Primary Care Occupational Therapy (PCOT)

McMillan IR & Nicol M (1999)
Department of Occupational Therapy, Queen Margaret University College, Edinburgh

Summary of Final Report

Aim of Project

This project evaluated the clinical effectiveness of occupational therapy rehabilitation provision for elderly patients at the Craiglockhart and Oxgangs Practices, South Central LHCC, Edinburgh and the occupational therapists at the Royal Infirmary, Edinburgh.. The aim was to provide a responsive service for maintaining the quality of life for older people living in the community.

This project took place over a two year period between the 1st April 1998 and the 31st March 2000.

328 referrals were received during this period and 308 were discharged up to the 31st of March 2000

Objectives

1. Clinical Effectiveness of the Occupational Therapy Service
   To determine the effectiveness of the Primary Care Occupational Therapist in maintaining elderly patients within their home environment. This included prevention of admission/readmission to the Royal Infirmary of Edinburgh.
   
   
2. Patient Perspectives
   To determine the satisfaction of service of the elderly population who are referred to the Primary Care Occupational Therapist.
   
   
3. Primary Care Team Perspectives
   To determine the existing Primary Care Team's perceptions of the effectiveness of the Primary Care Occupational Therapist role.
   
   
4. Economic Perspectives
   To determine if the provision of such a service provides a cost-effective addition to the Primary Care Team.

Project Design

This pilot project utilised a range of quantitative and qualitative research methods to determine effectiveness related to different perspectives of occupational therapy in the primary care setting. Survey methods were predominant, however a pre, post test design was also used in relation to outcome measures administered by the occupational therapist.

Results

1. Clinical Effectiveness of the Occupational Therapy Service was determined by collecting case load data on the number of patients discharged (N=308) by the occupational therapist in this period and administering three pre and post intervention outcome measures.

The Barthel Index (BI) N=248	The BI displayed higher scores that equate with more independence in the stated activities after occupational therapy rehabilitation
Assessment of Living Skills and Resources (ALSAR) N=246	The ALSAR displayed lower “at risk” scores that equate with more independence in the stated activities after occupational therapy rehabilitation
The Canadian Occupational Performance Measure (COPM) N=187	The COPM displayed higher scores that equate with more satisfaction of performance in the stated activities after occupational therapy rehabilitation.

These were administered to each patient after rehabilitation and all three measures display statistically significant results (P< 0.001) using the Wilcoxon Signed Rank Test for this sample.

The Canadian Occupational Performance measure (COPM) also collects qualitative data according to the perceptions of the patient. The data is categorised in three headings; Self-care, Productivity and Leisure. The following table illustrates some of the concerns/issues that patients raised during the initial contact with the occupational therapist.

Self Care	Productivity	Leisure
washing dressing functional mobility transfers pacing and goal setting conserving energy confidence in home environment (falls)	household management cooking laundry shopping transportation information on services ergonomic issues safety issues work access night classes	problems with socialisation reading, vision links with RNIB talking books tape recorders Library Link Service group activities swimming caring for pet at home walking the dog

2. Patient Perspectives were determined by administering satisfaction questionnaires (N=159). The perceptions of patients discharged after receiving intervention from the occupational therapist indicated “strong agreement” with statements about satisfaction regarding the service provision.

Additionally, semi-structured interviews (N=18) were also conducted and indicated rehabilitation was effective in maintaining individuals in the community and the occupational therapist demonstrated a client centred approach.

3. Primary Care Team Perspectives were determined by interviewing professionals (N=6) (2 General Practitioners, 2 Health Visitors, 1 District Nurse and 1 Community Psychiatric Nurse) on three different occasions over the duration of the project (beginning, at one year and end of the project). Opinions indicated the primary care team's perception that occupational therapists have a particular expertise that facilitates crisis intervention and improvement/enhancement in quality of life for patients in their own home, especially regarding safety and confidence issues. Opinion also indicated, there was no perceived overlap of role with existing primary care professionals.

4. Economic Perspectives proved to be inconclusive due to difficulties accessing suitable data.

Priority of referrals for each patient seen by the occupational therapist was categorised into one of three criteria that may point to financial savings (N=308), by preventing admission and/or maximising discharge from the Royal Infirmary of Edinburgh.

Priority A Aims to prevent crisis/ admission to hospital N=20 (6.6%);
Priority A Patients ought to be been seen within 2 working days

Priority A All of these patients were seen on the same day as the referral

Priority B Aims to prevent deterioration or crisis occurring and N=107 (34.7%) aims to maximise success of discharge;

Priority B Patients ought to be been seen within 5 working days

Priority B All of these patients were seen by the third day after referral

Priority C Aims to promote independence or maintain current functional ability N=181 (58.7%);

Priority C Patients ought to be been seen within 30 days

Priority C All of these patients were seen by the twenty-ninth day after referral

Case scenarios at the end of this document concerning the occupational therapists rehabilitation reflect the criteria A, B & C above.

