützer, J. (2006). Long term outcomes from the IMPACT randomized trial for depressed elderly patients in primary care.

British Medical Journal, 332, 259. https://doi.org/10.1136/bmj.38683.710255.BE

Describes a research study examining the effectiveness of a 12-month collaborative care intervention targeting patients aged 60+ with depression
- Team included PCP, depression care manager, and psychiatrist
- Interventions: individualized education, behavioral activation, antidepressants, brief behavior-based problem solving therapy, and relapse prevention
Results support tailored collaborative care.

Johnson, M. & Janssen, S. (2018, Feb 19). Malnutrition among older adults: The role of occupational therapy.

OT Practice, 23(3). Retrieved from https://www.aota.org/Publications-News/otp.aspx

Describes factors that lead to malnutrition and offer guidance for OTs to evaluation and treat older adults who have (or are at risk for) malnutrition
- Evaluation: Mini Nutritional Assessment (screen for adults age 65+); oral hygiene skills, meal preparation, mental functions, and symptoms of depression
- Limited evidence is available supporting OT’s role in addressing malnutrition.

Juang, C., Knight, B. G., Carlson, M., Niemiec, S. L. S., Vigen, C., & Clark, F. (2016). Understanding the mechanisms of change in a lifestyle intervention for older adults.

Gerontologist, 0, 1-9. doi:10.1093/geront/gnw152

RTC examines mechanisms of change in Lifestyle Redesign intervention, an activity-based OT program focused on promoting healthy habits and routines in older adults
Results: significant indirect effects from the intervention decreased depressive symptoms linked to increased activity frequency and activity significance
- Increased activity significance is associated with more perceived control, resulting in decreased depressive symptoms
- Higher activity frequency is associated with heightened social connections, resulting in decreased depressive symptoms
Understanding the internal mechanisms (perceived control and social connections) helps to clarify the relationship between the intervention and outcomes

Leland, N., Elliott, S. J., & Johnson, K. (2012). Occupational therapy practice guidelines for productive aging for community-dwelling older adults.

Bethesda, MD: AOTA Press.

Practice guidelines for OT intervention supporting productive aging in place

Leland, N. E., Elliott, S. J., O’Malley, L., & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence and future directions.

American Journal of Occupational Therapy, 66, 149–160. http://dx.doi.org/10.5014/ajot.2012.002733

Reviews prevention recommendation guidelines for falls, describing their relevance for OT intervention
- Evidence supports environmental modification, exercise, and multifactorial and multicomponent interventions
- Limited evidence overall

Mackenzie, L., Clemson, L., & Roberts, C. (2013). Occupational therapists partnering with general practitioners to prevent falls: seizing opportunities in primary health care.

Australian Occupational Therapy Journal, 60(1), 66-70. doi:10.1111/1440-1630.12030

Fall prevention is a large area of opportunity for OTs in primary care.
- This article discusses the OT role in fall prevention in Australia and how to partner with PCPs. Discusses opportunities within Australian Healthcare system.

Peterson, E. W., Finlayson, M., Elliott, S. J., Painter, J. A., & Clemson, L. (2012). Unprecedented opportunities in fall prevention for occupational therapy practitioners.

American Journal of Occupational Therapy, 66(2), 127 - 130. Retrieved from https://ajot.aota.org/article.aspx?articleid=1851549

Describes new opportunities in practice and research for OTs in falls prevention related to three initiatives:
- Publication of the Clinical Practice Guideline: Prevention of Falls in Older Persons (American Geriatrics Society & British Geriatrics Society, 2010)
- CDC’s efforts to disseminate four fall prevention programs that are shown to be effective
- State fall prevention coalitions

Piersol, C. V., Canton, K., Connor, S. E., Giller, I., Lipman, S., & Sager, S. (2017). Effectiveness of interventions for caregivers of people with Alzheimer’s disease and related major neurocognitive disorders: A systematic review.

American Journal of Occupational Therapy, 71, 7105180020. https://doi.org/10.5014/ajot.2017.027581

Review of interventions that facilitate ongoing participation in caregiver role for caregivers of people with dementia (PWD)
Dementia education, behavior management strategies, communication skills, environmental modification, stress and anger management, and coping skills
Cognitive reframing, mindfulness and stress reduction strategies, and physical activity for caregivers who express anxiety, stress, and depressive symptoms
Explain, discuss, and practice educational content rather than handouts
Information on respite options as part of educational content
Professionally led, in-person support groups to increase caregiver preparation and confidence in managing PWD’s memory loss
Promote interaction between the caregiver and PWD through communication training and memory books, photos of family members, and other memory aids
Training and practice using assistive devices (e.g., medication dispenser, raised toilet seat, monitoring system) to promote long-term use and carryover
Integrate of caregiver interventions into the PWD’s OT plan of care to promote insurance reimbursement.

Steultjens, E. M. J., Dekker, J., Bouter, L. M., Jellema, S., Bakker, E. B., Ende, C. H. M. (2004). Occupational therapy for community dwelling elderly people: A systematic review.

Age and ageing, 33, 453-460. doi:10.1093/ageing/afh174

Systematic review that demonstrates that OT is effective in interventions with community dwelling older adults.
- OT can be effective in maintaining functional ability, social participation and QOL for community dwelling elderly people.
- Home hazards assessment by an OT is effective in increasing functional ability.
- OT can be effective in decreasing falls in elderly at high risk of falling.
- Research on the efficacy of OT for dementia patients living in the community is needed.

Trudeau, S., Parsons, H., Delosh, A., Hooper, L., Dellinger, A. M., & Cameron, K. A. (2018, April). (AOTA) Primary Health Care and the Role of Occupational Therapy.

Presentation at AOTA National Conference, Salt Lake City, UT.

