Economic Effects of Occupational Therapy Services for Adults in Acute and Subacute Care Settings: A Systematic Review.

IMPORTANCE: Research supports the clinical effectiveness of hospital-based occupational therapy to improve functional outcomes, but no synthesis of economic evaluations of occupational therapy services provided in these settings has been published. OBJECTIVE: To determine the economic value of occupational therapy services in acute and subacute care settings. DATA SOURCES: MEDLINE, CINAHL, CENTRAL, EconLit, Embase, National Health Services Economic Evaluation Database, PsycINFO, ProQuest (Health and Medicine and Social Science subsets only), OTseeker, and gray literature. Study Selection and Data Collection: Eligible studies used trial-based or modeled economic analyses and included an adult population (ages ≥18 yr) and occupational therapy assessments or interventions provided in acute and subacute care. Two authors independently assessed abstracts and then full text. Articles were then appraised using the Evers Consensus on Health Economic Criteria. FINDINGS: The authors identified 13,176 unique abstracts and assessed 190 full-text articles for eligibility. Ten studies were included in the systematic review; they varied in their primary objectives, methodology, costs, and outcomes. Studies examined the cost-benefit, cost-effectiveness, cost-utility, or cost minimization of a range of occupational therapy services. Five studies suggested that occupational therapy services offer value for money (lower cost, higher benefit); 4 suggested that they offer higher cost and benefits. One study that investigated upper limb rehabilitation did not indicate value for money. CONCLUSIONS AND RELEVANCE: The findings suggest that occupational therapy for adults poststroke and post-traumatic brain injury, acute discharge planning, and pre- and post-hip replacement is cost-effective, but further research is needed to substantiate these findings. What This Article Adds: The findings provide preliminary evidence of the economic effectiveness of occupational therapy in acute and subacute care.

Allied Health Staff Perceptions of Workforce Staffing Models Across 7 Days and After-Hours in a Major Metropolitan Health Service.

OBJECTIVE: Weekend admissions to hospital are associated with worse patient outcomes. Casualisation of the weekend workforce and reduced access to allied health (AH) services may contribute to this phenomenon. Alternative AH staffing models have been proposed. This study explored the perceptions of AH staff regarding weekend and after-hour staffing models. METHODS: Mixed-methods study including descriptive and thematic analysis of survey and focus group data. Participants were AH staff and stakeholders from a major Victorian (Australian) public health service. RESULTS: 160 staff (21%) completed the online survey. Three focus groups (16 participants) were conducted. Most AH disciplines used a casual staffing model on weekends. Most survey respondents (79%) thought a staffing model across 7 days would improve patient outcomes. In the focus groups, staff reported that the existing weekend staffing model was inadequate and could be optimised by weekday staff working across 7 days. For AH staff to work across 7 days, they emphasised the importance of planning and flexibility to enable a healthy work/life balance. CONCLUSIONS: AH staff and stakeholders were dissatisfied with the casual AH work¬force model on weekends. Sustainable AH staffing models across 7 days are becoming increasingly important as healthcare resources become strained due to increasing demands.

Self-managed occupational therapy and physiotherapy for adults receiving inpatient rehabilitation ('My Therapy'): protocol for a stepped-wedge cluster randomised trial.

BACKGROUND: Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions. METHODS: This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios. DISCUSSION: The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs. TRIAL REGISTRATION: This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).

Trans-disciplinary advanced allied health practitioners for acute hospital inpatients: a feasibility study.

OBJECTIVE: To explore cost-efficiency, safety and acceptability of trans-disciplinary advanced allied health (AH) practitioners for acute adult general medicine inpatients. DESIGN: Quasi-experimental feasibility study. SETTING: Three acute general medical units in an Australian urban hospital. PARTICIPANTS: Two hundred and fifty-six acute hospital inpatients. MAIN OUTCOME MEASURES: Cost-efficiency measures included AH service utilization and length of stay (LOS). Patient outcomes were functional independence, discharge destination, adverse events, unplanned admissions within 28 days, patient satisfaction and quality of life data on admission, and 30 days post-discharge. Ward staff were surveyed regarding satisfaction with the service model, and advanced health practitioners (AHPs) rated their confidence in their own ability to meet the performance standards of the role. RESULTS: Patients allocated to AHPs (n = 172) received 0.91 less hours of AH intervention (adjusted for LOS) (95% confidence intervals (CI): -1.68 to -0.14; P = 0.02) and had 1.76 days shorter LOS relative to expected (95%CI: 0.18-3.34; P = 0.03) compared with patients receiving standard AH (n = 84). There were no differences in patient outcomes or satisfaction. AHPs demonstrated growth in job satisfaction and skill confidence. CONCLUSIONS: Trans-disciplinary advanced AH roles may be feasible and cost-efficient compared with traditional roles for acute general medical inpatients. Further development of competency frameworks is recommended.

