Predischarge occupational therapy home assessment visits: towards an evidence base

Background/aim:  Predischarge home assessment visits are a commonly accepted, but little researched, aspect of occupational therapy practice. The aim of this research was to systematically investigate current predischarge occupational therapy home assessment visit practices in a rehabilitation ward of a regional Australian hospital.
Methods:  A retrospective chart audit was conducted over a 7-month time period and included 227 patients discharged from the inpatient rehabilitation ward at the study hospital.
Results:  Fifty-five per cent of patients in the study sample received home assessment visits. At least one recommendation for change was made as a result of the visit for 99% of those patients receiving visits. A total of 139 visits were completed and resulted in 1179 recommendations for change. The median number of recommendations made for the home assessment visits was 10 (range 0–33). The most common types of recommendations, timing of visits, persons present during the visit and documentation of visits were also investigated.
Conclusion:  Although occupational therapy home assessment visits are routinely completed, there is limited research available to provide evidence-based guidelines relating to predischarge occupational therapy home assessment visit practices. Recommendations for future practice and areas for further research into occupational therapy home assessment visits are discussed.     

Use of contract occupational therapy services to facilitate early discharge from hospital

Early discharge is one of the new frontiers for occupational therapists. Casemix funding, with its emphasis on creating efficiencies in the hospital system and reducing length of stay, has challenged occupational therapists to explore new ways of providing traditional services. An early discharge scheme administered by the Gold Coast Hospital occupational therapy department used contract occupational therapists to provide home visiting services to patients discharged early from hospital. The first year of the programme demonstrated a cost-efficient and quality service provided to 124 patients in the categories of stroke, social admissions and falls. The present paper documents the administration of the programme plus the cost benefits and outcomes of the first year of the scheme.     

Community occupational therapists' clinical reasoning: identifying tacit knowledge

Background: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community‐dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions. Aim: To synthesise current knowledge about community occupational therapists’ clinical reasoning. Method: A scoping study of the literature on community occupational therapists’ clinical reasoning was undertaken. Results: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists’ clinical reasoning, were reviewed. Community occupational therapists’ clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists’ clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear. Conclusion: Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.     

Occupational therapy assessments used in acute physical care settings

Abstract

Objective: The aim of this study was to identify the assessments used by occupational therapists in acute care practice, their purpose, and the role of home visits and standardized tests. Methods: A cross-sectional survey containing closed and open questions was sent to therapists working in physical acute care settings using convenience sampling. This article reports on the responses of 70 New Zealand occupational therapists (response rate = 74%). Results: The study found that informal assessments (i.e. interviews and observations) were commonly used to evaluate daily living skills and to provide information about the home environment, cognition, transferring, leisure, and upper limb function. When situations were particularly complex, cognitive assessments and home visits were used judiciously to further investigate assumptions related to safety in discharge procedures. Standardized assessments were not widely used but were typically considered when cognitive ability needed to be confirmed. Conclusions: Occupational therapists' expertise lies in interviewing clients and in skilled observations of function. Standardized ADL assessments could complement occupational therapy practice but further research is needed to determine their value. In the final analysis, assessments should ensure that that both safety and client/carer concerns are at the centre of decision-making.     

Factors influencing home visits in Slovenian general practice

BACKGROUND: There is great variability in home visiting rates in Europe. The European General Practice Research Workshop (EGPRW) has conducted a pilot quantitative international study on home visits and developed a questionnaire, which has not yet been tested on a national level. In Slovenia, home visiting is decreasing, but the factors influencing home visiting by GPs in the country have not yet been examined. OBJECTIVES: The purpose of this study was to test the feasibility of the questionnaire on home visiting developed by EGPRW and to study home visiting in Slovenia. METHODS: A random representative sample of 165 Slovenian GPs were given a questionnaire, developed on the basis of former EGPRW projects. Each of the respondents provided data on 10 consecutive home visits made during office hours, data on his/her practice and number of consultations during the registration period. Multivariate modelling of home visits per working week as the dependent variable was performed. RESULTS: A 71% response rate was achieved, and the data from 1151 requests for home visits and 1015 completed home visits were analysed. The average number of home visits per working week was 2.5, with wide variation among the respondents (0-10, SD 1.89). Older GPs, trainees, GPs from rural areas and those with a higher proportion of elderly patients carried out more home visits. The selected logistic regression model fits the data well according to established criteria. CONCLUSION: It is possible to use the questionnaire developed by EGPRW on a national scale and to obtain representative valid national data. The home visiting rate in Slovenia is low compared with rates in other countries. Rural location of practice, GP's age, trainee status and the number of older patients on the list are the most important predictors of the home visiting rate.     

