From policy to practice: physicians' views on OBRA and mental health resources in long-term care

OBJECTIVES: The purpose of this national survey was to seek to clarify physician beliefs about nursing home mental health needs, understand the perceived effectiveness of OBRA legislation, determine physician exposure to OBRA PASARR Level II assessments, and understand the current role of community mental health interventions in the nursing home. DESIGN: A self-administered questionnaire. SETTING: Surveyed physicians were nursing home medical directors and/or attending physicians. PARTICIPANTS: The overall response rate for the 1000 physicians surveyed nationally, was 62% (n = 620). Fifty-nine percent (n = 361) of all responders were family physicians, and 41% (n = 250) were general internists. MEASUREMENTS/RESULTS: Only 48% (n = 291) of all respondents ever saw the recommendations from their patient's OBRA PASARR Level II assessment screening. Approximately one-third of all respondents viewed each discipline's recommendations as "very" or "somewhat" helpful. Thirty-seven percent (n = 228) of respondents viewed OBRA's psychotropic guidelines as only somewhat helpful. More than two-thirds (n = 412) believed OBRA regulations had not improved access to mental health care for their nursing home patients. CONCLUSIONS: This survey demonstrated that OBRA PASARR Level II assessments are not being viewed or valued by many physicians. In nursing homes, limited access to community mental health staff and psychiatric input may leave primary care physicians treating difficult behavioral problems themselves. Collaborating on helpful mental health interventions for nursing home patients is an ongoing critical issue in long-term care.     

COVID-19 outcomes among people with intellectual and developmental disability in California: The importance of type of residence and skilled nursing care needs

BackgroundPeople with intellectual and developmental disabilities (IDD) appear to be at greater risk for severe outcomes from COVID-19. The roles of congregate living and skilled nursing care needs in this disparity are unclear.ObjectiveTo determine the impact of residential setting and level of skilled nursing care on COVID-19 outcomes for people receiving IDD services, compared to those not receiving IDD services.MethodsUtilizing publicly available California data on COVID-19 outcomes for people receiving IDD services (early May through October 2, 2020), we report outcomes based on seven types of residence, differentiated by number of residents and level of skilled nursing care provided. We compared these results to the larger California published outcomes.ResultsCompared to Californians not receiving IDD services, in general, those receiving IDD services had a 60% lower case rate, but 2.8 times higher case-fatality rate. COVID-19 outcomes varied significantly among Californians receiving IDD services by type of residence and skilled nursing care needs: higher rates of diagnosis in settings with larger number of residents, higher case-fatality and mortality rates in settings that provided 24-h skilled nursing care.ConclusionsDiagnosis with COVID-19 among Californians receiving IDD services appears to be related to the number of individuals within the residence, while adverse COVID-19 outcomes were associated with level of skilled nursing care. When data is available, future research should examine whether these relationships persist even when controlling for age and pre-existing conditions.     

Occupational therapists’ perceptions of gender – A focus group study

Background/aim: Women and men are shaped over the courses of their lives by culture, society and human interaction according to the gender system. Cultural influences on individuals’ social roles and environment are described in occupational therapy literature, but not specifically from a gender perspective. The purpose of this qualitative study was to explore how a sample of occupational therapists perceives the ‘gender’ concept. Method: Four focus group interviews with 17 occupational therapists were conducted. The opening question was: ‘How do you reflect on the encounter with a client depending on whether it is a man or a woman?’ The transcribed interviews were analysed and two main themes emerged: ‘the concept of gender is tacit in occupational therapy’ and ‘client encounters’. Results: The occupational therapists expressed limited theoretical knowledge of ‘gender’. Furthermore, the occupational therapists seemed to be ‘doing gender’ in their encounters with the clients. For example, in their assessment of the client, they focussed their questions on different spheres: with female clients, on the household and family; with male clients, on their paid work. Conclusions: This study demonstrated that occupational therapists were unaware of the possibility that they were ‘doing gender’ in their encounters with clients. There is a need to increase occupational therapists’ awareness of their own behaviour of ‘doing gender’. Furthermore, there is a need to investigate whether gendered perceptions will shorten or lengthen a rehabilitation period and affect the chosen interventions, and in the end, the outcome for the clients.     

