What can Medicaid data add to research on VA patients?

This article is the first to describe Department of Veterans Affairs (VA) patients' use of Medicaid at a national level. We obtained 1999 national VA enrollment and utilization data, Centers for Medicare and Medicaid Services enrollment and claims, and Medicare information from the VA Information Resource Center. The research team created files for program characteristics and described the VA-Medicaid dually enrolled population, healthcare utilization, and costs. In 1999, VA-Medicaid dual enrollees comprised 10.2% of VA's annual patient load (350,000/3,450,000); 304,000 were veterans. These veterans differed marginally from VA's veteran patients, being on average half a year younger and having 1% fewer males. Dual enrollees with mental health diagnoses and care were almost three times as numerous as long-term care patients; these two groups accounted for ~60% of dual enrollees. Dual enrollees disproportionately included housebound veterans and veterans needing aid and assistance. Half the dual enrollees had 12 months of Medicaid eligibility, and total Federal expenditures per patient not in managed care programs averaged >$18,000 (median >$6,000). Dually enrolled women veterans cost ~55% less than men. Medicaid benefits complement VA and are more accessible in many states. VA researchers need to consider including Medicaid utilization and costs in their studies if they target populations or programs related to long-term care or mental disorders.     

Rehabilitation medicine within the Veterans Administration: report of a survey

The health care delivery system of the Veterans Administration (VA) represents the largest single group of physicians practicing physical medicine and rehabilitation. The long-term needs of the aged, often disabled, and poor veterans of America's wars suggest that rehabilitation should be a high priority within the VA system. Yet, Max Cleland, former VA Administrator, and a VA Task Force on Rehabilitation have indicated that operational performance falls short of promises and that programs are fragmented and uncoordinated, with minimal research production. The results are reported of a 17-page questionnaire sent to the 273 full- and part-time physicians in Rehabilitation Medicine Services (RMS) in an attempt to determine the state of rehabilitation medicine in clinical practice, teaching, education, publishing and research.     

A new era in acute care

Acute care continues to be the primary place of employment for occupational therapists. It is a challenging environment that requires the skills of our most experienced practitioners. Because the acute care hospital is likely to remain an entry point for rehabilitative care, this area of practice warrants continued attention in our professional literature. We hope this issue will stimulate therapists to write more articles, conduct more research, and develop more programs in acute care occupational therapy.     

Occupational therapy with patients with multiple personality disorder: personal reflections

Patients with multiple personality disorder are being admitted to acute care psychiatric units with increasing frequency. Occupational therapists have been confronted with setting treatment goals and designing interventions for this population with little information available in the occupational therapy literature. This paper describes how one therapist, the author, reviewed psychiatric and psychological literature on multiple personality disorder to delineate a role for occupational therapists who are working with this special population on an acute care psychiatric unit within the context of existing programs.     

Occupational Therapists' Perspectives on Practice Errors in Geriatric Practice Settings

Errors occur in health care practice. This study examined occupational therapy practitioner errors in geriatric practice in an effort to understand the phenomenon of errors and practitioners' response. Four focus groups were conducted with 29 therapists in four states. Results revealed factors that were internal or external and technical or moral that contributed to errors. Making errors had an emotional impact on occupational therapy practitioners. Occupational therapists instituted specific tactics to cope with emotional responses caused by making errors. Findings of the study have significant implications to current occupational therapy practice and professional training programs such as reexamining regulations and policies, strengthening communication skill training, facilitating collaborative team-work and encouraging truth telling and error disclosure.     

PSRO and quality assurance: what is the occupational therapist's role?

This article highlights the characteristics of the PSRO review process, looks briefly at the variety of patient care evaluation procedures and enumerates the ways in which occupational therapists can participate. There are two major steps the occupational therapists can take. The first is done on an individual or staff level. The second, involving a series of ongoing contacts, needs to be organized through a state or local occupational therapy association. Individual participation starts in your own service area with chart audit of the quality of occupational therapy care. The audit is based on criteria developed or adapted in the occupational therapy department. There are now many ways to gain the skills necessary for such a project. They are listed in the article. Occupational therapists can have input into the PSRO program through a PSRO committee of their state or local occupational therapy association. Selected representatives of the occupational therapy affiliates should contact all PSROs in their state. The area in which occupational therapists can interact with the PSRO are described.     

