Reform and reverberation: Australian aged care policy changes and the unintended consequences for allied health.

INTRODUCTION: Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. The purpose of this paper is to review these recommendations and the Australian Government's policy responses and explore the emerging changes in allied health service provision in residential aged care. METHODS: Data from the four available Quarterly Financial Reports from the 2022-2023 financial year were extracted and analysed in relation to staff costs and time per person per day across personal care, nursing, and allied health workers. Supplementary data sources including the 2020 Aged Care Workforce Census were accessed to provide contextual data relating to individual allied health professions, including occupational therapy. RESULTS: The analysis shows a modest increase in median registered nurse minutes per person per day, and cost per person per day, from the first to second quarter, and again in the third and fourth. By contrast, median time and cost for allied health declined. From 5.6 minutes per person per day in the first quarter, reported allied health minutes fell to 4.6 minutes per person per day in the second quarter, an 18% decrease, and by the fourth quarter was 4.3 minutes per person per day. This is just over half the Australian average of 8 minutes reported to the RCACQS in 2019. CONCLUSION: Under recent residential aged care reforms, aged care providers have regulatory incentives to concentrate their financial resources on meeting the mandated care hours for registered nurses, enrolled nurses, personal care workers, and assistants in nursing. These same reforms do not mandate minutes of allied health services. Although providers of residential aged care in Australia continue to employ and value allied health, we argue that mandating care minutes for personal and nursing care without mandating the provision of allied health creates a perverse incentive whereby access to allied health services is unintentionally reduced.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

A scoping review into the service needs of people from culturally and linguistically diverse backgrounds living with disability to engage in meaningful occupations.

INTRODUCTION: Although there is a large proportion of people from culturally and linguistically diverse backgrounds within Australia, their rate of access to disability services is disproportionately low. This review aims to understand the service needs of people from culturally and linguistically diverse backgrounds with disability to facilitate engagement in meaningful occupations. METHODS: Arksey and O'Malley's scoping review framework was employed. Ten databases were searched for Australian studies. A deductive content analysis framework was applied in the synthesis. RESULTS: Fourteen papers were included. Themes that emerged include language and cultural needs and considerations, which highlights the need for information sharing to take account of intergenerational, intercultural and sociolinguistic differences. It also identified the need for improved training and skills of existing interpreters. Culturally competent and responsive services was another theme identified, which emphasised the need to enhance the workforces' understanding of cultural practices. There is also a strong call for a more culturally diverse workforce to reduce the use of some interpreters and to build a more culturally competent workforce. The last theme was responsive service delivery, which requires the governance to support the development of a nurturing trusting therapeutic relationship. CONCLUSIONS: Service providers should be trained on the inequities and intersectionality of this population. Further research is required to explore current disability policy in Australia with an intersectionality lens to ensure recommendations can be made to address barriers and ensure this population receives services in a manner that enhances their ability to engage in occupations meaningfully.

Exploring the Sustainability of Home Modifications and Adaptations in Occupational Therapy.

Background. Many occupational therapists make home modification recommendations; however, it is unknown if sustainability considerations (i.e., economic, social, and environmental) are contemplated during this process. Purpose. To understand occupational therapists' perceptions regarding the sustainability of home modifications. Method. This study adopted a qualitative description approach. Researchers utilized semistructured interviews as the primary means of data collection. Findings. The ten female occupational therapists interviewed had three or more years of experience working with home modifications. The analysis identified three themes: It's not easy being green: environmental sustainability, stretching a dollar: financial inequities, and barriers and benefits in the home modification process. Implications. Findings suggest OTs have a varied and a general understanding of how to implement sustainability concepts in their practice. There is also a need to make access to home modifications more equitable. Further research is needed to build a more robust understanding of how OT recommended home modifications can contribute to sustainability.

Parents' ability to access community health occupational therapy services in a disadvantaged area: A proof of concept study.