OBRA 1987 and the quality of nursing home care

Because minimum government standards for quality regulate only part of the market failure, they may have unintended effects. We present a general theory of how government regulation of quality of care may affect different market segments, and test the hypotheses for the nursing home market. OBRA 1987 was a sweeping government reform to improve the quality of nursing home care. We study how the effect of OBRA on the quality of nursing home care, measured by resident outcomes, varied with nursing home profitability. Using a semi-parametric method to control for the endogenous effects of regulation, we found that this landmark legislation had a negative effect on the quality of care in less profitable nursing homes, but improved the quality in more profitable nursing homes during the initial period after OBRA. But, this legislation had no statistically significant effect in the later period when the regulation was weakly enforced. JEL Classification I18 . I11     

The inter-rater and test–retest reliability of the Self-care and Transfer scales,and intra-rater reliability of all scales of the Swedish Translation of the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT-S)

Abstract

Objective: The Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) are used internationally to measure the outcomes of occupational therapy services across diagnoses, ages, and health care settings. This study reports on the inter-rater and test–retest reliability of the Self-care and Transfer scales as well as the intra-rater reliability of all scales of the Swedish (AusTOMs-OT-S) translation. Methods: Fifteen occupational therapists rated 11 case study clients on two occasions, separated by two weeks. Test–retest reliability and inter-rater reliability were calculated for the Self-care scale and Transfer scales. Moreover, intra-rater reliability was calculated for each of the 15 therapists across all 12 scales. Results: The inter-rater reliability intraclass correlation coefficients (ICCs) were all found to be high to very high, ranging from ICC 0.762 to 0.904; the intra-rater reliability coefficients were also very good with 11 of the 15 therapists achieving ICCs of 0.745 or over, and finally the test–retest ICCs were also found to be high, ranging from 0.705 to 0.920. Conclusions: Although further research is required to confirm reliability, preliminary reliability of the AusTOMs-OT Swedish translation has been demonstrated and therapists can have confidence when using the scales.     

Occupational therapists as expert witnesses on work capacity

Aim: The aim of this study was to explore the particular challenges for occupational therapists during their cross‐examination as an expert witness on work capacity. Methods: Grounded theory methodology was used to collect and analyse data. Interviews were conducted with 31 participants with direct experience of occupational therapy work capacity assessments. Of these, 19 were occupational therapists, six were medical specialists and six were lawyers. Results: All participant groups perceived that maintaining one’s credibility in the witness box was of paramount importance. The occupational therapists identified 11 strategies that barristers may use to challenge their credibility as an expert witness. Conclusions: The three professional groups proposed practices that maintain occupational therapists’ credibility as expert witnesses on the work capacity of personal injury claimants.     

Development and content validity of the Norwegian Self-Assessment of Modes Questionnaire (N-SAMQ)

Background: The Intentional Relationship Model (IRM) introduced six therapeutic modes as ways of relating to clients. By increasing occupational therapists’ awareness of modes, and by increasing their skills in using them, therapists may improve their interactions with clients. The Self-Assessment of Modes Questionnaire may assist in increasing awareness of modes. Aim: To describe the process of developing a Norwegian version of the Self-Assessment of Modes Questionnaire (N-SAMQ) and to evaluate its content validity. Materials and methods: A 10-step translation and adaptation procedure was followed. Occupational therapists working in diverse practice areas completed the preliminary N-SAMQ version. Individual cognitive interviews were performed with these therapists in order to examine the comprehensibility and cultural appropriateness of the N-SAMQ. Results: Initially, one item was omitted. Following the pilot study (n?=?7), two of the remaining items were modified with a view to increasing their cultural relevance. Otherwise, modifications were made mostly in terms of words and phrasing. Conclusion: The N-SAMQ appears to have good face and content validity. Significance: With the N-SAMQ, Norwegian occupational therapists can assess their preferred therapeutic modes.     

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.     

