Week 7: Scaffa Chapter 25: Occupational Therapy in Primary Health-Care Settings

Primary Health Care

• The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community

• Includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of settings

• Is continuous, comprehensive care designed to maximize health and prevent disease that is provided near where people live, work, and play

Primary Care Physician

• Used to describe all physicians whose practice includes the provision of medical care for well individuals and who act as ‘gatekeepers’ to specialist services

• Include family and general practitioners, medical internists, pediatricians, obstetrician-gynecologists, psychiatrists, and physician extenders (ex: nurse practitioners, physician assistants)

Medical Home

• Accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care

• Team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, counselors, educators, and care coordinators

Health Promotion

• An important component of helping patients reach their health goals

• Purpose is to enable people to gain greater control over the determinants of their own health

Teachable Moments

• When direct links can be made between symptoms, behavior, and outcome

• Occur routinely during physician office visits

Three Critical Functions the Role of OT has in Health Promotion

• Promoting healthy lifestyles for all clients

• Emphasizing occupational participation as an essential component of health promotion efforts

• Providing interventions for populations, particularly those experiencing health disparities

Appropriate Health Promotion Theoretical Approaches in Primary Care Settings Include

• PRECEDE-PROCEED model

• Transtheoretical (or stages of change) model (TTM)

TTM and Health Promotion

• Can be utilized to identify the individual’s readiness to change

• The health-promotion strategies used should correspond with the stage of readiness, whether precontemplation, contemplation, preparation, action, or maintenance

Applying the Stages of Change to Prevention and Health Promotion Involves

• Bringing the risky behavior(s) to the person’s attention

• Helping the person to determine the need to change these risky behaviors

• Facilitating the decision to change and selecting strategies for change

• Maintaining and reinforcing the new healthy behaviors

• Reinstituting the healthy behaviors when lapsing into old habit patterns and behaviors

Health Promotion Process in Primary Care Consists of

• Assessing the person’s health-promotion needs

• Providing appropriate, culturally sensitive health education

• Setting realistic health goals collaboratively

• Facilitating the person’s acquisition and development of the skills needed to implement health behaviors

• Assisting individuals and their families to integrate health-behavior change into their daily lives

• Facilitating access to and use of community resources

• Evaluating outcomes through follow-up visits or contacts

Most Common Health Concerns for Lifestyle Intervention in Today’s Primary Care Medical Practice

• Diabetes

• Weight management

• Chronic pain

• Mental health problems, including substance abuse

Type 2 Diabetes/Hyperglycemia

• A chronic metabolic disorder that results from a combination of resistance to the action of insulin on the body’s cells and insufficient insulin production by the pancreas

Insulin

• A hormone needed by cells in the body to absorb and convert glucose into energy

Signs and Symptoms of Diabetes

• Increased hunger and thirst

• Frequent urination

• Fatigue

• Irritability

• Dizziness

• Unexplained weight loss

• Frequent infections

• Slow wound healing

• Visual and cognitive disturbances

A1C/Glycated Hemoglobin Test

• Measures average blood glucose levels over a period of 2-3 months

• Is considered the standard biomarker for adequate glycemic management and can be used to diagnose diabetes

A1C Levels

• 6.5% or higher is indicative of diabetes

• Between 5.7% and 6.4% is considered prediabetes

• Below 5.7% is considered normal

Complications of Diabetes Due to Poor Blood Sugar Control Can Include

• Neuropathy

• Cardiovascular conditions

• Retinopathy

• Kidney Disease

• Lower-extremity amputations due to nerve damage or poor blood flow

Diabetes Treatment Can Include

• Blood glucose monitoring

• Oral medications

• Insulin injections

• Healthy eating

• Physical activity

Diabetes and Depression

• Depression and/or anxiety are frequently comorbid with diabetes

• The relationship is bidirectional

  • Individuals with diabetes are at higher risk for developing diabetes, and individuals with diabetes are at higher risk for developing depression, particularly if they are experiencing secondary complications

  • Persons with diabetes and comorbid depression often have greater symptom severity and disease burden

Role of OT with Diabetes

• OT services are provided to persons who have experienced secondary complications from diabetes, such as amputation, low vision, stroke, myocardial infarction, and peripheral neuropathy

• Some evidence of OTs providing interventions focused on the self-management of diabetes, including blood glucose monitoring, nutrition, physical activity, and medication management