INTRODUCTION: In New South Wales, children from disadvantaged backgrounds have poorer health outcomes and reduced access to health services than their more advantaged counterparts. This study aimed to identify barriers and enablers to accessing child and family occupational therapy services in a disadvantaged area. METHODS: This was a mixed methods study that included: (a) a retrospective analysis of de-identified routinely collected Community Health service utilisation data from 2016 to 2017, and a (b) face to face interview guided survey with parents and carers. RESULTS: The retrospective data analysis showed outreach at the targeted suburbs' Early Childhood Health Centres (ECHC) improved attendance for families living in these suburbs. Parents' responses indicated that they were able to access the Community Health Centre (CHC) and certain barriers to accessing the service remain, including difficulty in parking and not having a license or car to attend appointments. Low health literacy was also a barrier to accessing health appointments as parents were unaware of the range of services provided at CHC, did not know how to make appointments, or that these services did not generate out-of-pocket expenses to clients. Conversely, enablers that would make it easier for parents to attend appointments include the provision of home visits, after hours and weekend appointments, and outreach such as delivering services in community spaces such as the ECHCs, library, or mosque. CONCLUSION: This research suggests that outreach occupational therapy services are valued by families in this disadvantaged area and contribute towards improving access to allied health services for disadvantaged families with young children. However, additional work is required to increase awareness among disadvantaged families on the role of allied health in improving child development outcomes and to reduce some of the transport and logistical issues that can reduce access to health care.

Transcending the individual: The promise and potential of collectivist approaches in occupational therapy.

BACKGROUND: In a globalised world, with injustices and inequities, occupational therapists have a moral and ethical obligation to use their knowledge and skills to work at a collective level with groups, communities, and populations rather than focus solely on individualistic approaches. OBJECTIVES: To review the literature exploring the question: What do occupational therapists do in their everyday practice that could be characterised as having a collectivist orientation? METHOD: A scoping review with searches on Web of Science, Scopus and CINAHL databases with the keywords 'occupational therapy' AND collectiv*. RESULTS: 161 articles were found and after screening of abstracts and/or full text, 19 were included. Articles were published in English (13) and Portuguese (6), in 12 different journals and one book, from 1988 to 2018. They were categorised as focussing on: social welfare - collectivism (n = 2); collective occupations (n = 11); and collective oriented practices (n = 6). CONCLUSION: A clear definition of collectivist approaches in occupational therapy practice was not found. What was evident, however, was a focus on experiential accounts of working with groups of people and the methods and processes utilised. It is argued that occupational therapy needs to further develop knowledge and practices aimed at injustices grounded in a collectivist epistemology.

Evaluation of an occupation-based, mental-health program: Meeting being, belonging and becoming needs.

INTRODUCTION: Being, belonging and becoming are important theoretical constructs for occupational scientists and therapists, and for members of Northern Initiative for Social Action (NISA), located in northern Ontario, Canada. Collaborative research with service users guided the development of NISA and its evaluation tool: the 3B~S Scale. The aim of this paper is to share the results of the 2018 program evaluation. METHODS: 113 participants completed a questionnaire consisting of the 3B~S Scale, demographic and program satisfaction questions, and open-ended questions. Quantitative analysis used descriptive statistics followed by ordinal logistic regression to determine the intersectional effects of gender, race and age on becoming and system impact outcomes. Open-ended responses were analysed thematically and triangulated with quantitative findings. RESULTS: Participants agreed-to-strongly agreed that the program met their 3B needs (x = 4.20, SD = 0.24). Participants indicated strong satisfaction with the program (x = 4.38, SD = 0.66), and agreement that participating in the program reduced their reliance on other system-based services (x = 3.96, SD = 0.24). The regression revealed no significant differences in gender, race or age in predicting six of 10 outcomes examined; race was not significant for any outcome. Younger females were more likely to agree that the work they do is part of a larger community charitable purpose, the program is helping them to achieve their goals, and is increasing their involvement in community. Younger participants were more likely to agree that participation facilitated a return to school or employment than older participants. CONCLUSIONS: Occupation-based, mental health programs that address participants' being, belonging and becoming needs can contribute to improvements in perceived mental health and well-being, as well as to improved community and system usage outcomes. The NISA model provides a framework for clinically operationalising the 3B's and may provide a unique contribution to ongoing theoretical discussions of these constructs within occupational therapy and science.

A scoping review of fall hazards in the homes of older adults and development of a framework for assessment and intervention.