“My view that disability is okay sometimes clashes”: experiences of two disabled occupational therapists

Abstract

Aims: While disability is the focus of much attention in occupational therapy, there has been little attention paid to disability within the profession. Disabled therapists not only bring valuable perspectives on disability, but also pose important challenges to taken-for-granted assumptions about impairment and disability within the profession. At the same time, their cultural beliefs and values may clash with core assumptions of the profession. Methods: This study analyses interview data from two disabled occupational therapists, part of a larger study with cultural minority therapists. Semi-structured interviews explored their experiences of professional practice in the context of societal belief in the superiority of non-disabled and “normal” ways of doing and being. Major findings: Some cultural values of participants clashed with the values and beliefs of their profession, particularly concerning independence. Negative attitudes of colleagues and managers were the key barriers to practice. The responsibility for bridging the disabled/non-disabled cultural divide rested with the disabled therapists, exacerbating inequity. Nonetheless, these therapists believed their disability experiences had advantages for practice. Conclusions: Disabled therapists may be required to engage in invisible work to communicate across cultural differences, and to educate others. Respectful openness to difference could enhance the practice competence of both disabled therapists and their non-disabled colleagues. This demands critical reflexive attention to ableism within the profession.     

Parent resuscitation preferences for young people with severe developmental disabilities

OBJECTIVE: To determine the relationship of providing explanatory information regarding resuscitation to DNR status for parents and guardians of young people who reside in a pediatric skilled nursing facility. DESIGN: Retrospective, quasi-experimental study of policy change, with each individual serving as his or her own control. Interval comparisons were made between resuscitation choices before and after information was provided to families. For those who were originally in the full resuscitation group, comparisons were also made between those who changed to DNR and those who did not. SETTING: Pediatric skilled nursing facility in Massachusetts. PARTICIPANTS: Sixty individuals with severe mental retardation and complex medical problems, between the ages of approximately 2 and 32 years. MEASUREMENTS: Review of records regarding resuscitation choices and changes, with each person serving as his or her own control. Both univariate and multivariate analyses were performed on individuals who were in the full resuscitation group at the initiation of the study to determine distinguishing characteristics between those who remained in that group from those who changed to DNR. RESULTS: The families of 11 (18%) of 60 patients had requested DNR orders prior to requirement of written preference for resuscitation or DNR in the event of cardiopulmonary arrest. After provision of informative material, there was an increase to 26 patients (43%) who were designated DNR (P < . 001). There was no significant difference in characteristics between the groups that changed to DNR and those that remained full resuscitation, although there was a marginal trend of children in the group with an acquired etiology for their developmental disabilities were more apt to have their resuscitation status changed than those with congenital diagnoses (P = .053). CONCLUSION: When families are provided with explanatory information regarding resuscitation in a nonacute, pediatric skilled nursing home setting, there is a significant increase in request for DNR.     

The self-reported use of research in clinical practice: A survey of occupational therapists in Sweden

Background: Today, healthcare providers and occupational therapists are increasingly required to rely on evidence-based practices. In both outpatient and inpatient settings, the use of research-based practices can be identified using the Research Utilization Measure questionnaire. Aim: This study explores how occupational therapists in Sweden perceive research utilization. Method: The Research Utilization Measure was sent to 807 randomly selected occupational therapists in Sweden, and the response rate was 59% (n = 472). Results: The majority of respondents (56%, n = 256) reported use of research-based knowledge in their practice “very or rather often”, although 49% (n = 225) of the therapists noted that they “very seldom or never” discussed research findings with their managers. Differences in answers for most items were related to degree of education and length of experience. Occupational therapists with higher education levels more often reported use of research in their clinical practice and therapists with greater experience less often reported use of research in their clinical practice. Conclusion: Education seems to influence the degree to which occupational therapists rely on research to inform their practices. A future challenge for managers and occupational therapists is to create strategic discussions on how to implement treatment that is based on current research.     