The impact of reimbursement systems on occupational therapy practice in Canada and the United States of America

Different funding and cost-control mechanisms in Canada and the United States of America (USA) have a powerful influence on occupational therapy practice in each country. Canada's public health insurance system emphasizes access to health care services based on medical need. Costs are controlled at the provincial government level by limiting the capacity of facilities and personnel. Occupational therapists in publicly-funded settings have considerable professional autonomy to use occupational therapy theoretical models and to be client-centred. The measurement of outcomes is not always required and the interventions of individual occupational therapists are infrequently scrutinized. The USA has no universal, publicly-funded, comprehensive health insurance. Health care policies are driven by financial priorities and cost control occurs at the service delivery level. Insurance companies define the scope of occupational therapy practice by identifying what services they will pay for and they scrutinize occupational therapy interventions. The emphasis on effectiveness and efficiency leads to critical examination of interventions by therapists. Canadian occupational therapists can learn much from their colleagues in the USA in this area.     

"To care for him who shall have borne the battle and for his widow and his orphan" (Abraham Lincoln): the Department of Veterans Affairs polytrauma system of care

Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs Polytrauma System of Care.The initiation of combat in Iraq and Afghanistan has resulted in a new cohort of active-duty service members and veterans seeking rehabilitation care through the U.S. Department of Veterans Affairs (VA). Service members injured in combat most often sustain multiple injuries (polytrauma) and require a unique service delivery model to meet their needs. The VA recognized this need and responded with the development of the Polytrauma System of Care (PSC). This national system of care balances access and expertise to provide specialized life-long care to the combat injured. The PSC is comprised of: 4 specialized regional rehabilitation centers that are accredited in brain injury by the Commission on Accreditation of Rehabilitation Facilities; 21 specialized outpatient and subacute rehabilitation programs; designated polytrauma teams at smaller, more remote VA facilities; and a point of contact at all other VA facilities. In addition, the PSC has developed a proactive case-management model, a specialized telehealth network, guidelines for long-term follow-up, and services for those individuals who are unable to return home. The following commentary and articles provide additional detail on this new and unique system of care.     

Determinants of VA utilization. The 1983 survey of aging veterans

By the end of the decade, fully one half of American males aged 65 years and over will be veterans. In anticipation of the increased demand for medical services, the Veterans Administration recently commissioned a survey of the needs of aging veterans. From a national probability sample, approximately 34,500 households were screened to yield interviews with 3,013 veterans aged 55 years and over. Using multivariate regression analyses, the present study employed this data set for two purposes: 1) to identify covariates of past and present service utilization in the VA system, and 2) to identify the conditions under which veterans will declare an intention to use VA services in the future. Independent variables included medical diagnoses, ADLs, demographic and background characteristics, convenience and proximity to VA facilities, alternative forms of insurance coverage, VA eligibility, and attitudes about the quality of VA care. The results suggest markedly different predictors for current use versus likelihood of future use; however, income was related to both current and intended future utilization. The implications of these findings for policy development and utilization projections are discussed.     

Evaluation of occupational therapy school-based consultation service for students with fine motor difficulties

PURPOSE: This paper describes a 2-year study that addressed the perceived occupational performance changes among students with fine motor difficulties receiving occupational therapy school-based consultation (OTSBC) services. METHOD: The sample included 52 stakeholders of students with fine motor difficulties who received occupational therapy services. Six exploratory focus groups and one participatory and action-based focus group were conducted with parents, teachers, occupational therapists, and Community Care Access Centre case managers. RESULTS: Results supported the benefits of OTSBC. Key concerns identified were the wait for service, confusion about service expectations, inadequate communication among stakeholders, school board issues, and constraints in the health care system. Recommendations identified were to train teachers, provide early intervention, address service delivery issues related to health and education systems, and promote awareness of occupational therapy service and its effectiveness. PRACTICE IMPLICATIONS: Occupational therapists working with students with fine motor difficulties could consider providing formal education programs for teachers, promoting early intervention of fine motor problems, and communicating to stakeholders regarding the expectations and effectiveness of OTSBC.     

The use of crafts in occupational therapy for the physically disabled

In this article, the historical use of crafts in occupational therapy for the physically disabled patient is reviewed and the results of a survey aimed at describing current craft use is presented. A questionnaire was sent to a random sample of 250 occupational therapists throughout the United States who chose physical disabilities as their specialty section. Results demonstrated that, while most therapists use crafts to some degree in their therapy programs, other treatment modalities such as therapeutic exercise and activities of daily living were used a greater percentage of the time. Reasons for using crafts, problems with justification of craft use, and participation of certified occupational therapy assistants in craft programs are discussed. Questions are raised concerning the role of therapeutic crafts in the past and present practice of occupational therapy for the physically disabled. Recommendations are made for future research.     

