Development of Occupational Therapy in a Homeless Shelter

SUMMARY

This paper describes a program which provides occupational therapy services to a population of homeless individuals residing in an emergency shelter in Ft. Lauderdale, Florida. Principles of community-built practice were combined with the use of the Canadian Model of Occupational Performance to provide the theoretical approach for the program. A needs assessment was done and the programming developed and implemented based on identified needs is described. Outcomes and recommendations for the future are discussed.     

The development of a transition medical home utilizing the individualized transition plan (ITP) model for patients with complex diseases of childhood

BackgroundAdvances in medicine and technology, have enabled greater numbers of children with complex illness to survive into adulthood. Adolescents with these conditions are at high risk for adverse outcomes when transitioning to adult health care. The “Staging Transition for Every Patient” (STEP) Program was developed to systematically improve the transition from pediatric to adult healthcare.ObjectiveThis article details the development of the STEP program and the novel use of “Individualized Transition Plans” (ITP) in the clinic setting.MethodsA provider needs’ assessment of the existing transition services among youth with specific diagnoses was performed, a steering committee was developed that created a transition policy, and a medical home within the adult system was established with an interdisciplinary approach. The ITP focuses on 5 individualized goals, it was developed and tested with the first-year cohort of patients.ResultsIn the initial needs assessment, 7 of 35 diagnoses were found to have an effective transition plan. The STEP program partnered with departments across the adult facility to conduct 267 interdisciplinary patient visits. In the first year, 169 new patients were seen in the clinic. The average age was 23.0 ± 4.1 years old. The ITP goals included referrals to adult specialists, advanced care planning, career and education, transition readiness, caregiver burden, and an emergency sick plan.ConclusionThere is a need for organized transition care for medically complex youth. The STEP program answers that need by addressing the unique needs of each patient. Individualized transition planning builds trust and addresses multiple domains of health.     

Estrategias de manejo de los antidepresivos desde la perspectiva de los pacientes: luchando interna y externamente

ObjectiveTo identify the consumption pathway and strategies of coping with antidepressants use from the patients perspective.DesignQualitative research.SettingTenerife.SamplingTheoretical sampling until saturation.MethodA total of 17 open interviews with patients who consumed antidepressants whether combined with tranquilisers or not. The age range was between 35-85 years, and there were 13 women. Ten lived in a more urban setting and the rest in rural areas.Interviews were audio-recorded, transcribed verbatim and analysed using a modified Grounded Theory supported by the software program ATLAS.ti.ResultsThe process identified as coping with antidepressants, was called “struggling internally and externally.” It consisted of the individual assessment of the benefits and risks of medication use (internal struggle), addressing stigma and social pressure (external struggle). The outcome of the assessment made by patients may lead to different strategies for adjusting to drug treatment: “unconditional acceptance”, “resigned acceptance” or “forced acceptance”.ConclusionsUnderstanding the evaluation process that the patient needs to go through, given the internal and external struggle in which they are immersed, can be useful to develop interventions that improve medication use. In fact, physicians have an important role, although not always explicitly sought in resolving the dilemma posed by patients using antidepressant drugs and, therefore, reducing the length of patient suffering.     

Supporting Sustained STAR-VA Implementation: Evaluation of a Sustainment Coaching Program