Associations between published quality ratings of skilled nursing facilities and outcomes of medicare beneficiaries with heart failure

IntroductionNursing Home Compare quality ratings are designed to allow patients, families, and clinicians to compare facilities based on quality, but associations of the current measures with important clinical outcomes are not known. Our study examined associations between ratings and readmission and mortality among Medicare beneficiaries admitted to a skilled nursing facility with a primary diagnosis of heart failure.MethodsWe conducted a retrospective cohort study of 164,672 Medicare beneficiaries discharged to skilled nursing facilities after hospitalization for heart failure in 2006–2007. The main outcome measures were readmission and mortality within 90 days.ResultsOne-fifth of the 13,619 skilled nursing facilities received a 1-star rating and 11% received a 5-star rating. Nearly half of the patients discharged to a skilled nursing facility were readmitted to a hospital within 90 days after discharge, and 30% died within 90 days. Compared with patients in 5-star skilled nursing facilities, patients in 1-star facilities had higher risks of 90-day readmission (hazard ratio, 1.08) and mortality (1.15). After adjustment for facility size and ownership type, the associations between the quality rating and readmission were not statistically significant, but the associations with mortality were significant.ConclusionPublicly reported Nursing Home Compare quality ratings of Medicare-certified skilled nursing facilities were modestly associated with 90-day readmission and mortality among Medicare beneficiaries discharged to these facilities after hospitalization for heart failure.     

Cervical cancer risk factors and predictors of cervical dysplasia among women in south‐west Nigeria

Aim: This study identified predictors of cervical dysplasia and assessed the prevalence of risk factors for cervical cancer among women of different socioeconomic classes in Ogun State, Nigeria. Method: In a two‐phase study, self‐reported information on cervical cancer awareness, risk factors and cervical cancer screening practices was obtained from 278 randomly selected working women. A random subset was screened for dysplasia using visual inspection with acetic acid (VIA). Results: Of the 278 women, 126 (45.3%) were semi‐skilled while 152 (54.7%) were skilled and professional workers. Median age at first sexual intercourse was 19 years (range 13–29) and lower than the median age at first marriage (25 years). Gonorrhoea and genital warts were the commonest reported sexually transmitted infections. Only 12.2% of the women used male condoms as their primary method of birth control and 4.7% of the women had ever had a Papanicolaou smear, a practice that was significantly higher among the professional/skilled compared with semi‐skilled workers (P = 0.031). Of the 125 screened, 20 (16%) had positive VIA. Young age at first sex (≤17 years) (OR = 3.7 (95% CI, 1.07–12.8)) and early first marriage (<25 years) (3.3 (1.00–10.9)) were associated with a positive VIA. Women with lower parity (0–3) had borderline significantly increased risk of having a positive VIA (3.1 (0.9–10.6)). Women currently over 34 years and those without a history of sexually transmitted infections had lower risk of positive VIA (P > 0.05). Conclusions: Acceptable screening services and cervical cancer awareness campaigns that address modifiable risk factors are urgently needed in this community.     

Assuring Professional Pastoral Care for Every Nursing Home Resident

SUMMARY

Ministry to persons in nursing homes is built on two mandates: “… He has sent me to bring good news to the oppressed, to bind up the brokenhearted, to proclaim liberty to the captives, and release to the prisoners; … to comfort all who mourn …” (Isaiah 61:1–3). The federal government provides the second: “Quality of Life. A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life” (OBRA '87, Guidance to Surveyors in Long Term Care Facilities, Code of Federal Regulations, Health Care Financing Administration, 1995, section 483.15, F240). This article discusses both the religious and the U.S. political history of caring for the old and frail. It concludes by describing political efforts in one state to increase the quality of that care and pastoral efforts to support the nursing assistants in long-term care facilities.     

Using a time-geographical diary method in order to facilitate reflections on changes in patterns of daily occupations

Abstract

Objective and methods: Time-use methodologies have been proposed to be established research techniques when exploring aspects of daily occupations. In this study, two graphs illustrating the time arrangement of occupations as they appear in a continuous sequence were used in order to encourage individuals to reflect on their everyday life. The aim was to investigate the usefulness of a time-geographical diary method (using illustrative graphs) in combination with stimulated-recall interviews, to facilitate reflections on how patterns of daily occupations change over time and the causes that lie behind these changes. The study had a qualitative design. The participants were two working, married mothers, i.e. individuals considered to have highly complex patterns of daily occupations. The data analysis was performed by using thematic content analysis. Results: The results showed that the stimulated-recall interviews, based on the graphs, facilitated new insights that came to light concerning the scope of the participants' daily life. The method enabled the participants to reflect on their patterns of daily occupations and become aware of changes relevant to explain the causes for engaging in occupations the way they did. Conclusions: The method thus seems useful in research and practice for occupational therapists working with individuals with a need to change lifestyle.     

