Operationalizing Stakeholder Engagement Through the Stakeholder-Centric Engagement Charter (SCEC).

There is a need for clear strategies and procedures to operationalize stakeholder engagement in research studies. Clear guidelines that promote shared leadership among study investigators and research stakeholders are important for inclusive and sustainable partnerships. Such guidelines may take the form of a governance charter and can be a means for encouraging the participation and inclusion of stakeholders who may have little to no experience with research or are otherwise underrepresented in research. This perspective article presents the Stakeholder-Centric Engagement Charter (SCEC), one effort to operationalize a stakeholder engagement approach between researchers and an advisory committee as guided by the Patient-Centered Outcomes Research Institute's (PCORI) Research Engagement Principles (i.e., reciprocal relationships, partnerships, co-learning, transparency-honesty-trust). Building on the SCEC can help future investigators develop a study-specific, dynamic, governance document outlining advisory committee and research team preferences in areas such as role expectations, study governance, and decision-making procedures.

Factors influencing utilization of cancer rehabilitation services among older breast cancer survivors in the USA: a qualitative study.

PURPOSE: Many older breast cancer survivors experience long-term disability due to cancer and cancer-related treatments. However, less than 20% of older breast cancer survivors utilize cancer rehabilitation services to address cancer-related disability. Further understanding of survivor experiences may reveal strategies to improve uptake cancer rehabilitation services in the USA. METHODS: Older breast cancer survivors were recruited from university-based registries, previous breast cancer research studies at our institution, community support groups, and geriatric oncology clinics. Participants completed a brief online survey to capture demographic and clinical characteristics. Semi-structured telephone-based interviews were recorded, transcribed, and thematically analyzed. Interviews facilitated conversation about access to rehabilitation and indications for cancer rehabilitation. RESULTS: Participants (n = 14) were, on average, 71 years old, primarily White, and an average of 36.5 months post-diagnosis. Five participants had formally received rehabilitation for a cancer-related concern. Participants described seven factors that influenced utilization of cancer rehabilitation services: (1) emerging awareness of disability; (2) coping styles; (3) comparison of cancer experience with others; (4) provider interaction; (5) perceptions of cancer diagnosis; (6) social support; and (7) cost of rehabilitation. CONCLUSIONS: Older breast cancer survivors consider multiple factors when determining utilization of cancer rehabilitation services. Development of shared decision-making tools addressing the seven described factors may enhance communication and referral to cancer rehabilitation services. Intervention research should adopt frameworks that enhance healthcare accessibility to improve relevance of intervention content and delivery features for older breast cancer survivors.

Differences in functional improvement based on history of substance abuse and pain severity following spinal cord injury.

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η2 = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64-10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

Exploring Occupational Therapists' Experiences in U.S. Primary Care Settings: A Qualitative Study.

IMPORTANCE: Occupational therapy's scope of practice aligns with the goals of comprehensive primary care set forth by the 2010 Patient Protection and Affordable Care Act (Pub. L. 111-148). To successfully integrate occupational therapy into primary care, we must understand occupational therapy practitioners' experiences in this setting. OBJECTIVE: To explore facilitators of, barriers to, and recommendations for integrating occupational therapy into primary care. DESIGN: A descriptive qualitative design that incorporated semistructured interviews, member checking sessions, and deductive thematic analysis. Interviews were structured to capture occupational therapists' experiences of and recommendations for practicing in primary care. SETTING: Primary care. PARTICIPANTS: A purposive sample of licensed occupational therapists with at least 6 mo primary care experience in the United States. RESULTS: Seven participants reported 1 to 8 yr of experience in primary care. Four themes emerged that contextualized the experiences of occupational therapists in primary care. The first theme captured the process of gaining entry onto the primary care team. Once structurally embedded on the team, the second and third themes, respectively, captured barriers and facilitators to navigating team-based care and providing patient-centered care. The fourth theme reflected participants' vision and ideas of how to expand reach nationally to promote consistent integration of occupational therapy into primary care. Conclusion and Relevance: Given the important role of an interprofessional primary care team in improving population health, this study is timely in that it explored occupational therapists' experiences in this emerging practice area. What This Article Adds: Occupational therapists in this study used their skills, resources, and networks to become part of a primary care team. They indicated that they contributed to positive outcomes through working with patients on self-management, functional problem solving, and behavior change.

Evidence for the Effectiveness of Interventions for Caregivers of People With Chronic Conditions: A Systematic Review.

