Abstract
Introduction
Acute care readmissions of older people are an ongoing concern in many countries. Occupational therapists are well positioned to play a significant role in contributing to improved outcomes and fewer readmissions following discharge from acute hospitals, yet there is a lack of empirical evidence to support this claim.
Methods
This study used a retrospective clinical audit of secondary hospital data to investigate and describe the time spent on occupational therapy, and the range of occupational therapy and other allied health services provided to older people admitted to acute care, in one Australian health care service.
Results
Occupational therapists conducted numerous assessments and interventions to support patients and to prepare them for safe discharge home. Occupational therapy was significantly associated with length of stay. Readmission was not related directly or significantly to time spent in occupational therapy or any other factor included in this study. However, of the people who received occupational therapy, there was a higher percentage readmitted when they had more services already in place on admission and when they lived alone.
Conclusions
This study provides preliminary evidence regarding the contact time and range of occupational therapy assessments and interventions provided to older people in the acute hospital setting.
Introduction
In Australia and similar countries, people are living longer but with more ongoing health conditions, often requiring more hospital admissions (Jönsson et al., 2017). People with multiple chronic medical conditions (CMCs) have more emergency department visits and longer hospital stays than those without (Leland et al., 2017). Acute care readmissions place additional financial burden on the health system, as well as impacting the patient and their family, and are an ongoing concern in Australia, the United States of America (USA), United Kingdom (UK), and similar countries (Roberts and Robinson, 2014). Multiple acute hospital admissions can result in loss of independence, decreased social and community participation, and decreased quality of life for older people (Jönsson et al., 2017; Leland et al., 2017). Potential contributors to unplanned hospital admission include having unmet functional needs, living alone, lack of self-management skills, or having limited education (Arbaje et al., 2008; DePalma et al., 2012).
Due to their scope of practice, occupational therapists have an important role in acute care. In particular, occupational therapists’ expertise lies in interviewing patients and in skilled observations of functioning (Robertson and Blaga, 2013), and then intervening to address functional issues during admission to maximise a patient’s occupational performance on discharge (Hoyer et al., 2013). Occupational therapists can play a significant role in implementing risk reduction strategies such as falls prevention, both during hospitalisation and in preparation for discharge, thereby contributing to improved outcomes and fewer readmissions following discharge from acute hospitals (Roberts and Robinson, 2014). Yet, there is a lack of empirical evidence to support these claims. One of the few studies to examine the efficacy of occupational therapy intervention during inpatient stays was a USA study by Rogers, Bai, Lavin, and Anderson in 2017. They investigated the association between hospital spending for Medicare fee-for-service patients aged 65 years and older (with a principal diagnosis of heart failure), 19 different spending categories of service, and three clinical outcomes: 30-day readmission rates for heart failure (n = 538,056), pneumonia (n = 461,268), and acute myocardial infarction (n = 194,927) (Rogers et al., 2017). Occupational therapy intervention was the only one of 19 categories where higher spending had a statistically significant association with lower readmission rates for all three medical conditions (Rogers et al., 2017).
Better understanding of the benefits of occupational therapy in acute care is important given the continual pressure on health care costs, including the contribution that occupational therapy makes within the array of allied health services received by older adults within acute hospital settings. However, while studies have explored the perceived role of occupational therapists in acute care including promoting early discharge (Brandis, 1998; Britton et al., 2015), what assessments are undertaken (Jönsson et al., 2017), and challenges for occupational therapists in acute care (Britton et al., 2016), there is a lack of research describing what occupational therapists are currently doing in acute settings. As a first step towards building evidence in this area, this study aimed to use secondary hospital data to investigate and describe the range of occupational therapy and other allied health services provided to older people with chronic medical conditions admitted to acute care in one Australian health care service. In addition, the study also aimed to describe time spent in occupational therapy and other allied health services, and their contribution to prevention of hospital readmission, to guide future investigations of the effects of occupational therapy services on readmission rates. For the purpose of this study, allied health was defined as the allied health staff employed at this particular health service. This included physiotherapists and social workers, as well as ‘other allied health’, including dieticians, speech pathology specialists, and allied health assistants.
The research questions guiding this study were: What is the profile of patients aged over 65 years with CMCs, either readmitted or not readmitted within 12 months, who receive occupational therapy services versus those who do not receive occupational therapy services? What are the recorded assessments and interventions provided to people aged over 65 years living with CMCs within acute occupational therapy services? What factors were associated firstly with receipt of occupational therapy services, and secondly with readmission within 12 months of discharge? Is there an association between total amount of occupational therapy input and other allied health services and length of stay?
