Implementation of the Community Occupational Therapy in Dementia program in Italy (COTiD-IT): qualitative survey to identify barriers and facilitators in implementation.

BACKGROUND: Community Occupational Therapy in Dementia in Italy (COTID-IT) is a feasible and effective treatment that aims improving the quality of life and well-being of people with dementia and caregivers. The implementation of the program in the national context has not been studied yet. AIM: The objective of this study is to identify barriers and facilitators in the Italian implementation of the program. METHODS: We designed a quantitative cross-sectional survey. A questionnaire was developed to collect descriptive data regarding the respondents, the perceived barriers and facilitators regarding the application of COTiD and possible actions to promote the implementation process. RESULTS: The questionnaire was sent to all 90 Italian OTs trained in the use of COTiD-IT from 2013 to 2020. 50 people responded (61%). Barriers to the implementation of the COTID-IT included lack of knowledge about Occupational Therapy and the COTID-IT program by other health professionals. In addition, the scarcity of economic funds invested in home rehabilitation is experienced as another significant barrier. Facilitators were found to be the presence of an interprofessional team interested in the COTID-IT program and occupational therapy and the fact that COTID-IT is supported by scientific evidence. The creation of national and regional inter professional education and support groups, the availability of online resources are seen as opportunities to better implement the COTID-IT program. CONCLUSIONS: Implementation of psychosocial interventions is complex. OTs in Italy should be increasingly included within health policies and care programs of people with dementia to promote the use of COTID-IT. Further studies are needed to detail the policy and methodological actions that OTs should take in the future to disseminate and consolidate this intervention.

Interventions for improving self-direction in people with dementia: a systematic review.

BACKGROUND: Dementia is a progressive disease that affects people's everyday functioning, including the ability to express values, needs and wishes, which can be considered key elements of self-direction. For the purpose of this review, self-direction refers to the organization and/or coordination of your own life, including professional and other care, with the objective of having what you perceive to be a good life. The aim of this systematic review was to assess and describe interventions that aim to improve self-direction of people with dementia. METHODS: A systematic search was conducted in PubMed, Embase, CINAHL, PsycInfo and the Cochrane Library. Empirical studies up to April 2020 were included that used qualitative and/or quantitative methods and reported on interventions for people with dementia aimed at improving self-direction. Stepwise study selection and the assessment of methodological quality were conducted independently by two authors. Data on study and intervention characteristics, outcomes related to self-direction and well-being of people with dementia and factors influencing the feasibility were extracted systematically and described narratively. RESULTS: Ten studies were identified describing a total of nine interventions. Interventions varied in terms of goals, content, target population and duration. Overall, interventions consisted of multiple components focusing on identifying "Who am I?" (beliefs, strengths, values, goals), identifying "What is important to me?" (meaningful activities and goal setting) and/or communicating about preferences with professionals and/or caregivers. The review provides indications that people with dementia may benefit from the interventions included. Overall, positive effects were found in studies on outcomes related to self-direction and wellbeing. However, outcomes measured using quantitative methods showed inconsistent effects between the studies. CONCLUSIONS: Although the methodological quality of all the studies included was 'good' or at least 'fair', the evidence base of interventions aiming to improve self-direction is still limited due to the low number of studies, the low number of participants and the frequent use of and their authors' own non-standardized measures. Nevertheless, the review points towards positive effects on self-direction and well-being. Identifying individual beliefs, strengths, values, goals and meaningful activities can be essential components of these interventions, as well as communication about the desired care and support.

Factors influencing the implementation of Home-Based Stroke Rehabilitation: Professionals' perspective.