IMPORTANCE: Caregivers are pivotal in supporting the growing population of people with chronic conditions. Yet, engaging in the caregiver role involves the risk of poor outcomes. Caregiver interventions are needed that address poor outcomes while fostering engagement in role-related activities. OBJECTIVE: To evaluate the evidence for interventions to support caregivers of adults with chronic conditions. DATA SOURCES: Five databases were searched for studies of interventions for caregivers and patient-caregiver dyads published between 1995 and 2019. Study Selection and Data Collection: We reviewed the titles, abstracts, and full-text articles of the initial search results (N = 12,216 studies) according to a predetermined protocol. FINDINGS: Forty-eight studies met the inclusion criteria. Psychoeducation and education with skills training were the two caregiver intervention themes. Studies evaluating psychoeducation (n = 28) provided low strength of evidence for improved psychosocial outcomes. Within this theme, problem-solving and coping skills training were common intervention components associated with significant improvements in depression and quality of life. Studies evaluating education with skills training (n = 20) provided moderate strength of evidence for improved knowledge and low strength of evidence for improved psychosocial outcomes. Dyadic self-management education and hands-on training were common components associated with significant improvements in knowledge, quality of life, and burden or strain. CONCLUSIONS AND RELEVANCE: We found low strength of evidence to support the use of psychoeducation and education with skills training. Within these approaches, problem-solving and coping skills training, dyadic self-management education, and hands-on training show promise for improving caregiver outcomes. What This Article Adds: Findings of this systematic review are inconclusive with respect to psychoeducation and education with skills training leading to improved caregiver well-being. Within these broad approaches, the findings support the use of problem-solving and coping skills training, dyadic self-management education, and hands-on training to improve knowledge and well-being among caregivers of people with chronic conditions.

Predictors of Discharge Settings After Total Knee Arthroplasty in Medicare Patients.

OBJECTIVES: To determine the factors associated with acute hospital discharge to the 3 most common postacute settings following total knee arthroplasty (TKA): inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and directly back to the community. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals submitting claims to Medicare. PARTICIPANTS: National cohort (N=1,189,286) of 100% Medicare Part A data files from 2009-2011. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Observed rates and adjusted odds of discharge to the 3 main postacute settings based on the clinical and facility level variables: amount of comorbidity, bilateral procedures, and facility TKA volume. RESULTS: Using IRF discharge as the reference, patients who received a bilateral procedure had lower odds of both SNF and community discharge, patients with more comorbidity had lower odds for community discharge and higher odds for SNF discharge, and patients who received their TKA from hospitals with lower TKA volumes had lower odds of SNF and community discharge. CONCLUSIONS: Clinical populations within Medicare beneficiaries may systematically vary across the 3 most common discharge settings following TKA. This information may be helpful for a better understanding on which patient or clinical factors influence postacute care settings following TKA. Additional research including functional status, living situation, and social support systems would be beneficial.

Making Functional Cognition a Professional Priority.

Functional cognition is a critical domain of concern for occupational therapy practice. As the health care system moves to assessing value through achievement of quality outcomes, the field of occupational therapy must address the inclusion of functional cognition in evaluation and treatment. Evidence indicates that impaired cognition contributes to risk of hospital readmission and poor overall health outcomes across diagnostic groups. Moreover, expenditure on occupational therapy services that address functional cognition has been shown to lower hospital readmission rates. To improve client outcomes, occupational therapists must consistently screen for and, when appropriate, evaluate and treat functional cognition impairments and consider functional cognition in the discharge planning process. Occupational therapy professionals must make a proactive, coordinated effort to establish the profession's role in evaluating and treating clients' limitations in functional cognition as a means to achieving improved quality care and client outcomes.

Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review.

Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners' efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.

Occupational Therapy Fall Prevention Interventions for Community-Dwelling Older Adults: A Systematic Review.

OBJECTIVE: Accidental falls among community-dwelling older adults are preventable and increase the risk of morbidity, hospitalization, and institutionalization. We updated and broadened a 2008 systematic review examining the evidence for the effectiveness of fall prevention interventions in improving fall-related outcomes, occupational performance, quality of life, and health care facility readmissions for community-dwelling older adults. METHOD: We searched and analyzed literature published from 2008 to 2015 from five electronic databases. RESULTS: Fifty articles met the inclusion criteria and were critically appraised and synthesized-37 provided Level I; 5, Level II; and 8, Level III evidence. Analysis was organized into four intervention themes: single component, multicomponent, multifactorial, and population based. Mixed evidence was found for single-component and multifactorial interventions, strong evidence was found for multicomponent interventions, and moderate evidence was found for population-based interventions. CONCLUSION: These findings can inform the delivery and integration of fall prevention interventions from acute care to community discharge.

Occupational Therapy Practitioners' Perspectives on Occupation-Based Interventions for Clients With Hip Fracture.

OBJECTIVE: Occupational engagement is the foundation of occupational therapy. We identified perspectives of 18 occupational therapy practitioners on integrating occupation-based interventions during postacute care (PAC) rehabilitation for persons with hip fracture to identify occupational therapy's distinct contribution. METHOD: We conducted six focus groups derived from a purposive national sample of occupational therapy practitioners (N = 18). A secondary analysis was conducted to analyze the transcripts for major subthemes around occupation-based interventions. RESULTS: Three major themes arose from practitioners' perspectives regarding the role of occupation in rehabilitation: (1) conducting an occupational profile, (2) integrating occupation-based intervention in the facility, and (3) identifying goals for occupational engagement after discharge. Challenges and strategies for integrating occupation-based interventions were also identified. CONCLUSION: Identifying practitioners' perspectives on integrating occupation into rehabilitation may inform strategies to facilitate occupation-based interventions in PAC and define occupational therapy's role in this setting.

