By Jeni Miller
Occupational therapy (OT) is a bit like case management. In both vocations, the greater healthcare community (and population in general) is not entirely familiar with their purpose. Both positions often are all-encompassing, diverse, and necessary as they consider the whole person. Both occupational therapists and case managers often play a role in helping control hospital spending.
The authors of a study noted “occupational therapy is the only spending category where additional hospital spending has a statistically significant association with lower readmission rates” for certain health conditions.1 This seems to be a significant fact to which case managers should take notice.
“In a hospital setting, everyone is looking toward where this person is going next and asking what would an appropriate discharge be? Occupational therapy practitioners look at this through several lenses: cognitive, physical, social supports — just the whole person,” says Heather Parsons, MSOT, vice president of federal affairs for the American Occupational Therapy Association. “We try to identify things that could otherwise go overlooked, and plan strategies and supports for the best discharge. This can help prevent readmissions.”
Colleen O’Rourke, senior vice president of clinical and network solutions at naviHealth, sees occupational therapy as vital to a successful and more permanent hospital discharge.
Occupational therapy can address functional issues that might allow a patient to bypass a skilled nursing facility (SNF) stay and transition directly home. “The literature tells us that when a patient is able to recover at home, they are less likely to fall, get an infection, and experience depression,” O’Rourke explains. “There are plenty of studies that show that when a patient transitions to their own environment, their quality of life score is much higher, and they report a more comfortable and faster recovery.”
But how can one discipline make such a difference? “OTs are the experts when it comes to activities of daily living [ADLs],” O’Rourke says. “They take a holistic and pragmatic approach to maximize a patient’s independence in skills like cooking, eating, and dressing. For instance, think about medication management. I am not talking about medication education or administration, but specifically management. Mismanagement of medications is one of the main reasons for hospital readmissions. Occupational therapists look at the unique patient, including social determinants of health, and help to make a specific medication management plan.”
O’Rourke emphasizes how OTs often ask different and detailed questions, and then go to work considering all the opportunities that result.
“What is the plan to fill the prescription?” she asks. “What happens when you run out? Where will the meds be stored? If stored in the cabinet, the patient may not remember to take it. If it is stored in a humid bathroom, the medication might lose its effectiveness. Does the patient have enough grip strength to open a childproof cap? The dexterity to remove a single pill? What if there is cotton in the bottle? What do you do if a pill falls on the floor? OTs think about all of these complexities.”
When OTs Intervene
OTs consider two main facets when determining next steps for a patient and their transition of care: cognition and home environment.
“With cognition, it’s not just their orientation to time and place, but asking whether this person has the cognitive skills to take care of themselves and function at home,” notes Parsons. “After assessing, an OT may make a recommendation, ‘I don’t think this person is safe at home,’ or make recommendations for additional supports they will need. We also ask whether their home environment itself will support the person being there safely. Even if they are given education at discharge, they may not always be able to follow those instructions if the environment doesn’t support them. Occupational therapy will ask: Are they at risk for a fall? Do they have an appropriate support person at home? With their medication plan, we don’t get involved in what the medications they take, but we think about whether they can open the bottle and remember when to take it.”
O’Rourke echoes these statements, adding the OT role is “so incredibly functionally based and detail-oriented when it comes to the overall functioning of the individual.”
“OTs are the unsung heroes for seniors especially, because they’re experts in daily living,” O’Rourke shares. “They can be very effective in the hospital setting, but unfortunately, what’s evolved over time is that therapists generally consulted toward the end of a patient’s stay and are asked a single, binary question: Can the patient go home, or do they need to go to a rehab setting? This, unfortunately, is an underutilization of their talent and skill.”
When OTs are brought in to help patients as soon as possible, they can help combat the likely debility that develops because of the hospitalization. This can be an investment that keeps hospital spending low.
Speaking of Spending
Researchers have noted “investing in occupational therapy has the potential to improve care quality without significantly increasing overall hospital spending.”1 This fact should catch the eye of hospital administrators as well as case managers.
“As far as intervention goes, we’re pretty cheap,” Parsons notes. “We’re just not that big of an expenditure. Not only that, but I think about how much we spend on medical care. [Bringing in OT] is not that much more to close the gap for a safe discharge and to set the person up for success long term.”
