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Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). medication reconciliation, providing patient education, arranging timely outpatient appointments, and providing telephone follow-up (Kripalani, Theobald, Anctil, & Vasilevskis, 2014). No single intervention alone reduced hospital readmissions within 30 days of discharge (Hansen, Young, Hinami, Leung, & Williams, 2011). Hoyer et al. (2014) found that patients with higher functional status at the time of hospital discharge have lower readmission rates than patients with more functional impairments. Thus, improving functional status during hospitalizations is thought to be an important strategy for lowering readmission rates. It is expected that our knowledge of the factors contributing to unplanned hospital readmissions will continue to expand rapidly in the coming years. It is essential that occupational therapy practitioners understand the impact occupational therapy services can have on hospital readmissions and be prepared to provide these needed services. Occupational therapy practitioners need to be a vital part of the discharge planning team, at all phases of a client’s hospital stay and transition back into the community. They have an opportunity to add value in discharge planning, fall prevention, home modifications, medication management, and assistive technology (AT) to reduce hospital readmissions. ROLE OF OT IN CARE COORDINATION AND DISCHARGE PLANNING Discharge planning is a process in which patients’ needs are identified and a plan is formed for a smooth transfer from one environment to another (CMS, 2014a). Occupational therapy practitioners provide a unique perspective on their clients’ functional abilities, which, in conjunction with medical considerations, influences the determination of the appropriate living arrangement after discharge. In addition, occupational therapy practitioners possess a broad skillset that is beneficial in identifying and coordinating individuals’ needs to ensure full participation in desired activities and roles. Having worked with the individual throughout his or her stay to increase functional abilities needed for day-to-day living, occupational therapy practitioners offer the most comprehensive insight about the individual’s functional abilities relative to his or her baseline level of function. When there is a change in functional status from baseline, occupational therapists are able to provide recommendations regarding how activities should be modified to eliminate activity barriers, and what level and type of assistance their clients need to complete daily activities safely. Occupational therapy practitioners collaborate closely with other health care team professionals, such as case managers, nurses, physical therapists, speech-language pathologists, and physicians, to create an interdisciplinary plan of care and a coordinated and appropriate discharge plan. The American Occupational Therapy Association (AOTA) has consistently shown support for increased involvement of occupational therapy in the discharge planning process. In November 2015, CMS proposed revisions to requirements for discharge planning in acute care hospitals, long-term care hospitals, inpatient rehabilitation facilities, critical access hospitals, and home health agencies. The intention of the proposed revisions was to allow patients and their families’ access to information that helps them make informed decisions about their post-acute care. In January 2016, AOTA submitted comments to the proposed revisions requesting that an occupational therapist be listed as part of the discharge planning team needed to perform discharge assessment and planning (Bogenrief, 2016). This was on the grounds that occupational therapists assess, treat, and consider discharge and transitions as part of the evaluation of a client’s functional and cognitive status on an ongoing basis. AOTA strongly supports the involvement of patients in determining their goals of care and discharge planning, as well as taking into account realistic caregiver support after discharge. Recent research points to the need for greater emphasis on functional and environmental factors during the discharge planning process. Changes in functional abilities place increased demands on the patient’s ability to participate in pre-hospitalization roles, and are cited as a factor contributing to preventable rehospitalization. For example, Tao, Ellenbecker, Chen, Zhan, and Dalton (2012) reported that the extent of self-care deficit was positively associated with risk of rehospitalization, and others have identified caregiver burden as a predictor of hospital readmission (Bonin-Guillaume et al., 2015; DePalma et al., 2012). DePalma et al. (2012) also reported that returning to the community from a recent hospitalization with unmet activities of daily living (ADLs) was associated with a higher probability of readmission. These findings suggest that an early identification of individuals in need of additional support, and coordination of necessary services, may prevent unnecessary re-hospitalization. Occupational therapy practitioners are well positioned to be an asset in this realm through offering their professional expertise in (1) analyzing pre-hospitalization roles and their clients’ likelihood of resuming them; (2) identifying the need for adaptive equipment and caregiver assistance; and (3) identifying and coordinating community needs in mobility, activity participation, and more. After the needs are delineated, occupational therapists can coordinate training sessions with family caregivers to ensure that the needs will be adequately met. In collaboration with social workers and case managers, occupational therapy practitioners can identify community resources, such as additional funds for home modifications and AT, transportation services, and support groups, to extend support services available. ROLE OF OT IN FALL PREVENTION Fall prevention is an important aspect of the discharge planning process, as it can reduce hospital readmission and increased disability. The rate of falls following discharge from a medical hospitalization are as high as 40%, and up to 15% of those who fall require re-admission to a hospital (Hill, 2011; Mahoney, 2000). In addition, 20% of older adults presenting to the emergency room for a fall have had one or more hospitalizations in CE-2 ARTICLE CODE CEA0816 AUGUST 2016 l OT PRACTICE, 21(15)
Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. the previous year (Close et al., 2012). Falls can have a range of negative effects on older adults including injury, activity restriction, institutionalization, and death. Because of the increased risk of falls after hospitalization and the potential for a fall to cause readmissions, fall prevention is an important area for occupational therapy to address in discharge planning. Falls are often preventable, with proven strategies to reduce older adult fall risk. Effective fall prevention programs include evidence-based practice of occupational therapy, durable medical equipment (e.g., home modifications), and referral to community programs (AOTA, 2010). Occupational therapists are distinctly skilled to assess the person and environment. Occupational therapists should identify personal limitations and environmental hazards that have the potential to cause falls and make subsequent recommendations for a combination of fall prevention interventions. Fall risk factors that occupational therapists may assess include lower-extremity weakness, impaired balance, cognitive impairment, incontinence, sensory impairment, fear of falling, medication adherence, and environmental hazards (AOTA, 2012). In addition to risk factors that put all older adults at risk for a fall, identifiable risk factors that are present in older adults at high risk for a fall post discharge include dependence in one or more ADLs before hospitalization, a history of falls, preexisting mobility impairments, and prior hospitalizations (Mahoney, 2000). Occupational therapy is well positioned to identify patients with fall risk factors and implement or assist with care coordination for recommended interventions. A recent systematic review conducted in conjunction with AOTA’s Evidence-Based <strong>Practice</strong> Project found home modification interventions are effective for high-risk older adults when high-quality interventions are implemented by an occupational therapist (Clemson, Mackenzie, Ballinger, Close, & Cumming, 2008). High-quality interventions include evaluating person and environment factors, using a valid fall hazard assessment tool, evaluating functional capacity within the home environment, and following up for modifications/adaptations. Interventions must include at least three of the four criteria to be considered high quality (Clemson et al., 2008). When implementing home modification programs for fall prevention, it is important for occupational therapy practitioners to ensure that they provide effective, high-quality, evidenced-based interventions. Home assessments pre-discharge from a rehabilitation hospital reduced falls within the first month post discharge for cardiac, spinal, deconditioned, and orthopedic trauma patients, indicating that these may be target populations to reduce fall readmissions (Johnston, Barras, & Grimmer-Somers, 2010). Another review found strong evidence for multifactorial programs, including home evaluations, physical activity or exercise, education, vision and medication checks, and AT (Chase, Mann, Wasek, & Arbesman, 2012). The most successful fall prevention interventions use a multifaceted approach. Recommended exercise programs include Tai Chi, for better balance (Wolf et al., 1996); Matter of Balance (Tennstedt et al., 1998); Otago Exercise Program (Robertson, Campbell, Gardner, & Devlin, 2002); and Stepping On (Clemson et al., 2004). Occupational therapy practitioners may also work with nonprofit organizations or government agencies to implement fall prevention initiatives within the community (AOTA, 2012). ROLE OF OT IN MEDICATION MANAGEMENT Medication management has been identified as one way to help reduce hospital readmissions. Research indicates that as many as 50% of patients do not adhere to medication routines (Lee, Grace, & Taylor, 2006) and 30% of patients failed to fill new prescriptions (Fischer et al., 2010). Medication non-adherence is primarily the result of patients forgetting to take their medication or choosing not to because of unpleasant adverse effects or their view that the medication is not necessary (Hughes, 2004). Between 23% and 40% of persons in a nursing home are admitted due to medication non-adherence (Pan, Chernew, & Fendrick, 2008; Strandberg, 1984). Factors in medication management include the patient’s or caregiver’s knowledge of the medications needed, the reason(s) for medication, the medication’s side effects, access to medication, and ability to administer it. Many different health care practitioners can provide education to increase adherence to medication routines; however, occupational therapists have the ability to identify the problems that individuals have in correctly adhering to their medication routine. In addition, occupational therapists and occupational therapy assistants have the skills and knowledge to help clients integrate medication administration into their daily routine effectively, thus increasing medication administration accuracy and compliance. Occupational therapist and occupational therapy assistants have the skills to help clients learn to manage taking medications and the impact of side effects on their daily activities to increase performance and safety. Often, patients are prescribed new medications or medication instructions change when they are hospitalized. Occupational therapists are able to review medication information sheets with their clients and evaluate their ability to understand and use this information. Practitioners can then help clients understand medication instructions and incorporate them into their daily routines and habits. For example, diuretics prescribed to manage congestive heart failure can cause patients to need to use the bathroom more frequently. The occupational therapy practitioner can discuss timed voiding, simplified clothing fasteners, and mobility issues related to accessing the bathroom, especially away from home, and other strategies to manage or avoid incontinence, and this in turn should increase the client’s compliance with taking the medication as directed (AOTA Legislative Affairs and State Regulatory Affairs, 2016). “The OT role in medication management can include: • Recording medication dosages and routes per agency policy when required as part of an assessment AUGUST 2016 l OT PRACTICE, 21(15) ARTICLE CODE CEA0816 CE-3
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Page 3 and 4: side The American Occupational Ther
Page 5 and 6: News Evidence Highlights Surviving
Page 7 and 8: Capital Briefing New Occupational T
Page 9 and 10: Familiar Pathways Learning From the
Page 11 and 12: thumb. Marty smiled. He really smil
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Page 15 and 16: OT on the Hill Day Jacquelyn M. Sam
Page 17 and 18: Missouri OT advocates meet with Rep
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Page 21 and 22: Evidence Perks New AOTA Practice Gu
Page 23 and 24: Perspectives A Magical Teacher Kirb
Page 25 and 26: Around the World Making Global Conn
Page 27 and 28: Save the dates! AOTA Specialty Conf
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