What’s Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes

Introduction Research has documented modest positive impacts of early childhood home visiting programs. However, understanding more about what home visitors do during visits and how much time they spend on specific topics may provide insight into the variability in effectiveness of services. Methods Outcome data were collected via parent survey at program enrollment and 12 months from 123 women in three MIECHV-funded home visiting models. Home visitors completed weekly home visit content and activity logs. Results Families received an average of 28 visits during the study (3.1 visits per month). Of ten content areas, the three most often discussed were early childhood development, physical care of children, and the parent–child-relationship. Multivariate regression models were used to explore the association of home visit dosage, home visit content and cumulative risk factors on parenting outcomes. Women whose visits were focused more on parenting topics reported lower parenting-related stress at follow-up compared to those whose visits had less parenting content. Additionally, higher-risk women who received greater numbers of home visits showed larger reductions in their attitudes about harsh punishment over time, compared to high-risk women with fewer home visits. Discussion Receiving home visits that emphasize parenting content may contribute to reduced parenting-related stress. For high-risk women in particular, receiving more visits overall may be important to achieving positive outcomes. Implications for practice include working to engage and retain high-risk families. Future home visiting research calls for improved methods for collecting data on content/activity during visits, the necessity for long-term follow-up, and testing for the effectiveness of varied and flexible visit schedules/content focus for women and families with trauma exposure.     

Recruitment and retention issues for occupational therapists in mental health: Balancing the pull and the push

Background/aim: Recruitment and retention issues for mental health occupational therapists have been the subject of significant concern for many years. This paper describes recruitment and retention issues as reported by mental health occupational therapists employed by a large Area Health Service in metropolitan Sydney. Method: Thirty‐eight mental health occupational therapists (response rate 84%) completed a survey in the first half of 2008. Key themes investigated were: overall satisfaction; attractive elements of positions; positive aspects of positions; constraints of positions; factors associated with leaving positions; supervision; professional development; career pathways; and interest in and access to management positions. Results: Key elements that kept respondents in positions included the nature of the work, being in a supportive team and the opportunity to use occupational therapy skills. Elements that prompted people to consider leaving positions were the desire for new and different types of work, a desire to work closer to home, insufficient time or high workloads, feeling ‘bored’ or ‘stale’, organisational change or juggling multiple demands, working in unsupportive or dysfunctional teams and family or other personal factors. Conclusions: The results supported the development of a ‘push and pull’ conceptualisation of recruitment and retention issues, including job‐related (intrinsic) and non‐job‐related (extrinsic) issues. This conceptualisation allows organisations to closely examine factors that attract practitioners to positions and those that support or damage staff tenure.     

National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary

OBJECTIVE: This report presents the most current (2005) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1995 through 2005 are also presented. METHODS: Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED and outpatient department (OPD) utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2005, an estimated 115.3 million visits were made to hospital EDs, about 39.6 visits per 100 persons. This represents on average roughly 30,000 visits per ED in 2005, a 31 percent increase over 1995 (23,000). Visit rates have shown an increasing trend since 1995 for persons 22-49 years of age, 50-64 years of age, and 65 years of age and over. In 2005, about 0.5 million (0.4 percent) of visits were made by homeless individuals. Nearly 18 million patients arrived by ambulance (15.5 percent). At 1.9 percent of visits, the patient had been discharged from the hospital within the previous 7 days. Abdominal pain, chest pain, fever, and cough were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.9 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 71.1 percent of visits, and procedures were performed at 47.3 percent of visits. Medications were either given in the ED or prescribed at discharge at 76.7 percent of visits, resulting in 204.9 million drug mentions. On average, patients spent 56.3 minutes waiting to see a physician, and 3.3 hours for the full duration of their ED visit. About 12 percent of ED visits resulted in hospital admission. The average total length of stay for those admitted was 5.2 days, and the leading principal hospital discharge diagnosis was nonischemic heart disease.     

