This is the second post in a series about occupational therapy in acute care. Read the first post in here.
One of the constant refrains of my occupational therapy program’s faculty was that we were all “change agents” with the power – and responsibility – to see and do things differently in order to achieve optimal outcomes for our patients and our profession. As a change agent, I make an effort to give my best and make positive change wherever I work, even when it’s easier to stick with the status quo. This is especially true in the acute care setting, where time, financial, and resource restraints can be huge barriers to holistic, occupation-based OT practice.
To be perfectly honest, I’ve had more meetings with management than I care to admit during my brief tenure at the hospital, typically to discuss my goals and plans of care for patients with needs that were deemed “not appropriate” to address within the acute care setting or goals that other team members “wouldn’t be able” to address after my initial evaluations (apparently because they weren’t BADL or exercise-based goals…). It hasn’t been easy, and each meeting is a valuable learning opportunity for me to learn what others think OT is or should be – and a platform for me to provide education and advocate for my profession and scope of practice. Without going into too much detail, I’ll simply say that I think there is a long way to go before truly holistic, progressive, and occupation-based occupational therapy is the norm – rather than the ideal – in most hospital settings.
My Acute Care Experience
Although there are many aspects of my job that I enjoy (the variety of diagnoses, interdisciplinary collaboration, and wonderful colleagues), working in the acute care setting has been difficult at times. Some of the challenges I’ve faced include:
- Limited time and opportunities to provide holistic, skilled intervention to patients
- Decontextualized hospital environment as the setting for intervention
- Poor awareness of OT’s distinct and meaningful contributions to patient care
- Few opportunities to monitor and progress patient plans of care
Of these barriers, one of the most challenging issues I face is having the time and opportunity to provide high-quality, holistic occupational therapy services and having my colleagues understand and respect what OTs can contribute to the care to hospitalized patients. Although OTs can and should play an important role in discharge planning (especially in the acute care setting), I work in a VERY PT-centric hospital where most physicians, case managers, payer sources, and others only care about physical therapists’ discharge or treatment recommendations. This isn’t to say that PTs and STs don’t make valuable contributions for discharge planning, but I find that they can often miss the mark on thoroughly evaluating a patient’s ability to return to meaningful roles and routines and perform safely and independently at the next level of care.
For example, I have seen many instances where a PT colleague will recommend a stroke survivor or other patient return home with home health (usually only home health PT…) because they are able to ambulate 200 feet or more – while neglecting the fact that this person demonstrated significant cognitive deficits and required nearly constant cues to safely navigate obstacles, recognize the need for a rest break, or even find their way back to their room. Or the fact that this person has difficulty getting dressed, participating in social activities, or leading fulfilling, meaningful lives due to pain, injury, or disability. This is also an issue with payer sources who seem to only look at the number of feet a patient ambulated as the sole indicator of his level of function (basically, the further he can walk, the more “independent” he is). Although there is evidence correlating higher gait speed with decreased fall risk and improved ADL/IADL performance, this is not the case for many patients – often referred to as “walkie talkies” – who mobilize well but have significant difficulty performing more physically or cognitively demanding tasks.
In one case, a patient I treated was able to ambulate over 500 feet to go to the kitchen with me but he wasn’t able to identify the ingredients to prepare a bowl of cereal or even sequence making cereal once I gave him a box, a bowl, and milk. In these situations, the patient may end up with worse outcomes or a readmission when discharge planners, therapists, and payers do not seek or value input from all disciplines and all perspectives – especially the holistic, function-based assessments OTs can provide. This type of scenario happens much more frequently than it should, but it helps drives me to continue advocating for a truly client-centered, interdisciplinary approach to discharge planning that considers and respects each participant’s strengths, challenges, and needs.
Acute Care OT Is More Than Just ADLs
As an acute care OT, I am most often pigeonholed by my rehab colleagues, coworkers, and even managers as being an expert in “ADLs and the upper body.” While I am more than happy to instruct patients in how they can regain or increase independence with ADLs in the hospital setting and beyond – and in fact spent three consecutive treatment sessions helping a paraplegic patient accomplish his goal of transferring to a bedside commode independently – this is such a reductionist and narrow-minded view of what OTs can and should be doing that it’s truly laughable.
To be fair, many patients in the acute care setting are critically ill or recovering from an acute illness or injury, and thus unable to perform ADLs to their satisfaction due to mobility or cognitive deficits, pain, environmental barriers, or other issues. Thus, it follows that many OT interventions in acute care are focused on helping patients perform basic activities of daily living as a matter of patient and/or caregiver preference. Additionally, because the hospital environment is pretty limiting in regards to space, infection control (one’s ability to use various media or tools for intervention), and other considerations, we are often forced to use ADL performance as a vehicle for addressing many other areas of occupational performance. However, acute care OTs shouldn’t limit themselves to ADL and early mobility training or therapeutic exercise as their sole areas of intervention. We are also responsible for educating our colleagues and others about the breadth and depth of our profession as it relates to patients’ goals of care, recovery, wellness, and discharge.