Still, this particular therapy is not as common in hospitals as it perhaps once was.
“Offering OT in hospitals has dwindled significantly,” O’Rourke laments. “We should ask, ‘What are we not doing from a clinical perspective to help the patient obtain and maintain their highest practical level of function, even while hospitalized?’ This is a lost art for hospitals, perhaps because once the patient is stable, the primary focus is discharge. Early mobilization programs, including ambulation, out-of-bed schedules, walking to the bathroom vs. using a bed pan will fight the debilitating effects of bed rest and help more seniors return home. This is where the hospital therapy teams excel. It’s the right thing to do.”
Case Manager Takeaways
How can hospital case managers best use the expertise of OTs for the benefit of the patient and the hospital?
• Observe. Staying alert and asking “why” questions can help case managers think about what might best help their patient.
“What is causing them to fall in their home?” Parsons asks. “I’ve known some [case managers] who have repeat patients. Asking these questions leads them to send in an OT to figure out what is going on, or order OT upon discharge to address chronic falls or failure to thrive.”
“Case managers already have the skills of astute observation,” O’Rourke adds. “They’re always paying attention to the verbal and nonverbal signs from the patient. If they walk into the room and see that the tray is half-eaten, they may pause and wonder, ‘Is it no appetite or inability to feed themselves? Should OT take a look?’”
• Refer. Taking that astute observation to the next level, case managers might consider when a referral to OT is appropriate. One piece of advice Parsons shares is to remember to ask the patient about his or her goals of care and function, or bring in an OT who can analyze further and help establish realistic goals for function and discharge.
“We ask the person what they want to do post-discharge,” Parsons explains. “How are you going to be in your home, and what are your priorities? The answer to that can change the importance of different skills and discharge recommendations. If someone loves to cook, but can’t do that safely, that’s an important consideration for education and discharge. But if someone else may just want to microwave a TV dinner and cooking is not important, that changes things”
O’Rourke also suggests hospital case managers consider how they can refer to OT in the hospital to get the ball rolling on things like home modifications and equipment needs, and then refer to OT in the home for follow-up.
“It makes good sense for hospital case management departments to understand the capabilities of rehab departments in the hospital,” she says. “They have expertise that is worth tapping into so the case manager does not have to go it alone.”
“Patients with congestive heart failure or COPD have the highest readmission rates,” O’Rourke continues. “The reason for the hospitalization is medical, but what brought them to the hospital is usually functional. A patient will ignore their shortness of breath until they are too winded to make it to the bathroom in time. Or a patient will disregard the fluid building up in their legs, only to call the doctor when those legs are too heavy to get into bed. It’s too late then. OTs can coach patients to recognize symptoms early and seek intervention sooner, possibly avoiding a readmission.”
• Collaborate. If possible, inviting the OT to the conversation earlier can potentially benefit the patient by bringing in another valuable perspective.
“One key piece is having OT in on patient rounds or other team meetings,” Parsons shares. “When staff meets about the patient, often OT is not included in that group. I would give OT the opportunity to collaborate immediately, because their focus is on helping people do what they need to do upon discharge. OT doesn’t always fit within the traditional medical model, but it is very person-centered and common sense. What we’re doing looks so simple sometimes, but truly we are looking toward maximum independence and safety.”
“Get the OT consult in earlier, not just 24 hours before discharge,” O’Rourke adds. “This can potentially make the difference.”
Reducing readmissions certainly is a worthy goal — and it makes extra OT referrals valuable and wise. They are the perfect partners for hospital case managers, similar in respect to their ability to look at the whole person, consider several different angles of patient care, and wear many hats to finish the job.
“Occupational therapists are ideal coaches because they have a unique skill set,” O’Rourke says. “They are innovative, clever, pragmatic problem-solvers focused on maximizing independence in life’s daily skills. They look at it from the perspective of a patient’s going home successfully and staying home successfully. It’s only the OT who will ask a patient, ‘How exactly are you going to get the trash to the curb every Wednesday?’ Believe it or not, those are the types of problems that cause readmissions that no one else ever thinks of.”
- Rogers AT, Bai G, Lavin RA, Anderson GF. Higher hospital spending on occupational therapy is associated with lower readmission rates. Med Care Res Rev 2017;74:668-686.