Conclusion

There is evidence from this pilot project that occupational therapy rehabilitation for an elderly population in this particular primary care setting is effective. The following points reflect this statement;

• Preventing crises occurring that would probably lead to emergency admission
• Preventing hospital admission
• Maximising independence immediately after discharge
• Maintaining current functional ability
• Addressing and improving general quality of life rather than focussing exclusively on physical functioning
• Displaying statistically significant results for this sample in relation to Barthel scores, ALSAR scores and COPM performance and satisfaction scores
• Occupational therapist objectively rating change in patient performance through the Barthel and ALSAR measures
• Patients subjectively identifying their own priorities and scoring performance and satisfaction with those performances through the COPM
• Patients are in strong agreement regarding satisfaction with service provision and provide positive statements about the role of the occupational therapist
• The client centred nature of the occupational therapy practice is evidenced by the data from the COPM, patient questionnaires and patient interviews
• The primary care team value the unique role of the occupational therapist in terms of crisis intervention, maintaining quality of life and the speed of response to patient need.
• The role of the occupational therapist in the primary health care team is also viewed very positively.

---

Case scenarios

Priority A

Mrs A is an 83 year old lady who was referred to PCOT. by the G.P. following an emergency house call. Mrs A had fallen that morning and had acute back pain and was unable to get up from her chair to access the toilet or bed, or deal with her basic needs. The GP had referred for crisis care input for 3 days and had referred to the PCOT for assistance with transfers and other activities of daily living. The PCOT initially worked in conjunction with crisis care workers, provided equipment and taught techniques to assist with chair and bed transfers and provided a commode. Mrs A was referred onto Social Work and homecare for 2 visits daily. Mrs. A required long term rehab from the PCOT as she has had ongoing problems with back pain and anxiety. She has received rehabilitation regarding washing and dressing, bath transfers, mobility, and problem solving regarding simple domestic tasks.

Outcome:
The PCOT probably prevented admission to the Royal Infirmary of Edinburgh. Mrs A is now independent in self care and simple meal preparation in the morning. Standing tolerance remains an issue and she continues to need homecare for main meal preparation and shopping.

Priority B

Mrs M is a 67 year old lady referred to PCOT from the OT at the Royal Infirmary of Edinburgh A&E dept. She had fallen and fractured her wrist and although advised to remain in hospital, was not keen to be admitted to hospital. She lives alone and had additional mobility problems caused by longstanding spino-cerebellar degeneration. Homecare was initially increased to assist with meal preparation and showering, as Mrs M could manage strip washing and dressing. The PCOT. worked to increase confidence in kitchen activities and provided/practised with a rutland trolley to increase safety on mobility. Mrs M also had an (unused) microwave oven, and through rehabilitation became proficient in using it for qiuick meals. Once the plaster of paris splint was removed, the PCOT worked with the Physiotherapist to improve wrist range of movement through exercise and functional activities.

Outcome:
The PCOT intervention saved resources in terms of the hospital OT time and facilitated early discharge from the Royal Infirmary of Edinburgh. Mrs M can now manage all pre morbid activities, is safer mobilising around her flat and is able to confidently use her microwave oven.

Priority C

Mrs S is a 79 year old lady who had been in Nursing Home care for 7 months following a stroke after cardiac surgery. She required all her care in a Nursing Home and her husband became concerned about her low mood. He had discussed with the GP his wish for her to be cared for at home and requested a trial period of 4 days to assess the possibility of successful resettlement at home. The PCOT became involved to co-ordinate the trial period, which involved liaising with a private nursing agency to provide care X3 daily, and provide a temporary commode, wheelchair and chair raisers. Following a successful trial period, discharge from the Nursing home was planned that involved set up of nursing care (private), and District Nursing support, provision of and teaching her carer the use of a hoist and safe transfers. The PCOT. has worked with the physiotherapist and Mrs S now transfers more safely and walks between two carers down 4 steps to the bathroom, where they can assist with a shower.

Outcome:
Prevention of potential readmission to the nursing home. Mrs S continues to improve and so it is easier for her carers to manage. Mr. S wishes to purchase a stairlift, and the PCOT. has referred him to the Disabled Living Centre and continues to support him through the process.

---

For further details, or copies of the complete report, please contact Ian McMillan, imcmillan@qmu.ac.uk

© Copyright The Royal Bank of Scotland Centre for the Older Person's Agenda, 2007