Methods
A retrospective clinical audit was conducted using secondary data from Monash Health (MH) in Melbourne, Australia. Major health services like MH typically collect large volumes of data, including medical records, which are primarily used for clinical, administrative, and supervisory purposes, and for funding accountability (Nilsson, 2017). This data is a potentially useful, easily accessible source of clinical information but is often overlooked as a source of information about practice. Monash Health collects data that includes, among other items, patient dates of admission and discharge to all services within MH, admitted patients’ primary and secondary diagnoses, patient age and gender, marital status, living arrangements, social support, health funding, minutes engaged in allied health services, occupational therapy occasions of service, and minutes engaged in direct occupational therapy.
Ethical approval for this study was obtained from Monash Health.
Sampling procedure
Convenience sampling was used to select 200 records from MH that met the following inclusion criteria: (a) people aged over 65 years; (b) had a medical history that included at least one of the following medical conditions: chronic obstructive pulmonary disease (COPD), diabetes, obesity, dementia, cardiovascular disease, osteoporosis, arthritis, stroke, heart failure, or kidney disease; (c) admitted to acute wards across three MH hospital sites; and (d) discharged home between June 2015 and June 2016. Exclusion criteria were: (a) people admitted from a nursing home; (b) people who died during the study period; (c) people discharged outside MH catchment; and (d) people discharged to residential care or inpatient rehabilitation. If the person’s medical history included one or more of the listed CMCs, they met the inclusion criteria. From these 200 records, further selection criteria were applied to randomly obtain four equal (n = 25) sub-samples consisting of: (a) patients who received occupational therapy and were not readmitted within 6 months; (b) patients who received occupational therapy and were readmitted within 6 months; (c) patients who did not receive occupational therapy and were not readmitted within 6 months; and (d) patients who did not receive occupational therapy and were readmitted within 6 months. For purposes of data analysis, further groupings by characteristic were done: Group A: Patients readmitted (n = 50); Group B: patients not readmitted (n = 50); Group C: patients who received occupational therapy (n = 50); Group D: patients who did not receive occupational therapy (n = 50) (see Table 1).
Group characteristics of sub-samples.
Detailed information about occupational therapy assessments and interventions specific to individual patients is not routinely recorded at MH. Therefore, a list of potential occupational therapy interventions undertaken at MH was developed through a consultation process involving the Monash University research team and current employed occupational therapy clinical experts at MH. For the purpose of this study, assessment was defined as any assessment reported in the O (objective) or A (assessment/analysis) in the subjective, objective, assessment, plan (SOAP) progress notes. That is, did not include subjective notes such as patient-reported. The included interventions listed in Table 2 were decided through a consultation process involving the Monash University research team and occupational therapy clinical experts at MH. Items were categorised as follows: assessment, intervention, equipment related, discharge preparation, and other, so as to capture the main areas of occupational therapy services provided. Proformas were then developed to enable data to be extracted from the medical records for the four patient groups of interest. These proformas are available on request from the authors. Other data extracted included: need for, and use of, interpreter services; living arrangements prior to admission and on discharge; total minutes engaged in social work; total minutes engaged in physiotherapy; and total minutes engaged in other allied health services.
Type and frequency of occupational therapy assessments and interventions conducted.
Group 1: People receiving occupational therapy not readmitted within 12 months.
Group 2: People receiving occupational therapy readmitted within 12 months.
Data management and extraction
Medical records and data were managed on the hospital premises in accordance with MH ethical clearance. Medical records were screened, and data were retrieved by one occupational therapist employed at MH who had clinical knowledge of acute services. Two university staff (LB and AL) provided directions and parameters around data retrieval/mining from the medical records. After piloting the data extraction with several sample cases, consultation occurred between these three researchers and any ambiguities were discussed and resolved. Records were not kept of any names or identifying features from patient records. Rather, research numbers were allocated for records 1–100. Only the hospital-based occupational therapist responsible for data mining had access to the list of patient hospital identification numbers and allocated research numbers; this material was password protected. Following record selection as described above, data were systematically extracted from the records. Any data provided to the rest of the research team were in a de-identified form. Data extracted included: demographic details; occupational therapy service data guided by the proforma; and minutes of service received during inpatient stay. Data were manually recorded in Excel. Regular meetings to verify recorded data occurred between the research team members and the occupational therapist extracting data.