National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1992 through 2001 are also presented. The report highlights new items on the continuity of care provided at ED visits, initial vital sign measurements, whether the patient's residence was a nursing home or institution, and duration of the ED visit. METHODS: The data presented in this report were collected from the 2001 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2001, an estimated 107.5 million visits were made to hospital EDs, about 38.4 visits per 100 persons. From 1992 through 2001, an increasing trend in the ED utilization rate was observed. Between 2 and 3 percent of ED visits were made by patients living in a nursing home or other institution. At approximately 3 percent of visits, the patient had been seen in the ED within the last 72 hours. In 2001, abdominal pain, chest pain, fever, and headache were the leading patient complaints accounting for nearly one-fifth of all visits. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits. There were an estimated 39.4 million injury-related visits during 2001, or 14.1 visits per 100 persons. Diagnostic/screening services and procedures were provided at 85.4 percent and 40.9 percent of visits, respectively. Medications were provided at 74.2 percent of visits, and pain relief drugs accounted for 34.2 percent of the medications mentioned. In 2001, approximately 12 percent of ED visits resulted in hospital admission. On average, patients spent 3.0 hours in the ED.     

Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits

Background  

Pre-discharge home visits aim to maximise independence in the community. These visits involve assessment of a person in their own home prior to discharge from hospital, typically by an occupational therapist. The therapist may provide equipment, adapt the home environment and/or provide education. The aims of this study were to investigate the feasibility of a randomised controlled trial in a clinical setting and the effect of pre-discharge home visits on functional performance in older people undergoing rehabilitation.     

National Hospital Ambulatory Medical Care Survey: 1998 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments in the United States. Statistics are presented on selected patient and visit characteristics. METHODS: The data presented in this report were collected from the 1998 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability survey of visits to hospital emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 1998, an estimated 100.4 million visits were made to hospital emergency departments (ED's) in the United States, about 37.3 visits per 100 persons. Persons 75 years and over had the highest rate of ED visits. There were an estimated 37.1 million injury-related ED visits during 1998, or 13.8 visits per 100 persons. Seventy-four percent of injury-related ED visits were made by persons under 45 years of age. Injury visit rates were higher for males than females in each age group under 45 years. According to ICD-9-CM classification, 77.2 percent of injury visits were unintentional. About 71 percent of the ED visits involved medication therapy, with pain relief drugs accounting for 31.5 percent of the medications mentioned. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits.     

National Hospital Ambulatory Medical Care Survey: 1998 outpatient department summary

OBJECTIVE: This report describes ambulatory care visits to hospital outpatient departments in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics. METHODS: The data presented in this report were collected from the 1998 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to hospital outpatient and emergency departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1998, an estimated 75.4 million visits were made to hospital outpatient departments in the United States, an overall rate of 28.0 per 100 persons. Visit rates did not vary by age except in a comparison of the 15-24 year old group with the 75 years and over age group. Black persons had higher rates of visits than white persons as did women compared with men. Of all visits made to hospital outpatient departments in 1998, 33.8 percent and 25.9 percent, respectively, listed private insurance and Medicaid as the primary expected source of payment, and 21.9 percent were made by patients belonging to a health maintenance organization. There were an estimated 7.1 million injury-related outpatient department visits during 1998.     

A case against generalisation of mental health occupational therapy in Australia

Background/aim: In 2009, the World Federation of Occupational Therapists International Advisory Group on Mental Health conducted a global survey that yielded data on mental health occupational therapy practice. The Australian dataset reflected aspects of the current situation of the Australian mental health occupational therapy workforce. Of particular interest were resource availability, workforce recruitment and retention, and perception of the future of mental health occupational therapy. Methodology: Using a cross‐sectional survey design, quantitative and qualitative data were gathered electronically over a one‐month period. Manual analysis indicated themes common to mental health occupational therapists across a framework of professional areas. Results: Findings suggested that role blurring negatively affected workforce retention. Workforce recruitment and retention were complicated by resource shortages. Some Federal Government initiatives were perceived as only partially beneficial to the profession. Conclusions: Survey respondents believed that mental health occupational therapy was a potential growth area particularly where occupational therapy specific skills were retained.     