Strategic planning: positioning occupational therapy to be proactive in the new health care paradigm

Strategic planning can be a powerful tool for occupational therapists seeking to position themselves to be leaders in the rapidly changing health care environment. The philosophical base and values of occupational therapy are consistent with those embraced by the emerging health care paradigm. However, occupational therapy staff at Victoria Hospital, an acute care university-affiliated health care institution, identified obstacles to seizing the opportunities offered by this shift in health care. In reviewing the literature, it was discovered that these obstacles were not unique to one particular facility, but were in fact common issues faced by the profession. The strategic planning process described in this paper provided a framework for addressing the identified barriers and positioning occupational therapists to play a proactive role in the evolving health care paradigm.     

The Effects of Exercise on the Elderly and Implication for Therapy

Physical and occupational therapy activity and exercise programs have historically been directed toward the restoration of function in the disabled elderly. These professions have not focused their attention on the well or mildly impaired elderly. The current research on exercise and the elderly described here documents the positive benefits of physical activity and exercise programs for the well or mildly impaired elderly. The potential for physical and occupational therapists to provide services to the non-disabled elderly population is explored and a model program is offered as an example of this expanded role for therapists.     

Three frames of reference in work-related occupational therapy programs

This paper discusses the relationship of a theoretical frame of reference to the implementation of a work-oriented program. Three frames of reference in occupational therapy are reviewed, and work-related theories and approaches available to therapists are categorized under each. Examples of the application of various frames of reference are given through an analysis of work programs described in the occupational therapy literature. We recommend that therapists select and apply frames of reference systematically when developing work programs to facilitate the development of a body of knowledge in this area.     

Studying outcomes and hospital utilization in the elderly. The advantages of a merged data base for Medicare and Veterans Affairs hospitals.

That veterans aged 65 years and older are eligible to receive care either in the Veteran Affairs (VA) health care system or in the private sector under Medicare confounds the analysis of veterans' health services utilization and outcomes in two ways. First, changes in eligibility or financial barriers to access with regard to either system influence veterans' decisions about where to seek needed care. Second, analyses of VA care for elderly veterans that rely solely on VA data sources underestimate both overall utilization and treatment complications. Similarly, failure to consider the contribution of health care delivery in the VA system may confound analyses of health care utilization by the Medicare-eligible population. To study the magnitude of such confounding influences, we linked the Medicare and VA health care administrative databases for residents of New England and New York. Results indicated that, for ten surgical procedures commonly performed in the elderly, as well as for hospitalizations resulting from acute myocardial infarction and hip fracture, VA patients receive from 17.6% to 37.4% of hospital care outside the VA system. Private hospitalizations account for 5.5% to 19.5% of the care received by veterans within 6 months after an initial episode of care in a VA hospital. It was also found that initial hospitalizations for study conditions in the VA accounted for 3.6% of all such hospitalizations among elderly Medicare-eligible men. Although overall hospital utilization appears to be underestimated in VA data sources, it was found that ascertaining mortality from sources available within the VA produced excellent results when compared with deaths recorded in the Medicare enrollment files. A national, merged VA-Medicare data base is feasible and would enhance the validity of analyses of health care delivery both for elderly veterans and for the Medicare population.     

The value of psychosocial Level II fieldwork

The shortage of occupational therapists choosing to practice in mental health and the increase of therapists electing to specialize in other areas led to a pilot study designed to gather information regarding the value of psychosocial Level II fieldwork. A survey was mailed to 152 practicing occupational therapists who had graduated from Colorado State University in Fort Collins between 1983 and 1988; of the surveys returned, 116 were used in this study. The results indicate that the psychosocial Level II fieldwork experience provides therapists with valuable training and experience regardless of their current area of practice or specialization. The results also suggest that to preserve the holistic approach that occupational therapists offer their clients, psychosocial Level II fieldwork must remain a requirement of occupational therapy programs.     

Perceptions of role assessment tools in the physical disability setting

Various role assessment tools in occupational therapy have been developed to help the clinician understand role performance and role adjustment and guide the structure of intervention. This study was designed to examine the clinician's perceptions of standardized role assessment tools in physical disability settings. A random sample of 450 occupational therapists was surveyed to learn about therapists' knowledge of four published role assessment tools. The study also examined the frequency of tool use in the acute care hospital, the rehabilitation center, and the long-term care facility. The results from 236 questionnaires (a 52% response rate) indicated that more than half of the respondents reported that their current initial evaluation did not effectively address role performance. Additionally, most of the therapists surveyed had a poor understanding of the four standardized role assessment tools, and only 5% were using an assessment instrument in their practice. The respondents reported a desire to learn more about these instruments and how they affect treatment planning. Training implications, educational opportunities, and recommendations for future research are discussed.