ObjectivesThe Veterans Health Administration (VA) STAR-VA program is a person-centered, interdisciplinary intervention for managing distress behaviors in dementia in VA nursing homes, called Community Living Centers (CLCs). Teams often struggle to sustain STAR-VA after site-lead partner turnover. The STAR-VA Sustainment Coaching Program was developed to support a new local STAR-VA behavioral coordinator and/or nurse champion (ie, site-leads) and engage the team to implement sustainment strategies. The aims of this evaluation were to document sustainment needs, barriers and facilitators, and effective strategies used during a sustainment intervention.DesignWe describe qualitative and quantitative findings of a program evaluation of the STAR-VA Sustainment Coaching pilot program.Setting and ParticipantsEight CLC teams participated in the pilot program, 5 training a new nurse champion, 2 a new behavioral coordinator, and 1 both new site-leads.MethodsCLC teams completed a needs assessment, developed sustainment goals and plans, tracked sustainment interventions implemented, and reported case outcomes. Outcome assessment and tracking reports were summarized and themes identified using a qualitative inductive approach.ResultsCommon sustainment needs were to train a new nurse champion, promote staff understanding of dementia and distress behaviors, and promote a culture of person-centered dementia care. Most sites selected sustainment goals of implementing training procedures and behavioral rounds. Sustainment barriers included limited staff time, staff turnover, lack of supportive routines and tools, and limited awareness of STAR-VA. Facilitators included leadership support, staff interest, and training resources. Most sites reported successful implementation of STAR-VA behavior rounds, whereas strategies to achieve training-related goals had variable success.Conclusions and ImplicationsThe STAR-VA Sustainment Coaching Program helped CLC teams identify and implement strategies to support sustained STAR-VA implementation. The results of this project are informing ongoing efforts to integrate STAR-VA components into usual care processes for CLC residents with dementia.     

Constructing a Program Development Proposal for Community-Based Practice: A Valuable Learning Experience for Occupational Therapy Students

SUMMARY

Skills required to develop and fund programs can advance an occupational therapist professionally, and innovative occupation-based programs are necessary for the future of occupational therapy. This paper describes a community-based learning experience embedded within the occupational therapy curriculum of the Medical College of Ohio. While developing the Program Development Proposal, each student practices needs assessment; marketing; goals- and objectives-setting; occupation-based programming; budgeting; staffing; program evaluation; and grantsmanship. Outcome surveys of graduates indicate that the experience was positive and provided graduates with a solid foundation for program development. The experience also enhanced partnerships with community-based sites.     

Development and pilot test of a process to identify research needs from a systematic review

ObjectiveTo ensure appropriate allocation of research funds, we need methods for identifying high-priority research needs. We developed and pilot tested a process to identify needs for primary clinical research using a systematic review in gestational diabetes mellitus.Study Design and SettingWe conducted eight steps: abstract research gaps from a systematic review using the Population, Intervention, Comparison, Outcomes, and Settings (PICOS) framework; solicit feedback from the review authors; translate gaps into researchable questions using the PICOS framework; solicit feedback from multidisciplinary stakeholders at our institution; establish consensus among multidisciplinary external stakeholders on the importance of the research questions using the Delphi method; prioritize outcomes; develop conceptual models to highlight research needs; and evaluate the process.ResultsWe identified 19 research questions. During the Delphi method, external stakeholders established consensus for 16 of these 19 questions (15 with “high” and 1 with “medium” clinical benefit/importance).ConclusionWe pilot tested an eight-step process to identify clinically important research needs. Before wider application of this process, it should be tested using systematic reviews of other diseases. Further evaluation should include assessment of the usefulness of the research needs generated using this process for primary researchers and funders.     

Design of a Nursing Home Infection Control Peer Coaching Program

ObjectiveTo pilot test and refine an infection control peer coaching program, Infection Control Amplification in Nursing Centers (ICAN), in partnership with providers.DesignIntervention design and pilot test.Setting and ParticipantsInfection preventionists (IPs) from 7 Connecticut nursing homes (NHs).MethodsWe codesigned and pilot tested the ICAN program with NH IPs. The initial program involved designating peer coaches to provide real-time feedback on infection control practices to coworkers and targeting coaches’ observations using data from both observations shared by coaches in daily huddles and weekly audit data about hand hygiene, masking, and transmission-based precautions. IPs tested the initial program while providing feedback to the research team during weekly calls. We used information from the calls, participant surveys, and the pilot process to update the program.ResultsDespite IPs reporting that the initial program was highly aligned with facility priorities and needs, their weekly call attendance dropped as they dealt with short staffing and COVID-19–related outbreaks and none implemented all of the program's components as intended. Most IPs described making changes to increase feasibility and reduce burden on staff amid short staffing and other ongoing issues exacerbated by the SARS-CoV-2 pandemic. We used information from the IPs and the pilot to update the program, including shifting from having IPs lead implementation solo to using a team-based approach. The updated program retains peer coaches and audit data, while broadening the mode of feedback from huddles only to communication using one-on-one meetings or emails, huddles, or other strategies. It also provides NH staff with flexibility to tailor implementation of each to their needs and constraints.Conclusions and ImplicationsWorking with staff, we developed an infection control peer coaching program that may be of use to NH leaders seeking strategies to strengthen infection control practices. Future work should involve implementing and evaluating the updated program.     