INTRODUCTION: Comprehensive evaluation and intervention provided by occupational therapists is effective in reducing the presence of fall hazards in the homes of older adults. The purpose of this study was to document known environmental hazards and to update a previous content analysis. A secondary goal reviewed a framework for evaluation and practice. METHODS: A comprehensive scoping review of published academic articles was performed from 1996 to 2019 to answer: What environmental hazards have been associated with falls in the homes of community-dwelling older adults? Data was extracted in a standardised critical appraisal worksheet and content analysis was conducted. A review of a conceptual framework for assessment and intervention was conducted by international experts (n = 6) in face-to-face interviews. RESULTS: Fourteen studies met the inclusion criteria for the scoping study. The studies reported 17 in-home environmental hazards: throw rugs/carpets, clutter, cords/wires, poorly placed light switches, items placed too low, items placed too high, no grab bars, toilet seats too low, uneven floor surfaces, slippery/wet surfaces, snowy/icy surfaces, backless/unsupportive shoes, unsteady stairs, inadequate lighting, inadequate heating/cooling, step stools without railings, and pets. CONCLUSION: A comprehensive list of specific fall hazards in and around the homes of older adults and a guiding framework offers occupational therapists an evidence-based foundation for fall prevention efforts.

Prenatal Predictors of Maternal-infant Attachment.

BACKGROUND.: Increasingly, occupational therapists are working with women in the perinatal period, including supporting the developing mother-child relationship. PURPOSE.: To examine prenatal predictors of maternal-infant attachment (maternal-fetal attachment, sensory patterns, adult attachment, perinatal loss, and mental health) that may provide possible avenues for assessment and intervention by occupational therapists. METHOD.: Women (N = 60) were assessed during pregnancy and within one year postpartum in a cohort study. Independent t-tests, correlations, and multivariate regression models were conducted. FINDINGS.: Low threshold maternal sensory patterns, more insecure adult attachment, and poorer quality of maternal-fetal attachment were each correlated with less optimal maternal-infant attachment. Quality of prenatal attachment was the best predictor of overall postnatal attachment in multivariate regression models. IMPLICATIONS.: Occupational therapists working in a range of clinical settings (e.g., mental health, substance use, and perinatal care) may work with women during pregnancy to promote their relationship with their developing baby in utero and after birth.

Meaningful Activity and Boredom in the Transition from Homelessness: Two Narratives.

BACKGROUND.: Few studies have examined boredom and meaningful activity during the transition from homeless to housed, and those that exist are retrospective. PURPOSE.: To prospectively examine how meaningful activities and boredom are experienced during the process of leaving homelessness. METHOD.: Using a mixed-methods case study design, we interviewed 13 homeless participants at baseline using a 92-item quantitative interview, followed by a semi-structured qualitative interview. Two participants were located six months later and were interviewed again using the same protocol. Quantitative data are presented descriptively. Qualitative data were analyzed using narrative analysis. FINDINGS.: Qualitative data revealed two unique narratives of boredom and meaningful activity engagement in the transition from homeless to housed, with opportunities for engagement in meaningful activity limited largely by the social and housing environments in which both participants were situated. Quantitative data indicates that boredom and meaningful activity changed little before and after homelessness. At both baseline and follow-up, boredom scores for both participants were comparable to a sample of participants who were exposed to a "boredom" condition in an experimental study (Hunter, Dyer, Cribbie, & Eastwood, 2016). IMPLICATIONS.: Formerly homeless persons may struggle to engage in meaningful activity, and boredom may negatively affect mental well-being. Research with larger samples is needed.

Occupational Therapy Roles in an Indigenous Context: An Integrative Review.

BACKGROUND.: Indigenous peoples experience health inequities linked in part to lack of access to culturally-relevant health care. The Truth and Reconciliation Commission of Canada (TRC) calls on all health professionals, including occupational therapists, to reduce health inequities through improved work with Indigenous communities. PURPOSE.: This integrative review of the literature explores how occupational therapists can improve their work with Indigenous peoples. KEY ISSUES.: Communication and building relationships are central to effective work with Indigenous communities, along with reciprocity regarding knowledge exchange. Issues surrounding service provision are a significant concern, yet improvements are unlikely to be effective unless therapists can critically examine the (mainstream) Western cultural assumptions that infuse the profession and their own practices. IMPLICATIONS.: Though nascent, there are identified directions for occupational therapists to meet the TRC's calls for more competent health care. Researchers should explore best ways for therapists to critically interrogate taken-for-granted professional assumptions mired in Western colonialism.

Establishing an occupational therapy assessment clinic in a public mental health service: A pragmatic mixed methods evaluation of feasibility, utilisation, and impact.