Data analysis
Data were imported into SPSS version 25 for analysis (IBM, 2017) To investigate the first and second research questions, the data were explored using descriptive statistics to determine the characteristics of split halves (readmission (Group A) or not (Group B) and receipt of occupational therapy (Group C) or not (Group D)). Following descriptive presentation of the frequency of factors associated with receipt of occupational therapy (versus not) and readmission (versus not), the third research question was addressed using inferential statistics (Mann Whitney U) to determine differences based on patient’s age, length of stay, and time spent in services. To address research question 4, two new variables were configured: (a) sum total of occupational therapy assessment, and (b) sum total of occupational therapy intervention. These variables were the sum total of the number of either assessments or interventions received by inpatients as outlined in Table 2. Correlations were then calculated to explore the associations between these variables (occupational therapy assessment and occupational therapy intervention) and the patient’s age, length of stay, and minutes in allied health services.
Results
The overall sample was predominantly female (66%) and ages ranged from 65 to 93 years, with a mean age of 79 years (SD = 7.2). The sample included 56 partnered individuals (married or de facto) and 17 people who required interpreter services at admission, and the average length of stay was 4.9 days (SD = 3.7). Most participants (86%) presented with, or had a documented medical history of, cardiovascular disease, and nearly half had either heart failure (46%) or diabetes (44%). Within the sub-samples, there was similar participant representation across each of the CMCs, other than Group 1 (people receiving occupational therapy not readmitted within 12 months), which had no participants with dementia. Differentiation of CMCs per group are provided in Table 3. Data pertaining to research question one are presented in the characteristics of participants in each group (see Table 3).
Characteristics of inpatients in Groups 1–4.
Group 1: People receiving occupational therapy not readmitted within 12 months
Group 2: People receiving occupational therapy readmitted within 12 months
Group 3: People not receiving occupational therapy and not readmitted within 12 months
Group 4: People not receiving occupational therapy and readmitted within 12 months
aIndividual could have one or more chronic medical condition.
Data pertaining to research question two, concerning the type and frequency of occupational therapy assessments and interventions conducted, are presented in Table 2. The most frequently recorded assessments were initial assessment, physical assessment, and cognitive assessment, whereas there were no recorded occupational therapy assessments in the areas of: home assessment; pre-surgery assessment; and operation meeting/planning. The most frequently recorded interventions were: equipment assessment/prescription and equipment provision, followed by patient or family education. There were no recorded occupational therapy interventions in the areas of: domestic skills; home assessment and report writing; intervention without equipment; splinting; funding investigations and applications; groups; family meetings; and community participation.
When the patient’s age, length of stay, and time in allied health services associated with readmission (Group A) versus non-readmission (Group B) were compared, there were no significant differences (see Table 4). These results suggest that there were no differences between the two groups based on these factors. When the same factors were compared between the two groups who received occupational therapy (Group C) and did not receive occupational therapy (Group D), the only significant difference was length of stay (p = .004). When age and services were compared (see Table 4), occupational therapy was the only factor significantly associated with longer length of stay.
Comparisons of services received between Groups A, B, C, and D using the Mann Whitney U statistic.
Note. ap ≤ .05
Group A: People readmitted within 12 months
Group B: People not readmitted within 12 months
Group C: People who received occupational therapy
Group D: People who did not receive occupational therapy
Associations between the patient’s age, time with all extracted allied health services, and length of stay were investigated using Spearman’s Rho statistic (see Table 5). As expected, time spent in occupational therapy was moderately correlated with length of stay (Rho = .48, p < .01) and sum total of intervention (Rho = .51, p < .01), and strongly correlated with sum total of assessment (Rho = .58, p < 01). Further, time spent in occupational therapy had the strongest correlation with length of stay compared with time spent in physiotherapy, social work, and other allied health services.
Correlations (Spearman’s Rho) between age of patient, length of stay, minutes spent in different allied health services.
*p ≤ .05; **p≤ .01
aSpeech pathology, dietician, allied health assistant
Discussion
This study described the range of occupational therapy and other allied health services provided to older people admitted to acute care in one Australian health service. In addition, time spent in occupational therapy and other allied health services was described, and contribution to prevention of hospital readmission investigated. In summary, the services and situation of patients with at least one chronic medical condition and aged over 65 years were profiled and patient characteristics and services compared. When patients who received occupational therapy were compared with those who did not receive occupational therapy, irrespective of being readmitted or not, there were few differences between these groups. However, when the two groups (occupational therapy and readmitted vs occupational therapy and not readmitted) were compared, noteworthy differences included a higher percentage of patients being readmitted if they had received more services at the time of admission (64% vs 44%), or had been discharged to live alone (28% vs 16%).