Perceptions of a multidisciplinary team regarding a pediatric rehabilitation modified needs assessment

Background: Efficient service delivery models that optimize processes and human resources are required in the current health care climate. A family-centered care approach is recognized as a model that can improve the effectiveness and efficiency of pediatric rehabilitation. The objective of this study was to explore the perceptions of a multidisciplinary health care team regarding the use of the Préparation au plan d’intervention (PAPI), a modified needs assessment tool designed to facilitate a family-centered care approach among children with cerebral motor deficits (CMD) and their families.

Methods: One focus group was conducted with the multidisciplinary team (n?=?10) of the CMD program at a pediatric rehabilitation center. It was audio recorded and transcribed verbatim for content analysis.

Results: Three overarching themes were identified from the analyzes: (1) a facilitator of open communication, (2) a way to gain the unique sense of the child and family and (3) parents as the experts of their child.

Conclusions: Health care professionals value the use of the PAPI as a way of facilitating a family-centered care plan process, specifically with children with cerebral motor deficits.     

Group Co-Leadership by Occupational Therapy Students in Community Centers: Learning Transitional Roles

SUMMARY

The experience of contact with community populations and settings at the beginning of fieldwork is essential in expanding the dimensions of non-traditional skills and roles for occupational therapy students. This article describes an initial fieldwork experience which builds on an occupational therapy group process course to enable students to supplement a community-based program with activities designed to meet a need of their group at the appropriate level of group interaction. Pairs of students select a receptive community site prior to the beginning of fieldwork to open dialog with the center's coordinator regarding performance areas, components, or contexts needed by the group. Working to assess the current programmatic offerings and desires of the participants for new activities and planning activities in collaboration with local staff, the students propose to conduct a series of five sessions addressing a theme desired or needed by the group. Upon immersion in the site's program, students are able to provide an in-depth assessment of the community group's psychosocial skill needs using the Group Level of Function Profile (Donohue, 2000).     

The implementation cost of a safety‐net hospital program addressing social needs in Atlanta

ObjectiveTo describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers.Data Sources/Study SettingCosts for a heart failure health care program based in a safety‐net hospital were reported by program staff for the program year May 2018–April 2019. Additional data sources included hospital records, invoices, and staff survey.Study DesignWe conducted a retrospective, cross‐sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities.Data CollectionProgram cost data were collected using a activity‐based, micro‐costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation.Principal FindingsProgram costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30‐day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities.DiscussionHistorically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.     

Introducing GRADE across the NICE clinical guideline program

ObjectivesGrading of Recommendations Assessment, Development and Evaluation (GRADE) is a system for rating the confidence in estimates of effect and grading guideline recommendations. It promotes evaluation of the quality of the evidence for each outcome and an assessment of balance between desirable and undesirable outcomes leading to a judgment about the strength of the recommendation. In 2007, the National Institute for Health and Clinical Excellence began introducing GRADE across its clinical guideline program to enable separation of judgments about the evidence quality from judgments about the strength of the recommendation.Study Design and SettingWe describe the process of implementing GRADE across guidelines.ResultsUse of GRADE has been positively received by both technical staff and guideline development group members.ConclusionA shift in thinking about confidence in the evidence was required leading to a more structured and transparent approach to decision making. Practical problems were also encountered; these have largely been resolved, but some areas require further work, including the application of imprecision and presenting results from analyses considering more than two alternative interventions. The use of GRADE for nonrandomized and diagnostic accuracy studies needs to be refined.     