INTRODUCTION: Employment of occupational therapists in generic roles in public mental health services (PMHSs) constrains capacity to undertake discipline-specific activity meaning consumers may be unable to access valuable occupational therapy assessments and interventions that could promote recovery. Establishing a dedicated occupational therapy clinic has been identified as one way of improving care provided and outcomes for organisations, therapists, and consumers. To inform such developments, this paper reports evaluation of feasibility, acceptability, and sustainability of a pilot clinic established within a PMHS. METHODS: An observational evaluation was used combining quantitative and qualitative data collected from service documents, clinic records, and in semi-structured interviews with 42 stakeholders. Quantitative data were used to describe referrals and flow through the clinic. Framework analysis of qualitative data examined the process and outcomes of referrals and enabled understanding of acceptability, perceived impact and areas for improvement. RESULTS: Substantial ground work, particularly stakeholder engagement, and redistribution of resources enabled establishment and successful operation of an assessment clinic for 12 months. Assessments were completed for 68% of the 100 accepted referrals, with the remainder in process or unable to be completed. Stakeholders agreed that the clinic enabled clinicians' timely access to specialist assessment, improving care for consumers. Occupational therapists valued the opportunity to deploy and develop discipline-specific skills and when there was some impact on work flow of occupational therapists' 'home teams', team managers judged the investment worthwhile. Strong leadership by the discipline lead and support from team managers who enabled allocation of occupational therapists to the clinic were critical to success. CONCLUSION: An occupational therapy assessment clinic can be established and operate successfully within a public mental health setting. Redistribution of resources supported increased efficiency and consumer access to specialist interventions that support their recovery.

Evaluation of an interactive showroom to increase general knowledge about welfare technology and its potential in municipal care settings.

Background: Welfare Technology (WT) can promote participation in activity. Thus, initiatives to support the implementation of WT products and services in municipality care settings needs to be developed and evaluated to benefit end-users.Objective: To evaluate an interactive showroom of WT.Material and method: Municipal employees (n = 217) filled in a questionnaire before and after they visited an interactive showroom of WT.Findings: The number of participants confirming WT's potential to contribute to municipal operation areas increased in seven out of eight areas after their visits (p < 0.05). A statistically significant increase was also found regarding general knowledge of and confidence in WT and its potential value.Conclusion: A visit to the interactive showroom increased the perceived general knowledge and appreciated value of WT. The perception of the possibility of implementing WT in various municipal operation areas also increased, which may contribute to the implementation of WT in municipal care settings.

Referral Prioritization in Home Care Occupational Therapy: A Matter of Perspective.

BACKGROUND.: Prioritizing referrals for home care occupational therapy is somewhat subjective, and public and patient perspectives on waiting list priorities are unknown. PURPOSE.: To explore the views of home care occupational therapists (OTs), older persons (OPs) and adults with disabilities on waiting list priorities, as well as issues and challenges underlying these priorities. METHOD.: We conducted in-depth interviews with 11 OTs, 10 OPs and 9 adults with disabilities. Participants were asked to prioritize referral scenarios while explaining their choices. Directed and conventional content analysis allowed the identification of themes for each group of participants. FINDINGS.: OTs experienced conflicts of values but mainly prioritized referrals based on client safety. OPs sought to maximize client's independence, and persons with disabilities aimed to improve clients' social participation. IMPLICATIONS.: OTs should seek the perspectives of their target clientele on referral prioritization criteria and strive to adjust prioritization practices accordingly.

Home visits by occupational therapists improve adherence to recommendations: Process evaluation of a randomised controlled trial.

INTRODUCTION: As part of hospital discharge planning, occupational therapists often provide recommendations to improve the interaction between a person and their home environment. The aim of this study was to investigate the number and type of recommendations made by occupational therapists during a home assessment visit compared to hospital-based assessment for patients recovering from hip fracture. A secondary aim was to explore adherence rates to the different types of recommendations. METHODS: Process evaluation of a randomised controlled trial of 65 participants recovering from hip fracture, returning to community living after hospital discharge. All participants received inpatient multidisciplinary rehabilitation and hospital-based assessment by an occupational therapist (usual care). In addition, the intervention group participated in a single home visit with an occupational therapist prior to hospital discharge. Analysis included the number and type of occupational therapy recommendations, adherence to recommendations at 30 days after discharge, and mediation analysis. RESULTS: Participants in the home visit group received more recommendations than the usual care group (mean difference [MD] 2.8, 95% CI 1.6 to 3.9) and adhered to a greater proportion of recommendations for assistive technologies (MD 11.4%, 95% CI 2.6 to 20.2) and task modifications (MD 10.0%, 95% CI 0.7 to 19.3). Participants in both groups had lower rates of adherence to recommendations for home modifications compared with other types of recommendations. Adherence to recommendations was a mediator in the relationship between participants' involvement in a pre-discharge home visit and reduced hospital readmissions. CONCLUSION: There was greater adherence to occupational therapy recommendations when patients recovering from hip fracture participated in a home visit compared to hospital-based assessment, contributing to reduced readmissions to hospital in the first 30 days. Home visits offer additional benefits to hospital-based assessment through the use of a collaborative approach to decision making in the home environment.