Falls: Modifiable risk factors
- Biological: Leg weakness, mobility problems, balance problems, poor vision
- Environmental: Clutter & tripping hazards, no stair railings or grab bars, poor lighting
- Behavioral: Psychoactive medications, 4+ medications, risky behaviors, inactivity
CDC: STEADI (Stopping Elderly Accidents, Deaths, & Injuries)
- www.cdc.gov/steadi
  - Offers materials, screening tools, educational materials, case studies
National Council on Aging (NCOA) Resources:
- Falls prevention: https://www.ncoa.org/healthy-aging/falls-prevention/
  - Grants available
- National Falls Prevention Action Plan: https://www.ncoa.org/healthy-aging/falls-prevention/2015-falls-prevention-action-plan/
- State fall prevention coalitions: https://www.ncoa.org/resources/list-of-state-falls-prevention-coalitions/
- Home Modification Resource Inventories: http://stopfalls.org/resources/home-modification-tools-programs-and-funding-landingpage/
  - A collaboration with USC’s School of Gerontology
- ASCP-NCOA Falls Risk Reduction Tool Kit: A companion to CDC’s STEADI Tool Kit
AOTA Comprehensive Falls Management Manual: currently being developed
CDC
- Home Fit Guide
- Falls Free: 2015 National Falls Prevention Action Plan

Overweight

AOTA. (n.d.). Obesity.

Retrieved from http://www.aota.org/practice/health-wellness/emerging-niche/obesity.aspx

AOTA website of OT obesity resources

AOTA. (2013). Obesity and occupational therapy

[Position Paper]. American Journal of Occupational Therapy, 67(6), S39-S46. doi: 10.5014/ajot.2013.67S39.

OT can help individuals gain a healthy lifestyle and reverse limitations on occupational performance through the use of everyday life activities.
OTs help clients develop and implement an individualized, structured approach for lifestyle change through analyzing and understanding performance patterns related to daily life activities, and employing interventions that facilitate participation by the client in modifying daily life habits, roles, and patterns that contribute to chronic conditions, including obesity.
Articulation of the ways in which OT approaches obesity intervention, changing patterns of performance, and engagement in social and physical activities toward the outcome of improved long-term health and satisfying participation in life.

AOTA. (2015). Bariatric Fact Sheet.

Retrieved April 25, 2016, from http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/Bariatric fact sheet.pdf

OT can help clients with obesity with the following:

ADLs with attention to areas requiring reach and flexibility (e.g., buttocks, back, and feet).
Activity tolerance, by grading functional tasks to progressively increase physical endurance.
Energy conservation and work simplification to facilitate occupational performance, particularly when respiratory insufficiency is a co-morbid condition.
Education on body mechanics for the client and/or caregiver to maintain safety during physical activities and transfers.
Skin monitoring/wound prevention
Strategies and adaptive equipment for IADLs
Home modification to promote activity participation, improved environmental access, and safety
Routines related to planning for healthier choices, food selection and shopping, meal preparation, meal times, and daily health management tasks.
Relaxation and sleep routines or positioning to increase comfort and facilitate sleep
Wellness groups for individuals and their families, facilitating health promotion through lifestyle change and engaging in supportive interpersonal relationships.
Education and coping strategies for pain, stress, and anxiety during daily activities, especially in social contexts.
Addressing sexual health including sexual expression, communication, positioning, and intimacy.
Community participation, including identifying opportunities the client feels comfortable accessing, to increase or maintain social and leisure activities.
Task and environmental modifications to increase energy expenditure safely for weight management, or sustained participation in valued roles and occupations.

Arbesman, M. & Mosley, L. J. (2012). Systematic review of occupation- and activity-based health management and maintenance interventions for community-dwelling older adults.

American Journal of Occupational Therapy. 66(3), 277-83. doi: 10.5014/ajot.2012.003327.

Systematic review examining occupation based and activity based health management and maintenance interventions for community dwelling older adults
- Moderate evidence that health education programs reduce pain and increase physical activity
- Moderate evidence that individualized health action plans improve participation in physical activities
- Use of cognitive-behavioral principles in physical activity improves long-term participation in exercise

Bailey, R. R. (2017). The issue is: Promoting physical activity and nutrition in people with stroke.

American Journal of Occupational Therapy, 71, 7105360010p1-7105360010p5. doi:10.5014/ajot.2017.021378

The prevalence of cardiovascular disease, diabetes, and obesity is high in people with stroke
Health behaviors are occupations (IADL of Health Maintenance), and are influenced by client factors, performance skills and patterns, environments and contexts.
Discusses the role of OTs in promoting physical activity and nutrition in people with stroke, including research to support these interventions
Physical activity
- Moderate to vigorous physical activity is important for people with stroke
- OTs are qualified to supervise and train people with stroke in exercise. Exercise and physical activity recommendations for stroke have been published
- Promote reduction of sedentary behavior
Nutrition
- OTs are not qualified to give advice on specific dietary needs, but can educate clients on the benefits of eating healthy foods
- OTs address selection and preparation of healthy food, and physical and cognitive abilities that meal preparation
Proposes roles for OTs in developing, testing, and providing physical activity and nutrition interventions for people with stroke, including in primary care settings.

Forhan, M. & Gill, S. V. (2013). Obesity, functional mobility, and quality of life.

Best Practice & Research Clinical Endocrinology & Metabolism, 27, 129–137. Retrieved from: http://www.bu.edu/motordevlab/files/2012/08/2013_Obesity-functional-mobility-and-QoL.pdf

OT can work with overweight clients on safe household and community mobility, including transferring in and out of a car, using public transportation, maneuvering safely in limited spaces, using mobility devices, and adapting vehicles (e.g., seat belt extender)
The health condition of obesity is influenced by complex biopsychosocial factors and greatly impacts an individual’s ability to participate in everyday occupations
OT interventions can enable participation in meaningful activities, thereby promoting health and wellbeing in this population
While there is not enough evidence supporting any particular occupation-based intervention, OT can contribute to prevention, treatment and management of obesity

Haracz, K., Ryan, S. Hazelton, M. James, C. (2013). Occupational therapy and obesity: An integrative literature review.