Overweight

• BMI greater than or equal to 25

Obese

• BMI greater than or equal to 30

Very Obese

• BMI greater than or equal to 35

Extremely Obese

• BMI greater than or equal to 40

Waist Circumference and Obesity

• More than 36-40 inches in men and more than 32-35 inches in women is highly correlated with obesity-related conditions such as hypertension, sleep apnea, diabetes, and heart disease

Medical Approach to Weight Management Combines

• Healthy nutrition

• Appropriate physical activity

• Behavior modification

• Psychotherapy

• Hypnosis

• Stress-reduction techniques

Role of OT and Weight Management

• OTs can assess an individual’s overall pattern of daily activity and make recommendations for occupational participation in IADLs, work, and leisure that increase the level of physical activity in which the person engages

• Can provide guidance to patients regarding incorporating physical activity into their daily routines

• Can introduce and encourage active leisure pursuits such as bicycling, volleyball, dancing, and swimming

Moderate Intensity Physical Activity

• Includes a brisk walk for 150 minutes per week

• The level recommended by the American Heart Association for raising the heart rate from 40% at baseline to 60% of its maximal capacity

Chronic Pain

• A complex biopsychosocial condition that has reached an epidemic proportion in the US

Low Back Pain (LBP)

• The most common musculoskeletal complaint seen in primary care medical practice

• A major source of activity limitation and disability

• Is often persistent or recurrent and is a significant cost to individuals, businesses, and society

• 5th most common reason to seek health care

• Can be due to a single event resulting in acute injury or to a cumulative process of stress and strain

Primary Goal of Intervention for Chronic Pain

• Return the worker to the job as soon as possible

Role of OT with Chronic Pain

• Should focus on improving quality of life by assisting clients to participate in occupations, particularly sleep and IADLs, that they were unable to perform without medication

• Can make recommendations for workstation design and the modification of work tasks, provide instruction on appropriate body mechanics in job performance, and address risk factors in the work environment

Prolonged Low Back Pain

• Can lead to a combination of physical, psychological, occupational and social impairment

Mental Health Problems in Primary Health-Care Settings

• Frequently manifest with physical symptoms such as chronic pain, insomnia, gastrointestinal disturbance, headaches, and difficulty breathing

• Addressing the emotional and psychological issues related to chronic medical conditions has been shown to improve overall health and is cost-effective

Most Common Mental Health Problems Encountered in Primary Care

• Depression

• Anxiety

• Substance abuse

• Eating disorders

• Posttraumatic stress disorder (PTSD)

CAGE Substance Abuse Screening Tool: Four Questions to Ask Clients

• Have you ever felt you ought to cut down (C) on your drinking or drug use?

• Have people annoyed (A) you by criticizing your drinking or drug use?

• Have you felt bad or guilty (G) about your drinking or drug use?

• Have you ever had a drink or used drugs first thing when you wake up to steady your nerves or to get rid of a hangover (eye opener) (E)?

• A total of two positive answers is considered clinically significant

Mental Health Problems

• Impose a significant burden on society in terms of lost work productivity, increased use of health services, and increased morbidity and mortality from chronic illnesses

• Are a leading cause of disability

• Have adverse effects on adherence to medical regimens and health habits, including poor diet, increased alcohol consumption and smoking, and sedentary lifestyle

Integrated Care

• Blends the expertise of mental health, substance use, and primary care clinicians, with feedback from patients and their caregivers

• Create a team-based approach where mental health care and general medical care are offered in the same setting

• Has been shown to increase access to mental health services, improve patient outcomes, reduce hospital readmission rates, and lower health-care costs

Role of OT with Mental Health Using Models

• Providing services in primary care offices

• Direct referrals from physicians to service provided at a community site

• Collaboration between a mental health service and primary care physicians

Benefits of Providing OT Services in Primary Care Offices

• Reduced time seeing patients with social and emotional problems

• Reduced prescriptions for anxiolytics and antidepressants

• Status in offering an extra service to patients

Positive Aspects of Providing OT Services in Primary Care Offices

• People needed fewer visits than in a hospital-based program because they were identified at an earlier stage

• People were more likely to accept the services provided in the primary care setting because the stigma of going to a mental health setting was eliminated

OT Services with Direct Referrals from Physicians to Service Provided at a Community Site: Home Health-Like Agency

• Provided individual and group interventions at homes, physician offices, and other community settings

• Several group interventions were run on a regular basis, including groups addressing anger management, anxiety management, and assertiveness skills

• Clients included women going through menopause, chronic fatigue syndrome, myocardial infarction (stress management and lifestyle changes), PTSD, and employment/unemployment issues