A qualitative investigation into the patient-centered goal-setting practices of allied health clinicians working in rehabilitation.

OBJECTIVE: To explore the ways clinicians engage rehabilitation patients in patient-centered goal setting and identify factors influencing the goal-setting process. DESIGN: Ethnographic study utilizing observed practice-thematic analysis. SETTING: Four rehabilitation wards of a large metropolitan hospital in Melbourne, Australia. SUBJECTS: Participants included 17 rehabilitation patients, 18 allied health clinicians and one family member. Disciplines represented were speech pathology, occupational therapy, social work and physiotherapy. METHOD: Multiple qualitative methods were used. A total of 18 routine goal-setting interviews between clinicians and patients were audio recorded and transcribed. Together with associated entries in the patient medical record, transcripts were coded and developed into themes using thematic analysis. Finally, focus groups with clinicians were conducted to validate themes identified. RESULTS: Three themes were identified describing factors which influence patient centeredness: "a goal-setting collaboration"-the interpersonal exchange between client and clinician; "the environment"-physical, temporal and structural; and "clinician self-awareness"-clinicians' insight into the ways they influence goal setting. The practice of patient-centered goal setting varied considerably between clinicians. Goals developed were strongly influenced by the clinician's views, although strategies of respect for the patient and reflective listening skills increased patient participation and the patient centeredness of goals developed. CONCLUSION: Goals developed with rehabilitation patients are more likely to be patient-centered when the interaction encourages the patient to express their needs and preferences, and these are heard by the clinician. For this to influence treatment, it must occur in an environment structured to support and value patient-centered goals.

Exploration of an allied health workforce redesign model: quantifying the work of allied health assistants in a community workforce.

The Victorian Assistant Workforce Model (VAWM) enables a systematic approach for the identification and quantification of work that can be delegated from allied health professionals (AHPs) to allied health assistants (AHAs). The aim of the present study was to explore the effect of implementation of VAWM in the community and ambulatory health care setting. Data captured using mixed methods from allied health professionals working across the participating health services enabled the measurement of opportunity for workforce redesign in the community and ambulatory allied health workforce. A total of 1112 AHPs and 135 AHAs from the 27 participating organisations took part in the present study. AHPs identified that 24% of their time was spent undertaking tasks that could safely be delegated to an appropriately qualified and supervised AHA. This equates to 6837h that could be redirected to advanced and expanded AHP practice roles or expanded patient-centred service models. The VAWM demonstrates potential for more efficient implementation of assistant workforce roles across allied health. Data outputs from implementation of the VAWM are vital in informing strategic planning and sustainability of workforce change. A more efficient and effective workforce promotes service delivery by the right person, in the right place, at the right time.

Building allied health workforce capacity: a strategic approach to workforce innovation.

OBJECTIVE: The aim of the present study was to identify areas where allied health assistants (AHAs) are not working to their full scope of practice in order to improve the effectiveness of the allied health workforce. METHODS: Qualitative data collected via focus groups identified suitable AHA tasks and a quantitative survey with allied health professionals (AHPs) measured the magnitude of work the current AHP workforce spends undertaking these tasks. RESULTS: Quantification survey results indicate that Victoria's AHP workforce spends up to 17% of time undertaking tasks that could be delegated to an AHA who has relevant training and adequate supervision. Over half this time is spent on clinical tasks. CONCLUSIONS: The skills of AHAs are not being optimally utilised. Significant opportunity exists to reform the current allied health workforce. Such reform should result in increased capacity of the workforce to meet future demands.