Australian Occupational Therapy Journal, 60(5), 356–365. doi: 10.1111/1440-1630.12063

Quantitative review: Not enough evidence, only three outcomes studies uncovered
Qualitative review
- Focus of intervention: Health promotion and prevention, increasing physical activity participation, modifying dietary intake and reducing the impact of obesity
- Intervention strategies: Assessment, modifying the environment, education, and introducing and adapting occupations

Healthé Habits For Living (n.d.). Occupational Therapist’s role in obesity rehabilitation

[PowerPoint presentation]. Retrieved from http://lota.camp9.org/Resources/Documents/OT'sroleinObesityRehabilitationpdf.pdf

This PowerPoint presentation gives multiple case study examples of people who benefitted from OT intervention for weight
- Average weight loss of 8.4 lbs over a 6 week, 12-session period (n=101), and average 50% functional status improvement (senior’s chair stand test)
- Use Guidelines (2013) for Managing Overweight and Obesity in Adults
- Healthe Habits For Living focuses on calorie reduction, increased physical activity, and behavior modification. 12 to 20 face-to-face sessions
- Disclose you are not a dietitian, do not recommend any prescription medications, do not give your patient a diet/meal plan/calorie count. Use basic, publicly available, generic information about food and nutrition
Healthē Habits for Living offers ongoing education classes too: www.healthehabitsforliving.com

Mosley, L., Jedlicka, J., LeQuieu, E., & Taylor, F. (2008, April 28). Obesity and occupational therapy practice: Present and potential practice trends.

OT Practice, 13(7) 9-16. Retrieved from https://www.aota.org/Publications-News/otp.aspx

The role of OT is to address the functional implications of obesity and equip the client with the tools necessary to improve occupational performance and QOL
Environmental changes to increase initiation and engagement in physical activity and to decrease opportunities for increased calorie consumption
Existing programs described: My Weight His Way for spiritual adults, and Wellness Camp for children with obesity
Applies Person-Task-Environment (PTE) to addressing overweight
OTs can analyze and modify occupations to increase activity demands or energy expenditure, which may facilitate weight management. 10 Planned Energy-Expenditure Principles (PEP) were developed that may be applied to occupational engagement to increase energy expenditure

Salles-Jordan, K. (2007). Community health promotion programs using USC Lifestyle Redesign.

AOTA Home & Community Health SIS, 14(2), 1-4. Retrieved from https://www.aota.org/Publications-News/SISQuarterly/entire-issue-pdf.aspx

USC Lifestyle Redesign Weight Loss Program led by an OT at USC, clinical outcomes over four years of programming have been tracked
- Average of 4.45% body mass loss and 8% fat mass loss for clients attending eight or more sessions over 16 weeks
- Focus: Help implement successful approaches for effective and sustainable changes in lifestyle that influence weight and improves overall health.
- 16-week program modeled after the Well Elderly therapeutic group structure.
  - Includes four elements: didactic presentation of educational material, peer discussion, direct experience, and exploration
- Clients are monitored each week for body composition (lean body mass, fat mass, total body water), blood pressure, and heart rate.
- Group participants engage in a therapeutic process of occupational self-analysis that results in setting short-term and long-term health goals.
  - Through this process, clients enact and experience realistic, sustainable changes that enable them to create health promoting habits and routines.
- With a physician referral and appropriate diagnosis, this program often is covered by insurance. In addition, the USC OT faculty practice has contracted rates with several insurance carriers offering special access to the program at low or no cost to the client.

Smith, K., Gamble, M., & Boggis, T. (2017, November). Addressing weight in primary care to help prevent chronic conditions.

Administration and Management Special Interest Section Quarterly, 2(4), 13 - 15. Retrieved from https://www.aota.org/Publications-News/SISQuarterly/Administration-Management/11-17-behavioral-change.aspx

Review of OT and weight management intervention themes and existing programs to inform communication with primary care stakeholders and help OTs design interventions targeting weight in primary care.
- Weight is a risk factor for the most prevalent, debilitating, and costly conditions.
  - Primary care is preventative care, and delivering best-practice interventions for the risk factor of overweight can be a significant value that primary care OT can add to interprofessional primary care teams
Current best practice themes, compiled from anecdotal, outcomes-based, and theoretical literature, in Person Environment Occupation (PEO) format:
- Person
  - Tailor intervention to the individual, and be flexible to meet personal needs
  - Address the complex biopsychosocial barriers to participation, such as depression; support coping strategies for pain, stress, and anxiety during daily activities, especially in social contexts
  - Provide culturally sensitive care, considering social stigma associated with weight
  - Include an education element, covering themes related to health and weight
  - Use evidence-based behavioral techniques within scope of OT including CBT, MI, and mindfulness
- Environment
  - Modify the environment to increase initiation and engagement in physical activity
  - Consider social environmental factors; reduce stigma to increase physical activity and social participation
  - Address environmental access and safety
  - Modify environments to reduce opportunities for eating unhealthy foods
- Occupation
  - Maintain an occupation-based perspective by focusing on what the client wants and needs to do, as opposed to only weight loss
  - Use energy conservation, assistive devices, and work simplification techniques to facilitate independent occupational performance.
  - Build activity tolerance by grading functional tasks to progressively increase physical endurance in occupation-based physical activities, such as walking with friends
  - Educate the client on body mechanics for safety during physical activities
  - Increase physical activity pattern awareness and energy expenditure. Consider using the 10 Planned Energy Expenditure Principles, which reverse energy conservation techniques and help clients plan to expend more energy during tasks, such as movement or standing breaks during sedentary activities
  - Modify dietary habits
Existing programs designed to address weight act as a guide for clinicians and administrators alike.
- Several programs designed and implemented by OTs in various settings report positive outcomes, including USC Lifestyle Redesign® Weight Loss Program, Healthé Habits For Living, Healthy Eating Active Living, and Partners in Achieving Total Health, an interprofessional collaboration.