OT Services with Collaboration Between a Mental Health Service and Primary Care Physicians

• Utilized the services of a multidisciplinary Community Mental Health Team (CMHT) that provided services to eight primary care practices

  • Was composed of an occupational therapist, psychiatric nurse, and social worker

  • Goals were to increase access to mental health services, offer services within the familiar surroundings of a primary care office, provide timely and effective brief interventions, an develop stronger relationships with primary care providers

Brief Office Interventions

• Short, targeted interactions between patients and health-care professionals for the purpose of changing health behaviors

• Are practical and cost-effective and can be implemented by a variety of health-care professionals, including occupational therapists

Medication Adherence

• A significant concern in primary care practice that can be addressed by occupational therapists through brief office interventions

Barriers to Medication Compliance

• Multiple drugs

• Multiple doses per day

• Problematic side effects or interactions

• Lack of family/social support

• Are magnified with advancing age and increased medical, cognitive, and psychiatric problems

Effective Motivational Strategies to Improve Medication Adherence

• Using daily reminder charts and daily pill holders

• Packaging medications in combination

• Training in self-determination

• Enlisting social/family support

• Offering phone calls from nurses and phone-linked computer counseling

Brief Office Intervention Model: The Five As

• Assess

• Advise

• Agree

• Assist

• Arrange

Brief Office Intervention Model: Assess

• Target a risky behavior identified by patient complaint and/or medical and social history

Brief Office Intervention Model: Advise

• Emphasize the importance of discontinuing the risky behavior, the improvements that can be gained in health status, and the willingness of the health-care provider to assist the patient in making the needed changes

• Clear, simple, and personalized advice provided in a warm, empathic, nonjudgmental way

Brief Office Intervention Model: Agree

• Collaboratively design and agree upon a course of action to change the target risk behavior

• Assess the patient’s readiness to change and design interventions accordingly

Brief Office Intervention Model: Assist

• Provide specific behavioral interventions

• Encourage and facilitate follow-up counseling and health education sessions

• Assess the effectiveness of physician-provided medications in assisting behavior change

Brief Office Intervention Model: Arrange

• Reinforce positive changes

• Revise intervention plans if necessary

• Provide ongoing follow-up and support by telephone, electronic communication, or office visits

Health Literacy

• The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

• Goes beyond the individual and that it is the mutual responsibility of the health-care provider to communicate information in ways that can be understood and applied

Low Health Literacy

• Is linked to higher hospitalization rates, more frequent use of emergency room services, less compliance with health recommendations, and more frequent errors with medication management

Health Literacy Services May Include

• Informal assessment of health literacy

• Creation and provision of culturally relevant health communication

• Creation and provision of “plain-language” health communications for persons with limited health literacy

• Health information sessions on a variety of topics

• Office staff training in effective communication with patients

• Health counseling

• In-person and online self-help and support groups

• Patient education on how to prepare for and participate in health-care interactions with providers

• Assistance for patients with medication management

• Patient education on how to assess the relevance, quality, and credibility of health information, particularly on the Internet

Chronic Diseases/Conditions in the Older Adult Populations

• Arthritis

• Cancer

• Diabetes mellitus

• Heart disease

• Hypertension

• Respiratory disease

• Cerebrovascular accident (CVA)

Chronic Disease Self-Management

• Involves individuals and families actively participating in the health-care process, self-monitoring symptoms or physiological processes, making informed decisions about their health, and managing the impact of the disease on their daily lives

• The programs are designed to enable individuals to prevent, control, and manage complications of their conditions

Program Elements of Chronic Disease Self-Management

• Tailoring the program and messages to specific individual needs and circumstances

• Grouping interventions in order to facilitate peer support

• Giving frequent feedback to the patient regarding progress in meeting self-management goals (including the use of technology applications for self-monitoring at home)

• Addressing psychosocial concerns

• Involving the health-care provider in program delivery

School of Medicine at Stanford University Chronic Disease Self-Management Program (CDSMP)

• Is provided in a workshop format for a total of 15 hours over several sessions

• Is facilitated by two trained leaders

  • A health-care professional

  • A person with a chronic disease

• Improved in health status, health-care utilization, and self-management behaviors

Chronic Disease Self-Management Program (CDSMP) Covered Topics

• Techniques to deal with problems such as frustration, fatigue, pain, and isolation

• Appropriate exercise for maintaining and improving strength, flexibility, and endurance