Doing Occupational Justice: A Central Dimension of Everyday Occupational Therapy Practice.

BACKGROUND.: The Canadian Association of Occupational Therapists (CAOT) and the American Occupational Therapy Association (AOTA) state that occupational justice is part of the domain of occupational therapy and that occupational justice is "an aspect of contexts and environments and an outcome of intervention" (AOTA, 2014, p. S9). KEY ISSUES.: Despite the increasing focus on justice in the occupational therapy and the occupational science literature, many practitioners in traditional settings do not see its relevance to their everyday practice (Galvin, Wilding, & Whiteford, 2011) or have difficulty envisioning how to enact a justice-informed practice. PURPOSE.: This paper demonstrates how occupational justice is germane to all settings of occupational therapy, and how it can be enacted at micro, meso, and macro levels of occupational therapy practice. IMPLICATIONS.: We argue that occupational therapy is a justice-oriented profession at its core and will discuss how occupational justice can be enacted at all levels of practice.

Perspectives of individuals receiving occupational therapy services through the National Disability Insurance Scheme: Implications for occupational therapy educators.

INTRODUCTION: With the introduction of the National Disability Insurance Scheme (NDIS) in Australia, occupational therapy graduates need to be adequately prepared to support service users in this new policy context. There is, however, limited research informed by service users themselves to inform contemporary occupational therapy curriculum redesign. The aims of this study were: (a) to explore the experience of occupational therapy service provision from the perspective of service users with lived experience of disability; (b) to gain an understanding of the perceptions of people with lived experience of disability regarding the NDIS and whether it will change how they work with occupational therapists; (c) to gain an understanding of the perspectives of people with lived experience of disability regarding the NDIS, and how this influences curriculum content for occupational therapy education. METHODS: A pragmatic qualitative design, underpinned by the constructivist paradigm was utilised. Demographic surveys and semi-structured interviews were completed with 10 participants who were purposively recruited. Peer debriefing and use of an audit trail were undertaken to enhance the rigour of the analysis. RESULTS: Three themes were identified: (a) Occupational therapists as gatekeepers for equipment provision; (b) experience of the NDIS (Knowledge and understanding of the NDIS; Uncertainty regarding the NDIS; Choice and control in the NDIS); (c) curriculum content for occupational therapy. CONCLUSION: The insights provided by the people with lived experience in this study inform key areas of focus for occupational therapy curriculum to adequately prepare graduates to work in the evolving NDIS environment. Involving service users in an authentic manner in curriculum design, content delivery and student assessment is crucial for "real-world" applicability of student education.

"We need more things for us": Being low income and underoccupied in older age.

BACKGROUND.: Low-income older adult populations have increased vulnerability to occupational engagement barriers and poor health outcomes while aging in community settings. PURPOSE.: The purpose of this study was to examine the relationship between community navigation and well-being for low-income older adults. METHOD.: Community-dwelling older adults (N = 10) were recruited for this multimethod observational cohort study, which employed GPS data, measures of well-being, and semistructured interviews across 12 months. Grounded theory processes were followed to analyze and integrate the qualitative, quantitative, and spatial data. FINDINGS.: Findings were three patterns of community navigation. In particular, patterns of being chronically underoccupied were noted for this low-income population. Specific place-based challenges are explained along with strategies used to mitigate these challenges. IMPLICATIONS.: Supporting community navigation, especially social interaction opportunities, can maximize well-being; and older residents' occupational participation may be unnecessarily curtailed by geographic, economic, and social factors beyond their control. Community navigation strategies should be considered holistically by occupational therapists as part of interventions supporting aging in place.