Pain

Breeden, K., & Rowe, N. (2017). A biopsychosocial approach to addressing chronic pain in everyday occupational therapy practice.

OT Practice, 22(13). CE1-CE8. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Current evidence supports a biopsychosocial approach to identify and treat functional implications of chronic pain
“Biopsychosocial Model for Pain and Disability ‘views pain and disability as a complex and dynamic interaction among the physiologic, psychologic, and social factors that perpetuates – and may even worsen – the clinical presentation.’” (CE-1)
Complex pain persists beyond expected time frame, and results in changes to the nervous system that act to make the pain increasingly persistent
Pain as a complex cognitive and emotional experience, influenced by context, attention, anxiety, experience, coping skills, psychological conditions, social factors, etc.
Impacts occupational participation. Article describes impacts using chronic pain cycle to illustrate.
OT’s role in chronic pain management
- Chronic pain as a chronic condition, focus on self-management of the condition and enabling occupational participation, rather than focusing on reducing pain
- Psychological approaches include: CBT, pain education, coaching, relaxation training/biofeedback and mindfulness, and pacing
- Social intervention approaches include: teach families to ignore pain behaviors and reinforce efforts to increase function, improve socialization
- Physical interventions include: addressing positioning and body mechanics, physical activity training

Choo, J. (2017). Occupational therapy: Untapped potential for chronic pain management.

Pain Medicine News, September 5th. Retrieved from https://www.painmedicinenews.com/Commentary/Article/02-17/Occupational-Therapy-Untapped-Potential-for-Chronic-Pain-Management/42204

Written by MD on interprofessional pain team, describing the valuable role of OT in addressing pain at his clinic, and in addressing the National Pain Strategy
- Barriers: Understanding the profession initially, difference between OT and PT, OTs did not have much experience working with chronic pain
- Assets: Chronic pain patients have often been frustrated with PT services but OT is a new angle, OTs help unburden the MD for working on self-management, OT can work from such an array of angles to address chronic pain

Driscoll, M. & Baker, N. A. (2016, October 24). Breaking the cycle: Occupational therapy’s role in chronic pain management.

OT Practice, 21(19), 8–14. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Empower clients to problem solve, set goals and select activities, provide pain management strategies, pain cycle education, pacing and planning for flare ups.
- Pain cycle is the relationship between physical pain, functional limitation, and emotional distress.
  - Accept pain, there is no cure. MI for active problem solving, use metaphors and comparisons
  - Help clients take an active role in recovery, setting priorities and goals, and reach out to educate others and stay socially engaged
- After education and intervention for pain cycle, pacing strategies can be introduced.
  - Build awareness of when pain is manageable and when activity can continue, and when a rest is needed. Build client’s sense of control
  - Teach client to track progress for accountability and self-efficacy
  - Educate on activity grading strategies
  - Encourage movement.
- Develop pain flare management plans
  - Relaxation & stress-reduction strategies, keep moving, educate that pain does not always mean that something is wrong

Gonzalez Gonzalez, J., del Teso Rubio, Maria del Mar, Walino Paniagua, C. N., Criado-Alvarez, J. J., & Sanchez Holgado, J. (2015). Symptomatic pain and fibromyalgia treatment through multidisciplinary approach for primary care.

Reumatologia Clinica, 11(1), 22-26. doi: http://dx.doi.org/10.1016/j.reuma.2014.03.005

This article discusses the results of a pre-test post-test study (n=21) to examine the impact of a multidisciplinary approach (primary care and OT), on performance of ADL, IADL, and QOL of participants with symptomatic pain and fibromyalgia.
- There was significance to suggest that this approach increases independence in ADL and IADL.
- OT services were provided in seven sessions, and clients met with a PCP for 3 appointments before, during, and after these sessions
  - Introduce OT and psychomotor therapy (mind-body therapy that helps address fear and barriers to movements, and engage in pain free movement)
  - Psychomotor therapy to adapt to new situations despite restrictions, and promote social engagement
  - Pool psychomotor to reduce gravity and therefore enhance ideomotor praxis
  - Encourage social engagement and energy conservation strategies
  - Restructuring and grading occupational activities
  - Positively reinforce learning from previous section
  - Clients walked for 45 min with OT and PCP

Hardison, M. E. & Roll, S. C. (2016). Mindfulness interventions in physical rehabilitation: A scoping review.

American Journal of Occupational Therapy, 70(3), 1-9. doi:10.5014/ajot.2016.018069

A rigorous scoping review on using mindfulness to address musculoskeletal pain and chronic pain disorders.
- Preliminary support suggests that chronic pain reduction and pain acceptance, amongst other benefits, could be achieved through the use of mindfulness.
  - But further research is needed to examine the use of mindfulness techniques and pain, specific to OT.

Lambeek, L. C., Bosmans, J. E., Van Royen, B. J., Van Tulder, M. W., Van Mechelen, W., & Anema, J. R. (2010). Effect of integrated care for sick listed patients with chronic low back pain: Economic evaluation alongside a randomised controlled trial.