There were several differences between patients who received occupational therapy services and were readmitted to hospital and those patients who did not receive occupational therapy and were readmitted. Patients who did not receive occupational therapy and were readmitted included higher percentages of males (52% vs 28%), married persons (68% vs 48%), people living with their partner on admission (52% vs 24%), and people discharged to live with a partner/offspring (72% vs 36%). Further, patients who did not receive occupational therapy and were readmitted received less allied health services overall including: less social work (20% vs 8%), less physiotherapy (92% vs 40%), and less other allied health (44% vs 12%). Although this data represents only a small percentage of hospital inpatients, interesting trends for readmission included more males, already highly serviced people, people living with a spouse on admission and discharged to live with spouse/offspring, and people who received less or no allied health services (occupational therapy, physiotherapy, social work, other) during their admission.
This study did not analyse expenditure on the different services, but the results are broadly in alignment with those of Rogers et al. (2017), who found that higher spending on occupational therapy intervention had a statistically significant association with lower readmission rates. In the current study, when the factors associated with readmission were further investigated, there were no differences between patients readmitted or not, based on age, length of stay, or time spent in any allied health services. When factors associated with receiving occupational therapy services were investigated, patients receiving occupational therapy services were slightly but not significantly older (81 vs 79, p = .057). Further, patients in receipt of occupational therapy stayed significantly longer than patients not in receipt of occupational therapy (4.7 vs 3.3 days, p = .004). Time spent in occupational therapy was significantly and moderately to strongly correlated with longer length of stay, greater sum total of assessment and intervention in occupational therapy, and more time spent in social work and physiotherapy. Further, time in occupational therapy had the strongest correlation with length of stay compared to time spent in physiotherapy, social work, and other allied health services. While this study did not confirm a statistically significant relationship between readmission and occupational therapy or other factors, the aforementioned trends and differences in the group of patients readmitted with and without occupational therapy services suggest that some patients are more vulnerable to readmission. It is possible that maintaining or improving a patient’s functional status during acute care hospitalisation will contribute to decreasing future readmissions, as was found by Hoyer et al. (2013). Future research might investigate this further using a prospective study design.
The most commonly administered occupational therapy assessments were personal care assessments and cognitive assessments. Undertaking personal care or activities of daily living (ADL) assessments, and reporting results of these to the multi-disciplinary team, is consistent with the perceived role of occupational therapists in expediting the discharge process (Britton et al., 2015). Providing supports and interventions to address ADL issues is known to be important in preventing readmission of older adults (DePalma et al., 2012). Further, cognitive impairment or decline has a major impact on older people’s participation and contributes to higher rates of falls (Close et al., 2014; Perlmutter et al., 2010), so screening for cognitive impairment is important for identifying participation restrictions that impact discharge planning (Perlmutter et al., 2010).
An important finding from this study was that no occupational therapy home assessments were completed for any of the patients included. Conducting a visit to a patient’s home prior to discharge typically provides valuable information about how the person functions within their own environment that cannot be replicated within the hospital environment (Lockwood et al., 2019; Atwal et al., 2008). Home visits also contribute information regarding risks to the patient related to returning home, which may not otherwise be identified (Atwal et al., 2008). This finding is especially noteworthy given that the readmission profiles of patients who received occupational therapy revealed that 28% lived alone. One possible reason for there being no home assessments could be the pressure to discharge patients in the shortest possible time, as found by Britton et al. (2016) in a qualitative study conducted in Australia.