Use of vitamins,trace elements,or herbal products does not differ between cancer patients and population in general

Objective: To examine how widely cancer patients use vitamins, trace elements, and herbal products. Methods: The Health and Social Support Study (HeSSup) population consisted of a stratified random sample drawn from the Finnish Population Register in four age groups: 20–24, 30–34, 40–44, and 50–54 years. The survey was carried out by postal questionnaire during 1998, with a response rate of 40.0%. Altogether, 19 626 individuals returned the follow-up questionnaire during 2003, a response rate of 75.8%. The sample comprised 167 individuals diagnosed with malignant cancer from 1998 to 2002 according to the Finnish Cancer Registry. Respondents in 2003 were asked about their use of vitamins, trace elements, or herbal products during the last year. Four randomly selected age- and sex-matched controls for comparison were selected for every cancer patient. Results: One in three among both cancer patients and controls had not used vitamins, trace elements, or herbal products at all. In this respect, there were no statistically significant differences between cancer patients and their respective controls.

Conclusion: If the use of these products is useless, cancer patients act as reasonable as the population in general. If their use is generally recommended for supplementary therapy, cancer patients do not follow recommendations.     

Test of Visual Perceptual Skills--Revised: An Overview and Critique

Paediatric occupational therapists frequently assess and treat children and youth presenting with visual perceptual problems. Difficulties in this skill area can have a negative impact on a number of occupational performance and functional skill areas for children and youth including their ability to successfully complete activities of daily living, participate in play/recreational activities, complete school-related work and accomplish age-related developmental tasks. Therefore, it is important for occupational therapists to utilize visual perceptual assessments that possess sound measurement properties (such as validity, reliability, responsiveness and clinical utility). The Test of Visual Perceptual Skills--Revised is an instrument frequently used by paediatric occupational therapists to evaluate children and youth presenting with visual perceptual dysfunction. Occupational therapists need to be cognizant of the measurement properties of the assessments they use in order to provide the best quality care for the paediatric clients they serve. Therefore, a review and critique of the Test of Visual Perceptual Skills--Revised is presented.     

The Impact of Managed Care on the Practice of Occupational Therapy by Hand Therapists

Current Occupational Therapy (OT) literature on managed care is limited to opinion or anecdotal experience. Questionnaires were mailed to 214 OTs practicing as hand therapists nationwide to test the null hypothesis that there was no difference in reimbursement or barriers to practice for OT services between patients enrolled in managed care organizations and those enrolled in fee-for-service insurance plans. Statistically significant results were obtained indicating greater barriers to reimbursement for OT under managed care. The primary effect has been the increased administrative demands it places on both therapists and patients. [Article copies available for a fee from The Haworth Document Delivery Service: 1–800–342–9678. E-mail address: getinfo@haworth.com]     

Creating connections to life during life-threatening illness: Creative activity experienced by elderly people and occupational therapists

Objective. The aim of this study was to discover and characterize components of engagement in creative activity as occupational therapy for elderly people dealing with life-threatening illness, from the perspective of both clients and therapists. Despite a long tradition of use in clinical interventions, key questions remain little addressed concerning how and why people seek these activities and the kinds of benefits that may result. Method. Qualitative interviews were conducted with 8 clients and 7 therapists participating in creative workshops using crafts at a nursing home in Sweden. Analysis of the interviews was conducted using a constant comparative method. Findings. Engaging in creative activity served as a medium that enabled creation of connections to wider culture and daily life that counters consequences of terminal illness, such as isolation. Creating connections to life was depicted as the core category, carried out in reference to three subcategories: (1) a generous receptive environment identified as the foundation for engaging in creative activity; (2) unfolding creations—an evolving process; (3) reaching beyond for possible meaning horizons. Conclusion. The findings suggest that the domain of creative activity can enable the creation of connections to daily life and enlarge the experience of self as an active person, in the face of uncertain life-threatening illness. Ultimately, the features that participants specify can be used to refine and substantiate the use of creative activities in intervention and general healthcare.