British Medical Journal (Clinical Research Ed.), 341, c6414. doi:10.1136/bmj.c6414

RCT of integrated care in multiple settings, (including hospitals, and primary care OT, PT, and occupational health) on the cost-effectiveness of chronic back pain sufferers on sick leave from work.
- The integrated care approach was significantly more cost effective: $1 invested in integrated care could produce a $29.58 return.
- Implementation of an integrated care program for patients on sick leave with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve QOL, and improve function on a broad scale.

Lambeek, L. C., van Mechelen, W., Knol, D. L., Loisel, P., & Anema, J. R. (2010). Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life.

British Medical Journal (Clinical Research Ed.), 340, c1035. doi:10.1136/bmj.c1035

RCT of integrated care in multiple settings, (including hospitals, and primary care OT, PT, and occupational health) for clients with chronic back pain on sick leave.
- The integrated care program substantially reduced disability due to chronic low back pain in private and working life.

McLean, A., Coutts, K., & Becker, W. J. (2012). Pacing as a treatment modality in migraine and tension-type headache.

Disability & Rehabilitation, 34(7), 611-618. doi:10.3109/09638288.2011.610496

Literature review on the limited material about using pacing principles to manage migraine, with OT.
- Though limited in scope, the results show that pacing principles taught by OTs can significantly impact the intensity, onset, and duration of migraines

Meredith, P. J., Rappel, G., Strong, J., & Bailey, K. J. (2015). Sensory sensitivity and strategies for coping with pain.

American Journal of Occupational Therapy, 69(4), 6904240010p1-6904240010p10.

Cross sectional study of the relationship between sensory processing and coping with pain in (n=116) healthy adults.
- Results shed light on how clinical practice can be formed to address pain with sensory strategies.
- These insights can offer support to clinical assessment and treatment of pain through sensory processing analysis and application.

O'Sullivan, K., Dankaerts, W., O'Sullivan, L., & O'Sullivan, P. B. (2015). Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study.

Physical Therapy, 95(11), 1478-1488. doi:10.2522/ptj.20140406

Cognitive functional therapy (CFT) found to be clinically significant for reducing both disability and pain. Depression, anxiety, back beliefs, fear of movement, catastrophizing and self-efficacy were all improved. Maintained at 12 month follow-up
- CFT is a behaviorally targeted intervention that combines normalization of movement and abolition of pain behaviors with cognitive reconceptualization of the low back pain, while targeting psychosocial and lifestyle barriers to recovery
- Similar to effective CBT and Rational Emotive Behavioral Therapy for chronic pain, but from a PT perspective, with understanding of what is harmful to the body, and what movements are safe.
  - CFT intervention stages
    - Cognitive training,
      - Pain mechanisms, the factors that contribute to the pain disorder, the multidimensional nature of chronic pain, how cognitions, beliefs, emotions and behaviors can reinforce the disabling cycle.
    - Functional movement and postural training,
      - Behavioral modification approach to rehabilitations, patients taught strategies to improve body awareness with mirrors and feedback, relaxation and breathing, relaxing muscle tension during pain-provoking tasks. Reconceptualizing that pain does not equal harm.
    - Functional integration,
      - Integrating these new functional patterns into occupational patterns. Including occupations that they have been avoiding due to pain
    - Physical activity & lifestyle training.
For more information on CFT:
- eAppendix available through link in article https://academic.oup.com/ptj/article/95/11/1478/2888268
- O’Sullivan, P. (2012). http://www.jamesdavisphysio.co.uk/wp-content/uploads/downloads/2013/11/03-OSullivan-2011-Time-for-a-change.pdf

Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders.

Physical Therapy, 95(11), 1582-1591. doi:10.2522/ptj.20140575

Therapy for chronic musculoskeletal disorders should be directed at all of the places in the nervous system that are changed by the pain experience
- Interventions
  - Top down
    - Reconceptualizing pain: educating that pain does not equal damage
    - Addressing maladaptive thoughts and behaviors: CBT
    - Acceptance-based: ACT and Mindfulness based stress reduction
    - Priming the brain for movement: graded exposure, the just-right challenge. Including motor imagery
    - Other: transcranial magnetic stimulation, or other PAMs
  - Bottom up
    - Sensorimotor discrimination therapy, like two point discrimination, and peripheral electric stimulation. Requires active patient engagement.
    - Mirror therapy

Poole, J. L., & Siegel, P. (2017). Effectiveness of occupational therapy interventions for adults with fibromyalgia: A systematic review.

American Journal of Occupational Therapy, 71, 7101180040. http://dx.doi.org/10.5014/ajot.2017.023192

Review concludes there is strong evidence supporting: “cognitive-behavioral interventions; relaxation and stress management; emotional disclosure; physical activity; and multidisciplinary interventions for improving daily living, pain, depressive symptoms, and fatigue.”
- Few interventions were occupation-based, though there were within the scope of OT
Few interventions resulted in better sleep, limited evidence for self-management

Stanos, S. (2012). Focused review of interdisciplinary pain rehabilitation programs for chronic pain management.

Current Pain and Headache Reports, 16(2), 147-152. doi: 10.1007/s11916-012-0252-4

Interdisciplinary pain rehabilitation programs (IPRPs), which are based on a functional restoration model of treating chronic pain; and which often include PT & OT, pain psychologists, medical pain management providers, vocational rehabilitation, relaxation training, and nursing educators.
- Discusses desirable features of IPRPs and teams, describes four successful programs, as well as psychometric outcome tools and other relevant questions.
The article offers guidance to the organizational modeling and realistic probing into the associated challenges of interdisciplinary pain rehabilitation programs

Uyeshiro Simon, A., & Collins, C. E. R. (2017). Lifestyle Redesign® for chronic pain management: A retrospective clinical efficacy study. American Journal of Occupational Therapy, 71, 7104190040. https://doi.org/10.5014/ajot.2017.025502

Lifestyle Redesign interventions can improve patient functioning, self-efficacy, and QOL in people who experience chronic pain
- Efficacy of interventions was measured with the COPM, the Brief Pain Inventory, and the Pain Self-Efficacy Questionnaire
Lifestyle interventions are an important component of chronic pain treatment and Lifestyle Redesign principles can be applied in any treatment setting
- Authors recommend citing research in clinical documentation to prevent/overcome insurance payment denials.