Measuring quality of care: considering measurement frameworks and needs assessment to guide quality indicator development

ObjectiveIn this article, we describe one approach for evaluating the value of developing quality indicators (QIs).Study Design and SettingWe focus on describing how to develop a conceptual measurement framework and how to evaluate the need to develop QIs. A recent process to develop QIs for injury care is used for illustration.ResultsKey steps to perform before developing QIs include creating a conceptual measurement framework, determining stakeholder perspectives, and performing a QI needs assessment. QI development is likely to be most beneficial for medical problems for which quality measures have not been previously developed or are inadequate and that have a large burden of illness to justify quality measurement and improvement efforts, are characterized by variable or substandard care such that opportunities for improvement exist, and have evidence that improving quality of care will improve patient health.ConclusionBy developing a conceptual measurement framework and performing a QI needs assessment, developers and users of QIs can target their efforts.     

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

BackgroundChildren and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.ObjectiveThe objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.MethodsWe developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.ResultsDuring the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.ConclusionsThe telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.     

Assessing Foods and Nutrition Competencies in Youth

ObjectiveTo develop a comprehensive assessment of foods and nutrition competencies with robust psychometric properties for the 4-H Foods and Nutrition Project.DesignThe Assessment of Foods and Nutrition Competencies in Adolescents was developed through a systematic measurement development process by a group of researchers, practitioners, and program alumni familiar with the theory of change and implementation procedures of the 4-H Foods and Nutrition Project.SettingRecruitment was conducted through the 4-H Online membership management program for 4-H members throughout Texas to complete online survey questions.ParticipantsFour hundred twenty-four Texas 4-H members in grades 6–12.Variables MeasuredSurvey items addressing 6 specific foods and nutrition competencies dimensions.AnalysisA series of reliability and confirmatory factor analyses were conducted to assess the psychometric qualities of Assessment of Foods and Nutrition Competencies in Adolescents.ResultsAssessment of Foods and Nutrition Competencies in Adolescents was found to possess good factor structure, reliability, validity, and measurement invariance. Program participants showed an advantage over nonparticipants in most core foods and nutrition competencies concerning positive behavioral changes.Conclusions and ImplicationsAssessment of Foods and Nutrition Competencies in Adolescents comprehensively captures the core competencies promoted by the 4-H Foods and Nutrition Project and possesses the psychometric qualities critical for program evaluation. A more diversity-focused outreach effort is needed for inclusive youth programs like the 4-H Foods and Nutrition Project to benefit the general youth population.     

Determining policy-relevant formats for the presentation of falls research evidence

ObjectivesPopulation modelling holds considerable promise for identifying the most efficient and cost-effective falls prevention measures, but the outcomes need to be in a readily useable form. This paper describes an iterative, collaborative process undertaken by researchers and falls prevention policy officers to develop such a format for falls prevention intervention evidence.MethodsThe researchers developed a draft template that underwent several iterations and improvements, through three collaborative consultations with policy officers.ResultsAlthough the researchers initially identified many key information needs, active engagement with policy officers ensured that policy requirements were met and that the value of the reporting formats for policy decision-making was maximised. Importantly, they highlighted the need to articulate underlying modelling assumptions clearly. The resulting formats, with complete data, were given to policy officers to inform their local jurisdictional policy decisions.ConclusionsThere is strong benefit in researchers and policy officers collaborating to develop optimal formats for presenting scientific evidence to inform policy decisions. Such a process can reduce concerns of researchers that evidence is not incorporated into policy decisions. They also meet policy officers’ needs for evidence to be provided in a way that can directly inform their decision-making processes.     