A recently published randomised controlled trial by Lockwood et al. (2019) found that patients who received an occupational therapy home visit prior to discharge from hospital following hip fracture (in addition to usual care and rehabilitation) had a reduced risk of readmission to hospital in the first 30 days, in addition to a reduction in falls in the first 30 days. This research provides empirical evidence of the efficacy of occupational therapy home visits on patient outcomes. However, the current study aligns more with Lannin et al. (2011), who make the point that there remains a wide variation in the frequency of pre-discharge home visits completed. In their survey of occupational therapists, four key issues were identified as impacting the frequency of home visiting: (a) shorter lengths of hospital stay resulting in less time for occupational therapists to conduct home visits; (b) staff shortages and greater patient numbers resulting in re-prioritisation of interventions; (c) an increase in state-funded hospitals referring patients to federally funded, community-based services for their home visit assessments post-discharge; and (d) lack of evidence to demonstrate the impact of pre-discharge home visits on patient outcomes. Hence, there is increasing evidence of the cost effectiveness of occupational interventions in reducing readmission rates (Rogers et al., 2017) and that occupational therapy home safety assessments before discharge can decrease the occurrence of falls-related readmissions (Johnston et al., 2010). Nevertheless, the current study suggests that this evidence may not yet have translated into practice.
The current study findings warrant consideration of the requirements for record-keeping during inpatients stays. It is common practice for large health organisations to require clinical staff to record information about patient characteristics, and assessments and interventions used. One of the advantages of using such information for research purposes is that it is non-intrusive and limits ethical dilemmas if patient identity is protected (Nilsson, 2017). However, one of the main concerns is the reliability and validity of such data (Nilsson, 2017). Issues include differences in therapists recording what they have done in sufficient detail and inconsistency between therapists as to how they record what they have done. In this study, conducting a retrospective audit meant the analysis was restricted to variables for which routinely collected data was available. While this has provided some information regarding occupational therapy practice with older people in the acute setting, further work is needed to identify in more detail the specific types of assessments and interventions completed by occupational therapists in this setting. In addition, a greater understanding of the use of occupationally focussed practice in the acute setting would be useful to further inform the effective provision and documentation of allied health services in this area.
Limitations
This study provides a snapshot of inpatient occupational therapy services from one Australian health care organisation; therefore, the broader applicability of the results is limited by the small sample size. In addition, analysis was restricted to variables for which routinely collected data were available and dependent upon the type and quality of record-keeping about occupational therapy and other allied health services within Australian acute hospitals. The method of identifying medical records for the pre-determined four groups of 25 previous inpatients restricts the generalisability of findings. Future studies might select a larger random and more representative sample. Future studies might also include prospective data collection, including specific types of assessments and interventions implemented, to improve the quality of data collected and better inform occupational therapy service provision and practice within acute care settings.
Conclusions
This research project investigated the characteristics of inpatients over 65 years and their occupational therapy service usage by conducting a retrospective clinical audit. It revealed that occupational therapists in acute care engage in numerous assessments and interventions to support patients over 65 years when they are in hospital and to prepare them for safe discharge home. Occupational therapy was significantly associated with length of stay and correlated with other allied health service usage. Readmission was not related directly or significantly to time spent in occupational therapy or any other factor included in this study. However, of people who had received occupational therapy, there was a higher percentage of people readmitted when they had more services already in place on admission and when they lived alone. This research provides preliminary evidence about the contact time and broad range of occupational therapy assessments and interventions provided to older people in the acute hospital setting. To determine the effectiveness and contribution of occupational therapy to preventing hospital readmissions of older people with CMCs, there is a need for more accurate and comprehensive data to be collected routinely. This will inform the future development of responsive, cost-effective, and effective services for older adults.
Key findings
Occupational therapists in acute care settings undertake numerous assessments and interventions with patients over 65 years to prepare them for safe discharge home. Home visits are not completed routinely for older people admitted to acute hospitals. Evidence regarding the nature and impact of acute occupational therapy services for older people with CMCs is needed. More comprehensive routinely collected hospital data is needed to better inform occupational therapy service planning.
What this study has added
This study provides preliminary evidence regarding the contact time and range of occupational therapy assessments and interventions provided to older people in the acute hospital setting.
Footnotes
Research ethics
Ethical approval for this study was obtained from [removed for blind review].
Consent
As this study utilised conducted using secondary data, written consent was not required.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
This research was supported by two small grants: an Occupational Therapy Australia Research Fund grant and a Monash University School of Primary and Allied Health Care Seeding grant.
Contributorship
All authors contributed to design of the study. Linda Barclay coordinated the overall aspects of the study. Aislinn Lalor and Bianca Furmston completed data collection. Helen Bourke-Taylor, Aislinn Lalor, and Linda Barclay analysed the data. Linda Barclay, Aislinn Lalor, and Helen Bourke-Taylor drafted the manuscript. Alison Smith, Ellie Fossey, and Louise Farnworth contributed to drafts of the manuscript.