Pediatrics

AOTA (2013). Addressing childhood obesity.

Tips for Living Life To Its Fullest. Retrieved from http://www.aota.org/-/media/Corporate/Files/AboutOT/consumers/Youth/obesity.pdf

PDF of tips for families, and OT expertise to help with childhood obesity

Fabrizi, S., Riley, B., & Zachry, A. H. (July 2017). Building partnerships with pediatricians.

OT Practice, 22(13), 19 - 21. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Discusses the importance of identifying developmental delays early, and tendency to miss developmental delays in primary care
Promotes collaboration in primary care settings between OTs and pediatricians to identify and address developmental needs
Survey of PCPs: most interaction with OT is through referral (70%) or consult (20%), most common reason for referral is developmental delay followed by “potential challenges” in a wide range of occupations (eating/feeding, coordination, self-care, self-regulation, handwriting, etc.)

Flick, J., & Zachary, A. H. (2018, April). Occupational therapy in a pediatric primary care setting.

Presentation at AOTA National Conference, Salt Lake City, UT.

An OT and OT students provide free developmental screenings in a pediatric primary care clinic, through grant-funding
- Used ASQ-3 as screener assessment, Modified Checklist of Autism in Toddlers- Revised (MCHAT)- 16 to 30 months, and PSOC (Parenting Sense of Competence Scale)- efficacy subscale
- Supported parents in obtaining Early Intervention for qualifying children
- Provided parenting education sessions
Reported increases in PSOC scores, indicating an increase in parent competency and self-efficacy.

Kugel, J., Hemberger, C., Krpalek, D., Javaherian-Dysinger, H. (2016). Occupational therapy wellness program: Youth and parent perspectives.

American Journal of Occupational Therapy, 70(5). 7005180010p1-7005180010p8. doi: 10.5014/ajot.2016.021642.

Outlines several behavioral and environmental intervention initiatives, as well as the importance of family-centered intervention
Community-based OT can affect daily habits and routines of youth and their families.
- The Pizzi Healthy Weight Management Assessment is useful for facilitating occupation-centered behavior changes
- Enabling youth with family-centered ideas for physical activity can increase active time, and reduce sedentary time
- Empowering youth with easy and practical ideas can encourage them to incorporate health-promoting occupations into daily routines.
- Socioeconomic status impacts time use, routines and habits, and must be considered when providing community programming

Lau, C., Stevens, D., & Jia, J. (2013). Effects of an occupation-based obesity prevention program for children at risk.

Occupational Therapy in Health Care 27(2): pp. 163-75. doi:10.3109/07380577.2013.783725.

12-week after-school program in an urban area led by OT students, aimed to increase children’s experience with physical activity and healthy foods to promote self-efficacy related to a healthy lifestyle
- Intervention was effective in creating positive changes in food behavior, food self-efficacy, and vegetable consumption in children

Pizzi, M. A. (2016). Promoting health, well-being, and quality of life for children who are overweight or obese and their families.

American Journal of Occupational Therapy, 70(5). 7005170010p1-7005170010p6. doi: 10.5014/ajot.2016.705001.

OT can collaborate with other professions and contribute towards achieving national goals for obesity prevention:
- Institute of Medicine
  - Make physical activity an integral and routine part of life
  - Create food and beverage environments that ensure healthy options are the routine, easy choice.
  - Transform messages about physical activity and nutrition: positive messages, enhancing health literacy and supporting behavioral change
  - Expand the role of healthcare providers, insurers, and employers in obesity prevention
  - Make schools a national focal point for obesity prevention: OT needs to document link between weight and school participation
- World Health Organization
  - Implement comprehensive programs that promote physical activity and healthy eating, and reduce sedentary behaviors and unhealthy foods
  - Integrate noncommunicable disease prevention to reduce the risk of childhood obesity
  - Guide and support a healthy diet, sleep, and physical activity in early childhood
  - Promote healthy school environments, health and nutrition literacy, and physical activity
  - Provide family-based, multicomponent, lifestyle weight management services for children who are overweight

Substance Use & Mental Health

Brooklyn, J. R., & Sigmon, S. C. (2017). Vermont hub-and-spoke model of care: Development, implementation, and impact.

Journal of Addiction Medicine, 11(4), 286-292. doi:10.1097/ADM.0000000000000310

Hub-and-spoke model was developed in Vermont to address the epidemic of opioid use disorders by increasing access to medication-assisted treatment services
- Clients initiate services at specialized clinics (“Hubs”), where they are assessed and started on medication-assisted treatment if appropriate. Once stable, care is transferred to qualified office-based treatment (“Spokes”), where PCPs continue to prescribe and monitor medication use to treat addiction. If the client becomes more complex, PCPs can refer the client back to the Hub.
- This increases access to services by reducing strain on specialized clinics, while supporting PCPs who may otherwise feel they do not have the resources necessary to care for these clients.
Adoption of this model has increased the Vermont’s treatment capacity

Costa, D. (2017, January 23). Occupational therapy’s role counteracting opioid addiction.