Adoption in practice: The relationship between managerial interpretations of evidence and the adoption of a healthcare innovation

ObjectivesOur work explores the gap between evidence, management practices and the adoption of innovations. The article draws on the results of a longitudinal study examining the adoption of remote care (telecare) services.MethodFive UK organisations form purposively chosen case studies. In the process of adoption, we explore how managers interpret and construct evidence to inform practice.ResultsManagerial interpretations of evidence are negotiated through a series of interlinked frames of practice. These frames align evidence with existing professional practices and needs, and mobilise collective decision-making and strategic action.ConclusionsThe degree to which resulting managerial practice is consistent with aims and objectives of the recipient organisation serves to mediate innovation spread.     

Strengthening of causality assessment of adverse events following immunization in the WHO South East Asia and Western Pacific regions: Lessons from the 2014 SEAR inter-country workshop

BackgroundPoorly managed AEFI undermine immunization programs. Improved surveillance in SEAR countries means more AEFIs but management varies. SEAR brought countries together to share AEFI experiences, and learn more about causality assessment.MethodsThree day 10 country workshop (9 SEAR; 1 WPR). Participants outlined county AEFI experiences, undertook causality assessment for 8 AEFIs using WHO methodology, critiqued the process by questionnaire and had a discussion.ResultsAll 10 valued AEFI monitoring and causality assessment, and praised the opportunity to share experiences. Participants determined a range of AEFI and causality assessment needs in SEAR such as adapting WHO Algorithm, CIOMS/Brighton definitions, WHO verbal autopsy to fit context, requesting a practical guide – AEFI definition, time interval, rates of AEFI for different vaccines and evidence for vaccine related causes of death under 24 h.ConclusionsLMIC need WHO AEFI tools adapted to better fit LMIC. Learning from each other builds capacity. Sharing AEFI experiences, case reviews help LMIC improve practices.     

Transitional care for patients with acute stroke—A priority‐setting project

BackgroundThe scope of this priority‐setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority‐setting methods are time‐consuming and require extensive resources. They are therefore not feasible in small‐scale research. This article describes a pragmatic priority‐setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke.MethodsA pragmatic priority‐setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list.ResultsThe process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories ‘patients and caregivers’ needs and health literacy’, ‘health personnel''s common understanding’, ‘information flow between health personnel and patients and caregivers’, ‘available interventions and follow‐up of patients and caregivers’, ‘interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare’ and ‘disabilities after stroke’.ConclusionThis paper outlines a pragmatic approach to identifying and prioritizing users'' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke.Patient and Public ContributionMembers of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.     

Lasting results: A qualitative assessment of efforts to make community-led total sanitation more inclusive of the needs of people with disabilities in Rumphi District,Malawi

BackgroundIn low-income countries, like Malawi, approaches aimed at improving access to household sanitation for persons with disabilities have been limited, and often do not include post-intervention process evaluations. 6% of Malawi's population reports defecating outside rather than in a sanitation facility, and 4% of its population live with a disability; these groups of individuals live predominantly in rural areas.ObjectiveThis article describes a post-program evaluation of an inclusive Community-Led Total Sanitation program that specifically responds to household-level needs of people with disabilities in Rumphi District, Malawi.MethodsData collected from safety and accessibility audits of household latrines used by persons with disabilities and interviews with implementers at 18 months post-intervention were used to determine sustainability.ResultsThe household latrine audit results show that existing conditions for sanitation access are still not optimal for persons with disabilities and that changes may require more time to be implemented. Some of the training program steps had more lasting impact on the implementers than other steps, such as the squatting exercise. There was limited evidence implementers had made additional changes or innovations or had transferred their knowledge more widely to other implementers. There is also a need to ensure local vernacular is available to mitigate the social stigma associated with people with disabilities.ConclusionsImplications for future replication show the need to invest in training a wider group of people to assist with implementation and to keep the program simple and focused on more active learning methods to make sustainable behavioral changes.