Ultimately, while ADL performance is a valued occupation for many patients and has long been considered the “bread and butter” of our professional role in many settings, I would argue that acute care OTs need to begin thinking bigger, doing better, and practicing within the full scope of our licenses and our professional training. Specifically, we need to break out of the “ADL box” and begin practicing in a truly holistic manner that requires us to think beyond the present day “treat ‘em and street ‘em” model of acute care. We must go beyond addressing only the symptoms and begin addressing the root causes of our patients’ hospitalizations.
Acute Care OT Could Be Amazing
It is important to acknowledge that an important role of rehabilitation professionals in the acute care setting is to identify the patient’s most urgent needs, address these needs, and discharge the patient to the next level of care when they are medically ready. In comparison to inpatient rehab, SNF, or even outpatient settings, acute care practitioners do not necessarily have the time, freedom, or flexibility to address every area of concern or goal that a patient may identify. However, the beauty of the acute care setting is that whenever a patient is hospitalized and receives orders for occupational therapy, we have the opportunity to help these people change their entire healthcare trajectory.
In my experience, the current acute care therapy dynamic is set up as a false dichotomy – either you’re working on ADLs or “functional mobility” with a patient or they’re discharged from the caseload. But what if we started taking a “both-and” approach to treatment? What if we addressed a diabetic patient’s difficulty with donning lower body clothing and provided education about how they could better manage their chronic condition after discharge? What if we taught a person with a new limb amputation desensitization techniques and provided interventions and resources related to mental health and wellness? What if we as OTs took a different approach – one that allowed us to fully flex our highly-specialized muscles in understanding a patient’s background, roles, performance barriers, and goals to help them recover, stay well, and stay out of the hospital not only during an acute care stay but afterwards as well? If we did these things, I think our patients and our profession would reap a multitude of benefits that would change the world.
There needs to be a paradigm shift away from viewing acute care OT as a setting where clinicians are focused solely on toilets and toothbrushes to one where our focus is on identifying and treating the psychological, social, environmental, and other barriers impeding our patients’ participation in meaningful occupations to reduce readmissions and healthcare costs.
If you want to continue practicing like a worn out, one-trick pony in acute care, focused on hip kits and home exercise programs – so be it. Just don’t be surprised when your next stop is the glue factory (aka the unemployment line) as they find people who can do the same things for lower salaries. But if you’re ready to step into the multi-faceted, challenging, and dynamic future of acute care OT then read on to find out how you can join the force for change happening in hospitals across the country.
The Future of OT in Acute Care
What changes would you like to see in the acute OT area in the next five years?
I would like to see a shift in the reimbursement structure; research has proven that providing OT treatment through lifestyle changes can improve health and wellness by preventing acute and chronic health-compromising conditions. OT’s have a lot to offer high level/functioning acute care patients with regard to prevention; however, it is not reimbursable and deemed appropriate for acute care patients at this point in time. – Dominic Bruzzese OTR/L, 6 years in practice
Source: OT Potential
This quote gives me hope that other OT practitioners in the acute setting realize how much we could be doing in this arena – and how far we have to go in showing patients and others our distinct value.
Some of the potential areas for OT’s role expansion in acute care include:
- ICU liberation programs (delirium prevention, sedation weaning, early mobility)
- Chronic disease management and prevention
- Behavioral health and psychiatric units (UNC Chapel Hill hospital OTs are treating and triaging patients with behavioral health needs directly from the emergency department as part of a pilot project)
- Pain management and participation
- Diabetes and lifestyle management
- Substance abuse and addiction
Although the majority of these health conditions will require patients to continue working with a skilled OT or other provider after discharge, it is important that acute care clinicians set the stage and help start patients on the path to true wellness during their hospitalization. This means changing the way we assess, evaluate, and treat patients who are entering the hospital for the first or fortieth time.
With the forthcoming arrival of new payment systems based on value, not volume, now is the time for us to lead the charge and take responsibility for being the change we want to see in our profession and other providers’ knowledge of our profession. This starts with changing the way we practice and provide value to clients and hospital systems, and continues with advocacy at the local, state, and national levels to protect and promote higher standards of practice.
In closing, consider this: How much does it matter if a person with diabetes can don and doff their socks and shoes if they don’t know how or when to test their blood sugar, can’t access their primary care physician or endocrinologist, are struggling with complications of morbid obesity, or don’t even understand the basic components of the disease and its impact on overall health and longevity? This is where OT can step in to make the biggest difference in a patient’s entire life – by not only helping them get their diabetic shoes on, but helping them change the direction the shoes are headed!