Occupational Therapy and Primary Care: Updates and Trends.

As our health care system continues to change, so do the opportunities for occupational therapy. This article provides an update to a 2012 Health Policy Perspectives on this topic. We identify new initiatives and opportunities in primary care, explore common challenges to integrating occupational therapy in primary care environments, and highlight international works that can support our efforts. We conclude by discussing next steps for occupational therapy practitioners in order to continue to progress our efforts in primary care.

Occupational Therapy and Management of Multiple Chronic Conditions in the Context of Health Care Reform.

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

Napping and Nighttime Sleep: Findings From an Occupation-Based Intervention.

OBJECTIVE: To describe sleeping behaviors and trends over time among an ethnically diverse group of community-living older adults. METHOD: A descriptive secondary data analysis of a subsample (n = 217) from the Lifestyle Redesign randomized controlled trial was done to explore baseline napping and sleeping patterns as well as 6-mo changes in these outcomes. RESULTS: At baseline, the average time sleeping was 8.2 hr daily (standard deviation = 1.7). Among all participants, 29% reported daytime napping at baseline, of which 36% no longer napped at follow-up. Among participants who stopped napping, those who received an occupation-based intervention (n = 98) replaced napping time with nighttime sleep, and those not receiving an intervention (n = 119) experienced a net loss of total sleep (p < .05). CONCLUSION: Among participants who stopped napping, the occupation-based intervention may be related to enhanced sleep. More research examining the role of occupation-based interventions in improving sleep is warranted.

An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care.

BACKGROUND: Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers. OBJECTIVES: Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome. RESEARCH DESIGN: Retrospective observational study. SUBJECTS: Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006. MEASURES: Successful community discharge, sites of readmission after PAC discharge. RESULTS: Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile. CONCLUSIONS: Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

Client Centeredness and Health Reform: Key Issues for Occupational Therapy.

Health reform promotes the delivery of patient-centered care. Occupational therapy's rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapy's perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapy's research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

What is occupational therapy's role in addressing sleep problems among older adults?

Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Association's Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, multicomponent interventions, and other interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.

Understanding the Experiences of Family Caregivers of Nursing Home Residents With Dementia: A Grounded Theory Study.

BACKGROUND AND OBJECTIVES: Alzheimer's disease and related dementias progress over time and result in cognitive decline, loss of independence, and behavioral and psychiatric symptoms of dementia that can lead to nursing home placement. Research has focused on examining the effects of nursing home placement on the family caregiver; however, their experiences are less understood. We sought to investigate the experiences and perceptions of family caregivers of nursing home residents with dementia. The objective was to create a conceptual model that explains the complex nature of the family caregiver experience. RESEARCH DESIGN AND METHODS: This study is part of a larger randomized controlled trial. Following a grounded theory approach, we completed 30 in-depth, one-on-one interviews with family caregivers of nursing home residents with dementia. Data analysis followed an iterative process that employed open, axial, and selective coding. RESULTS: Our conceptual model depicts the interrelationship between contributing factors that interrelate and impact family caregiver satisfaction with nursing home care. Six factors contribute to family caregiver satisfaction: family caregiver interactions with nursing home staff; staff management of resident behavioral symptoms; nursing home context; family caregiver knowledge of dementia; family caregiver strain; and the resident experience. DISCUSSION AND IMPLICATIONS: Our findings revealed family caregiver experiences that are unique to the institutional nursing home setting and not reflected in prior work focusing on experiences within community-based settings. Understanding family caregiver experiences and the contributors to how satisfaction in care is perceived, may foster collaboration and teamwork among families and staff.

The Impact of State Dementia Training Requirements for Nursing Homes on Antipsychotic Medication Use.

OBJECTIVES: Nursing home (NH) staff often report not having adequate dementia-specific knowledge to effectively care for these residents. Between 2011 and 2019, 9 states in the United States implemented dementia training requirements for NH staff. This study evaluated whether the state-mandated dementia training for NH staff was associated with improving resident outcomes. DESIGN: Compared trends in antipsychotic medication before and after implementation of state training requirements to trends in states without requirements. SETTING AND PARTICIPANTS: NHs. METHODS: Data from Care Compare for NHs and LTCFocus were linked to state policy data. We excluded 14 states that had implemented training requirements before the start of the study period in 2011. We estimated difference-in-differences models that compared trends in antipsychotic medication use before and after implementation of training requirements in states that have newly implemented requirements to trends in states without requirements. We also investigated whether the impact of training was larger in states with more stringent training requirements (eg, specifying a minimum number of training hours) and in NHs with a special care unit for dementia and examined similar analyses for restraint use and falls. RESULTS: We found that training requirements were associated with a 0.59-percentage point reduction (95% CI -0.91 to -0.27) in antipsychotics use. Effects were larger in NHs with a special care unit for dementia and in states that had stricter training requirements. We also found that training requirements were associated with a 0.17-percentage point reduction (95% CI -0.26 to -0.07) in restraint use measure and had no impact on falls. CONCLUSIONS AND IMPLICATIONS: State requirements for NH staff dementia training were associated with a small, but significant, reduction in the use of antipsychotic medication and physical restraints.