Pre-admission orthopaedic occupational therapy home visits conducted using the Internet

We evaluated the feasibility and accuracy of conducting occupational therapy home visits using the Internet. Studies were conducted at the homes of 40 patients who were scheduled to undergo a total hip or knee replacement: home visits were conducted, on the same day, by both a face-to-face therapist and an online therapist. The online therapist conducted the visit via a low-speed, dial-up Internet connection using a specially developed telerehabilitation system. This system combines real-time videoconferencing (320 x 240 pixel resolution) with a suite of calibrated assessment tools which the operator can use to measure real-scale angular displacement/velocity and linear distances during the videoconference. Both therapists completed a home environment questionnaire, assessed patients' transfer ability and measured the heights of six objects/pieces of furniture. For the questionnaire items which related to variables in the home environment, the mean percentage exact agreement was 98.9% (SD 2.6; range 90-100), while there was 100% agreement on the items related to transfers. The mean absolute difference in measured heights between the two therapists ranged from 0.1-3.3 cm. The results suggest that conducting pre-admission orthopaedic occupational therapy home visits via the Internet is both feasible and accurate.     

Economic analysis of home vs hospital-based parenteral nutrition in Ontario, Canada

BACKGROUND: Advances in technology and infrastructure have facilitated transfer of complex services from acute care hospitals to the home. This increases the burden on community resources but may provide net savings to the health care system. We undertook a retrospective cohort study of patients transferred from hospital to home while receiving home parenteral nutrition (PN) to assess their costs of care. METHODS: A detailed review of medical records was undertaken for all patients managed by the Hamilton Health Sciences Home PN Program between 1996 and 2001 whose PN was initiated in hospital. Mean per diem direct medical costs were estimated from the perspective of the provincial Ministry of Health for 3 periods: the last 2 weeks before discharge and the first month after discharge. Costs were compared among time intervals and among patients subgroups defined by age and underlying disease. RESULTS: Twenty-nine eligible subjects were identified. Common indications for PN included malignancy (n = 12), inflammatory bowel disease (n = 6), and intestinal ischemia (n = 4). Mean per diem costs in the last week of hospitalization were higher than those in the first month after discharge (dollars 567 vs dollars 405, p < .0001). Acute care resources accounted for <10% of the overall costs on home PN. The estimated monthly savings per patient maintained on home PN were dollars 4860 (95% confidence interval dollars 2700-dollars 7000). Savings were even greater among patients with underlying malignancy and advanced age. CONCLUSIONS: Home PN is cost saving when compared with hospital-based PN. Neither age nor underlying malignancy should pose a barrier to receipt of home PN.     

Occupational therapy with people with depression: Using nominal group technique to collate clinician opinion

Aims. This aim of this study was to obtain a consensus from clinicians regarding occupational therapy for people with depression, for the assessments and practices they use that are not currently supported by research evidence directly related to functional performance. The study also aimed to discover how many of these assessments and practices were currently supported by research evidence. Methods. Following a previously reported systematic review of assessments and practices used in occupational therapy for people with depression, a modified nominal group technique was used to discover which assessments and practices occupational therapists currently utilize. Three online surveys gathered initial data on therapeutic options (survey 1), which were then ranked (survey 2) and re-ranked (survey 3) to gain the final consensus. Twelve therapists completed the first survey, whilst 10 clinicians completed both the second and third surveys. Major findings. Only 30% of the assessments and practices identified by the clinicians were supported by research evidence. A consensus was obtained on a total of 35 other assessments and interventions. These included both occupational-therapy-specific and generic assessments and interventions. Principle conclusion. Very few of the assessments and interventions identified were supported by research evidence directly related to functional performance. While a large number of options were generated, the majority of these were not occupational therapy specific.     

Refugee settlement workers' perspectives on home safety issues for people from refugee backgrounds

Background/aim: Refugees experience higher levels of emotional, psychological and physical distress than the general migrant population during settlement in a new country. Safety in the home can be a major concern and is an issue of which occupational therapists should be aware. Occupational therapists working with refugees in many contexts feel unprepared and overwhelmed. As refugee settlement workers attend to home safety of refugees during the settlement process, this study aimed to develop an in‐depth understanding of their perceptions of this issue. Such information can contribute to occupational therapists’ knowledge and practice when working with refugees. Methods: An exploratory qualitative case study approach used 16 semi‐structured interviews and observation of a settlement worker assisting newly arrived refugees. Participants were settlement service staff (an occupational therapist, case coordinators and cultural support workers). Results: Three themes are reported: considerations for safety in the homes of refugees; factors influencing home safety for refugees; and sensitivity to culture. Participants described tailoring home safety‐related services to each individual based on factors that influence home safety and sensitivity to culture. Conclusion: Awareness of home safety issues can increase cultural competence and inform practice and policy.