• Appropriate use of medications

• Effectively communicating with family, friends, and health professionals

• Nutrition and meal planning

• Evaluating new treatments and making informed treatment decisions

Role of OTs and Chronic Diseases

• Develop chronic disease self-management programs in primary care settings

• Train persons with chronic diseases to instruct and lead groups

• Evaluate the outcomes

A Comprehensive Health-Promotion Program in a Primary Care Setting Would Include

• Health risk appraisals, including mental health screenings

• Health education and counseling

• Caregiver education and training

• Phone call follow-up

• Home visits

• Brief office interventions

Health Risk Appraisals (HRAs)

• Assessments that profile an individual’s risk factors and estimate the probabilities of certain diseases manifesting

• Ask the participant a number of questions related to health behaviors and thereby raise awareness about the impact of lifestyle on health

• Some provide suggestions for improving one’s health status

Caregivers and Health Education

• Includes counseling

• Is needed regarding the needs of the care recipient and their own health needs as caregivers

• Providing support, information about community resources, and training to prevent caregiver injury and stress can reduce caregiver burden and improve caregiver well-being

Home Visits

• Are used to assess safety, support systems, psychosocial issues, and home modification

• Are particularly beneficial for those who have a difficult time getting to health-care facilities and who might otherwise need to move to a long-term care facility

Developing a Health-Promotion Program for the Primary Care Setting

• Gather evidence for program planning

• Conduct needs assessment

• Establish a protocol for health promotion services

• Identify reimbursement and funding sources

• Institute a tracking and documentation system

• Pilot the program and collect efficacy data

Developing a Health-Promotion Program for the Primary Care Setting Step 1: Gather Evidence for Program Planning

• Preventative interventions should be based on the best research evidence available

• Evidence on appropriate assessment strategies, early detection procedures, and effectiveness of known interventions is essential

Developing a Health-Promotion Program for the Primary Care Setting Step 2: Conduct Needs Assessment

• Can be done in a variety of ways using surveys, focus groups, epidemiological data, and chart reviews

• The choice of targets for health-promotion interventions should be based on current morbidity and mortality profiles of the community in which the primary care practice is situated

Developing a Health-Promotion Program for the Primary Care Setting Step 3: Establish a Protocol for Health Promotion Services

• Outlines how patients will be evaluated, potential interventions that may be used, and community resources that are available as support services

• Should include clear referral criteria and describe the services the occupational therapist can provide

Developing a Health-Promotion Program for the Primary Care Setting Step 4: Identify Reimbursement and Funding Sources

• In addition to private health insurance, Medicare, Medicaid, and other reimbursement mechanisms for billable services, sources of revenue may include grants, fee-for-service, and foundation funding

Developing a Health-Promotion Program for the Primary Care Setting Step 5: Institute a Tracking and Documentation System

• May involve creating flow sheets, checklists, and other strategies for monitoring the provision of screenings and other health-promotion services

• Funding sources often dictate documentation style and content

Developing a Health-Promotion Program for the Primary Care Setting Step 6: Pilot the Program and Collect Efficacy Data

• The health-promotion program is ready to be piloted and evaluated

• Quarterly process assessments of services provided, patient satisfaction, and outcome measures are needed to document the efficacy and cost-effectiveness of the program

• Data are collected and used to modify and enhance program components

• Electronic health record that can track patients by age group, diagnosis, or other characteristics may be helpful for program evaluation purposes

• Program evaluation must be systematically planned throughout the earlier stages of program development

Primary Care Physicians and OTs

• Physicians may need to be informed regarding the potential benefits of offering occupational therapy services to patients

• Primary care physicians are unaware of the duration and training or range of skills and scope of practice of occupational therapy practitioners that would be applicable in a primary care practice setting

• OT practitioners must be able to clearly articulate and support with evidence the unique value of occupational therapy in primary care

OT and Primary Care

• Can enhance the health outcomes while the physician focuses on treating illness and preventing disease

Benefits of Primary Care Physicians Utilizing OTs to Provide Health-Promotion and Prevention Services in their Practice Settings

• Availability of high-quality prevention and health-promotion services on-site, thus increasing the physician’s time to focus on medical intervention

• Better patient health outcomes as a result of comprehensive health-promotion services

• Less need for medications and better compliance with self-management regimens

• Identification of patients who have mental health needs not readily recognizable in a short medical office, including alcohol and drug abuse problems, domestic violence, depression, anxiety, bereavement, etc.

• Detection of performance deficits that may affect safe participation in everyday activities

• Early identification of patient lack of adherence to medical treatment plans, thereby preventing secondary complications of medical conditions

• Can enhance a physician’s earnings