OT Practice, 22(1), 13 - 16. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Offers brief background information on opioid addiction, especially it’s role with adolescents and in chronic pain
Resources:
- Evidence-based screening tools for adults and adolescents: https://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/screening-assessment-drug-testing-resources/chart-evidence-based-screening-tools-adults
- Publications: Opioid Overdose Prevention Toolkit from SAMSHA (2016), CDC Guidelines for Prescribing Opioids for Chronic Pain (CDC, 2016), and the National Pain Strategy from HHS (2016)
Role of OT is described, includes: setting goals, addressing pain triggers such as ergonomic issues in the workplace, energy conservation, teaching coping for pain, physical agent modalities, addressing sleep, managing stress, and more

Ikuigu, M. N., Nissen, R. M., Maassen, A., & Van Peursem, K. (2017). Clinical effectiveness of occupational therapy in mental health: A meta-analysis

[Centennial Topics]. American Journal of Occupational Therapy, 71, 7105100020. https://doi.org/10.5014/ajot.2017.024588

Meta-analysis concludes that theory-based OT may be effective in improving wellbeing and occupational performance in people with a mental health diagnosis

Korthuis, P. T., McCarty, D., Weimer, M., Bougatsos, C., Blazina, I., Zakher, B.,… Chou, R. (2017). Primary care-based models for the treatment of opioid use disorder: A scoping review.

Annals of Internal Medicine, 166, 268 - 278. doi: 10.7326/M16-2149

Implementation of medication-assisted treatment (MAT) for opioid use disorder in primary care increases access to these services.
Models for implementation of MAT in primary care vary. Common components include “pharmacotherapy with buprenorphine or naltrexone, provider and community education, coordination and integration of opioid use disorder treatment with other medical and psychological needs, and psychosocial services and interventions”
Different models of implementation are reviewed and discussed

Lambert, R. A., Harvey, I., & Poland, F. (2007). A pragmatic, unblended randomized controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care.

Journal of Affective Disorders, 99(1-3), 63-71.

Anxiety rates are on the rise in the UK. Medication and psychological treatment is most common, but outcomes are sometimes poor, with high relapse rates. Lifestyle has a potential role in treatment, but is not often considered in clinical guidelines.
- A 16-week RTC was conducted in 15 UK primary care practices that compared a controlled PCP care routine to that of an OT-led lifestyle treatment approach. Outcome results were measured using the Beck Anxiety Inventory.
- A lifestyle approach is at least as effective as routine care, with significant improvements in anxiety compared with routine care by the end of the treatment.

Novalis, S. D. (2017, November 27). Suicide awareness and occupational therapy for suicide survivors.

OT Practice, 22(21), CE-1 - CE-7. Retrieved from https://www.aota.org/Publications-News/otp.aspx

Provides guidance on identifying risk factors and warning signs of suicide, and appropriate response. Also considers the needs of those who have lost others to suicide.

Rojo-Mota, G., Pedrero-P ́erez, E. J., & Huertas-Hoyas, E. (2017). Systematic review of occupational therapy in the treatment of addiction: Models, practice, and qualitative and quantitative research

[Centennial Topics]. American Journal of Occupational Therapy, 71, 7105100030. https://doi.org/10.5014/ajot.2017.022061

Review of literature on OT’s role in addiction yields 16 theoretical and professional role studies, 8 qualitative studies, and 14 quantitative studies.
- Studies had low level evidence
Conclude that while OT has been involved in treatment for people with substance abuse and behavioral addiction, research published on the topic is poor

Stoffel, V. C., & Moyers, P. A. (2004). An evidence-based and occupational perspective of intervention for persons with substance-use disorders.

American Journal of Occupational Therapy, 58, 570-86. doi:10.5014/ajot.58.5.570

Interprofessional review of interventions for substance use disorders that fit within the OT scope, as part of an evidence-based literature review project
AOTA guidelines for OT and substance use, is mostly based on expert opinions, and needs to be supplemented with this evidence
- Purposes of this article are therefore to: Describe effective interventions from different disciplines; Use an OT perspective to modify those interventions; Use all those findings to suggest research questions that would examine the effectiveness of the modified interventions
The interventions that are of interest to OTs include those that touch on the following:
- Cognitive performance, Health maintenance, Work play and leisure, Psychosocial skills, Relationships and family participation, Self-help group skills
Effective interventions that are of interest to OTs include:
- Brief interventions, CBT, Motivational strategies, 12-step programs

Primary Care Occupational Therapy Annotated Bibliography

Category One

Role and Value

AOTA. (n.d.). Primary care.

AOTA. (2013, Dec 24). AOTA engaged in ongoing effort to promote role of OT in primary care.

AOTA. (2014a). The occupational therapy practice framework: Domain and process.

AOTA. (2014b). The role of occupational therapy in primary care

AOTA (2015a). Occupational therapy’s role in health promotion

AOTA (2015b). The role of occupational therapy in chronic disease management

AOTA (2016). Wellness & prevention: Occupational therapy’s opportunity in the era of health care reform

CAOT (2013). CAOT position statement: Occupational therapy in primary care.

Dahl-Popolizio, S., Doyle, S., & Wade, S. (2018): The role of primary health care in achieving global healthcare goals: Highlighting the potential contribution of occupational therapy,

Dahl-Popolizio, S., Muir, S., Davis, K., Stuart, K., Wade, S., & Voysey, R. (2017). Occupational therapy in primary care: Determining the receptiveness of occupational therapists and primary care providers.

Devereaux, E. B., & Walker, R. B. (1995). The role of occupational therapy in primary health care.

DHS. (2018). 2020 LHI topics.

Killian, C., Fisher, G., & Muir, S. (2015). Primary care: A new context for the scholarship of practice model.

Muir, S. (2012). Occupational therapy in primary health care: We should be there

Pizzi, M. A., & Richards, L. G. (2017). Guest Editorial—Promoting health, well-being, and quality of life in occupational therapy: A commitment to a paradigm shift for the next 100 years.