BACKGROUND: Stroke has a major impact on survivors and their social environment. Care delivery is advocated to become more client-centered and home-based because of their positive impact on client outcomes. The objective of this study was to explore professionals' perspectives on the provision of Home-Based Stroke Rehabilitation (HBSR) in the Netherlands and on the barriers and facilitators influencing the implementation of HBSR in daily practice. METHODS: Semi-structured focus groups were conducted to explore the perspectives of health and social care professionals involved in stroke rehabilitation. Directed content analysis was performed to analyze the transcripts of recorded conversations. RESULTS: Fourteen professionals participated in focus groups (n = 12) or, if unable to attend, an interview (n = 2). Participants varied in professional backgrounds and roles in treating Dutch clients post stroke. Barriers and facilitators influencing the implementation of HBSR in daily practice were identified in relation to: the innovation, the user, the organization and the socio-political context. Participants reported that HBSR can be efficient and effective to most clients because it facilitates client- and caregiver-centered rehabilitation within the clients' own environment. However, barriers in implementing HBSR were perceived in a lack of (structured) inter-professional collaboration and the transparency of expertise of primary care professionals. Also, the current financial structures for HBSR in the Netherlands are viewed as inappropriate. DISCUSSION: In line with previous studies, we found that HBSR is recognized by professionals as a promising alternative to institution-based rehabilitation for clients with sufficient capabilities (e.g. their own health and informal support). CONCLUSION: Multiple factors influencing the implementation of HBSR were identified. Our study suggests that, in order to implement HBSR in daily practice, region specific implementation strategies need to be developed. We recommend developing strategies concerning: organized and coordinated inter-professional collaboration, transparency of the expertise of primary care professionals, and the financial structures of HBSR.

Effectiveness of a training package for implementing a community-based occupational therapy program in dementia: a cluster randomized controlled trial.

OBJECTIVE: Evaluate the effectiveness of a training package to implement a community occupational therapy program for people with dementia and their caregiver (COTiD). DESIGN: Cluster randomized controlled trial. SUBJECTS: A total of 45 service units including 94 occupational therapists, 48 managers, 80 physicians, treating 71 client-caregiver couples. INTERVENTIONS: Control intervention: A postgraduate course for occupational therapists only. EXPERIMENTAL INTERVENTION: A training package including the usual postgraduate course, additional training days, outreach visits, regional meetings, and access to a reporting system for occupational therapists. Physicians and managers received newsletters, had access to a website, and were approached by telephone. PRIMARY OUTCOME: The intended adherence of therapists to the COTiD program. This was assessed using vignettes. SECONDARY OUTCOMES: clients' daily functioning, caregivers' sense of competence, quality of life, and self-perceived performance of daily activities of both clients and caregivers. Between-group differences were assessed using multilevel analyses with therapist and intervention factors as covariates. RESULTS: No significant between-group differences between baseline and 12 months were found for adherence (1.58, 95% CI -0.10 to 3.25), nor for any client or caregiver outcome. A higher number of coaching sessions and higher self-perceived knowledge of dementia at baseline positively correlated with adherence scores. In contrast, experiencing more support from occupational therapy colleagues or having conducted more COTiD treatments at baseline negatively affected adherence scores. CONCLUSION: The training package was not effective in increasing therapist adherence and client-caregiver outcomes. This study suggests that coaching sessions and increasing therapist knowledge on dementia positively affect adherence. CLINICAL TRIAL NUMBER: NCT01117285.

Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care.

BACKGROUND: A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists' (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy. METHODS: A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis. RESULTS: The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs' skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician's network. CONCLUSION: Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions.

Effectiveness of a multifaceted implementation strategy on physicians' referral behavior to an evidence-based psychosocial intervention in dementia: a cluster randomized controlled trial.