Reitz, S. M. (1992). A historical review of occupational therapy's role in preventative health and wellness.

Scaffa, M. E., Van Slyke, N., & Brownson, C. A. (2008). Occupational therapy services in the promotion of health and the prevention of disease and disability.

WHO (1978). Declaration of the Alma-Ata.

Being an Advocate

AOTA. (in press). The importance of primary care education in occupational therapy curricula.

Doll, J. (2017, September 25). Promoting OT’s role in ambulatory care primary care teams.

Donnelly, C., Letts, L. (2013). 10 tips to integrate occupational therapy in primary care teams.

Lamb, A. (2016, Nov 9). Demonstrating our distinct value in your daily practice.

Metzler, C. A. (2016). A new year, a new way to promote OT.

Patel, P. (2015). The role of occupational therapy in primary care.

Sample, J. M. (2016, August 22). Planning a successful state OT on the hill day.

Leadership

AOTA (2016). Emerging leaders development program.

AOTA. (2018). Leadership Development Toolkit.

Ellie, E., Grady, A., & Nielson, C. (2011). Mentoring leaders: The power of storytelling for building leadership in health care and education.

Fleming-Castaldy, R. P. & Patro, J. (2012). Leadership in occupational therapy: Self-perceptions of occupational therapy managers.

Hobbs, M. & Lamb, A. J. (2016). A mindful path to leadership series module 3: Mentoring and leadership.

OTCommunityofLeaders. (2016). OT Leadership Live Podcast.

Phipps, S. (2015, August). Transformational and visionary leadership in occupational therapy management and administration

Primary Care Progress (n.d.). Homepage.

Rogers, P., Killian, C., Hudgins, E., & Pollard, T. (2016, May). Transitioning from clinician to manager.

Sweetman, M. M. (2016, July). Authentic leadership in occupational therapy.

Waite, A. (2016, September 26). Alert the media: Tips for talking with reporters about occupational therapy.

Category Two

Healthcare Policy

AOTA (2012). Accountable care organizations and medical homes

AOTA. (2018). Individual measures for occupational therapists.

Braveman, B., & Metzler, C. A. (2012). Health care reform implementation and occupational therapy

Halle, A. D., Mroz, T. M., Fogelberg, D. J., & Leland, N. E. (2018). Occupational therapy and primary care: Updates and trends

Lamb, A. J., & Metzler, C. A. (2014). Defining the value of occupational therapy: A health policy lens on research and practice.

Leland N. E., Crum K, Phipps S, Roberts P, & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery.

Leland, N. E., Fogelberg, D. J., Halle, A. D., & Mroz, T. M. (2017). Occupational therapy and

management of multiple chronic conditions in the context of health care reform

Metzler, C. A., Hartmann, K. D., & Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy

Parsons, H. (March 2017). Promoting OT’s role in mental and behavioral health services.

Parsons, H & Hooper, L. (2018, April). Health care reform update.

Willmarth, C. & Hooper, L. (2016, Nov 10). Health care reform update

Integration Strategies

McColl, M. A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O’Brien, P., & Donnelly, C. (2009). Models for integrating rehabilitation and primary care: A scoping study.

Behavioral Health

AOTA (n.d.). Occupational therapy practitioners: A key member of the Community Behavioral Health team.

Lute, R. M. & Manson, L. (2015). Integrated Care and Specialty Behavioral Health Care in the Patient-Centered Medical Home.

Care Coordination

Fader, J., Goldstein, D., & Vause-Earland, T. (2016, November 7) Hotspotting collaborative student efforts to identify and intervene with emergency service “super-utilizers.”

Moore, K. (2013). Wellness navigator: An innovative role in primary health care for occupational therapists.

Moyers, P. A., & Metzler, C. A. (2014). Interprofessional collaborative practice in care coordination

Robinson, M., Fisher, T. F., & Broussard, K. (2016). Role of occupational therapy in case management and care coordination for clients with complex conditions

Models in Action

Benthall, D. (2017, February 20). Out of the physician’s office and into the home: Exploring OT’s role on a home-based primary care team.

Brown, C., & Diamond-Burchuk, L. (2013). Occupational therapists providing interprofessional education and enhancing health within a teaching primary care centre.

Donnelly, C., Brenchley, C., Crawford, C., & Letts, L. (2013). The integration of occupational therapy into primary care: A multiple case study design.

Donnelly, C. A., Leclair, L. L., Werner, P. F., Hand, C. L., & Letts, L. J. (2016). Occupational therapy in primary care: Results for a national survey.

Duddy, K. J., (2016). Primary care occupational therapy: An occupation-based approach for veterans with chronic conditions

Eichler, J., Royeen, L. (2016). Occupational therapy in primary health care clinic: Experiences of two clinicians.

Garvey, J., Connolly, D., Boland, F., & Smith, S. M. (2015). OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: a randomized controlled trial.

Koverman, B., Royeen, L., & Stoykov, MA., (2017). Occupational Therapy in Primary Care: Structures and Processes that Support Integration.

Krpalek, D., Javaherian-Dysinger, H., & Hewitt, L. (2016). Designing occupational therapy services in a primary care setting: Successful strategies and lessons learned

Lang, J. (2016, February 9). Pacific University clinic offers affordable primary care and much much more.

Murphy, A. D., Griffith, V. M., Mroz, T. M., & Jirikowic, T. L. (2017). Primary care for underserved population: Navigating policy to incorporate occupational therapy into federally qualified health centers

Rogers, O., Heck, A., Kohnert, L., Paode, P., & Harrell, L. (2017). Occupational therapy’s role in an interprofessional student-run free clinic: Challenges and opportunities identified.

Serfas, K. L. (2016, October 10). Pediatrics in primary care: Insights and experiences from one faculty practice model.

Population/Public Health