BACKGROUND: To evaluate the effectiveness of a multifaceted implementation strategy on physicians' referral rate to and knowledge on the community occupational therapy in dementia program (COTiD program). METHODS: A cluster randomized controlled trial with 28 experimental and 17 control clusters was conducted. Cluster included a minimum of one physician, one manager, and two occupational therapists. In the control group physicians and managers received no interventions and occupational therapists received a postgraduate course. In the experimental group physicians and managers had access to a website, received newsletters, and were approached by telephone. In addition, physicians were offered one outreach visit. In the experimental group occupational therapists received the postgraduate course, training days, outreach visits, regional meetings, and access to a reporting system. Main outcome measure was the number of COTiD referrals received by each cluster which was assessed at 6 and 12 months after the start of the intervention. Referrals were included from both participating physicians (enrolled in the study and received either the control or experimental intervention) and non-participating physicians (not enrolled but of whom referrals were received by participating occupational therapists). Mixed model analyses were used to analyze the data. All analyses were based on the principle of intention-to-treat. RESULTS: At 12 months experimental clusters received significantly more referrals with an average of 5,24 referrals (SD 5,75) to the COTiD program compared to 2,07 referrals in the control group (SD 5,14). The effect size at 12 months was 0.58. Although no difference in referral rate was found for the physicians participating in the study, the number of referrals from non-participating physicians (t -2,55 / 43 / 0,02) differed significantly at 12 months. CONCLUSION: Passive dissemination strategies are less likely to result in changes in professional behavior. The amount of physicians exposed to active strategies was limited. In spite of this we found a significant difference in the number of referrals which was accounted for by more referrals of non-participating physicians in the experimental clusters. We hypothesize that the increase in referrals was caused by an increase in occupational therapists' efforts to promote their services within their network. TRIAL REGISTRATION: NCT01117285.

A survey of evidence-based practise among Dutch occupational therapists.

This study explored how the evidenced-based practise (EBP) is perceived by Dutch occupational therapists (OTs), what sources of research data are used to make clinical decisions, and what barriers are identified in implementing EBP. A self-administered, pre-tested, questionnaire was distributed through an email survey and postal mail among the 200 randomly stratified selected OTs out of a total population of 2,019 Dutch OTs. Analyses of data comprised descriptive statistics of all variables and test statistics to evaluate the differences between demographical groups. Dutch OTs have a very positive attitude toward the EBP. Barriers experienced are mostly related to a lack of skills needed to implement the EBP and to the characteristics of the work environment. The attitude, experiences and barriers are mainly similar to research findings in other countries or professions. A unique barrier to the implementation of the EBP found in this study was that Dutch OTs perceived evidence written in a foreign (non-Dutch) language as a barrier to using evidence in non-Dutch languages. The results of the study, derived from a partly representative group of working OTs, implicate universal problems regarding the effective implementation of the EBP. Solutions to increase the implementation of the EBP from an international point of view are called for and need to be evaluated.

A new combined strategy to implement a community occupational therapy intervention: designing a cluster randomized controlled trial.

BACKGROUND: Even effective interventions for people with dementia and their caregivers require specific implementation efforts. A pilot study showed that the highly effective community occupational therapy in dementia (COTiD) program was not implemented optimally due to various barriers. To decrease these barriers and make implementation of the program more effective a combined implementation (CI) strategy was developed. In our study we will compare the effectiveness of this CI strategy with the usual educational (ED) strategy. METHODS: In this cluster randomized, single-blinded, controlled trial, each cluster consists of at least two occupational therapists, a manager, and a physician working at Dutch healthcare organizations that deliver community occupational therapy. Forty-five clusters, stratified by healthcare setting (nursing home, hospital, mental health service), have been allocated randomly to either the intervention group (CI strategy) or the control group (ED strategy). The study population consists of the professionals included in each cluster and community-dwelling people with dementia and their caregivers. The primary outcome measures are the use of community OT, the adherence of OTs to the COTiD program, and the cost effectiveness of implementing the COTiD program in outpatient care. Secondary outcome measures are patient and caregiver outcomes and knowledge of managers, physicians and OTs about the COTiD program. DISCUSSION: Implementation research is fairly new in the field of occupational therapy, making this a unique study. This study does not only evaluate the effects of the CI-strategy on professionals, but also the effects of professionals' degree of implementation on client and caregiver outcomes. CLINICAL TRIALS REGISTRATION: NCT01117285.