Exploring the meaning of value-based occupational therapy services from the perspectives of managers,therapists and clients

Abstract

Introduction

There is a worldwide trend towards value-based health care, which strives to control healthcare costs while maximising value for clients. The main concept of value has been defined as health outcomes achieved per US dollar spent. This research explored how clients of occupational therapy services, managers and occupational therapists perceived value in occupational therapy services.

Method

A qualitative design was used to explore the perspectives of clients (n = 11), occupational therapists (n = 7) and occupational therapy managers (n = 7). Appreciative inquiry guided the two phases of semi-structured interviews (n = 5) and focus groups (n = 6). Inductive and deductive coding were used to establish themes.

Findings

Conclusion

Participants attributed value to occupational therapy services when they encountered personalised goal setting, focused on meaningful outcomes, managed personal costs and experienced positive therapeutic relationships. Enhancing services could focus on (1) developing skills in collaborative goal setting, (2) determining suitable outcome measures which are meaningful at personal- and service-level reporting, (3) encouraging self-management strategies, and (4) emphasising therapeutic relationships and supporting therapeutic communication skill development.

Keywords

Occupational therapy services value cost outcomes quality of care value-based healthcare

Introduction

There is a worldwide trend towards value-based health care (VBHC), which strives to control healthcare costs while maximising value for people accessing services. The objective of VBHC is to maximise what matters to people, such as health outcomes and personal experience, relative to the cost of achieving those outcomes (European Commission, 2019). The approach is consistent with occupational therapy as VBHC focuses on the person’s experience throughout their care and delivering person-centred care. However, to remain relevant in the healthcare transformation, occupational therapy services will need to be explicit in how they align with VBHC principles (Lamb and Metzler, 2014).

To implement VBHC, it is important to understand what value means to people in relation to occupational therapy services, as multiple understandings of what value means may exist in parallel. Therefore, the aim of this research was to explore how occupational therapy managers, occupational therapists and clients perceived value in occupational therapy services in a large tertiary hospital in Singapore.

Literature review

Health care in Singapore is provided by a combination of public and private healthcare facilities and is consistently ranked as one of the world’s most efficient healthcare systems with good outcomes (Lim, 2017). Despite having a world class healthcare system, Singapore only spends an average of 4.5% of its gross domestic product on health care (Lee, 2020). Although health care is subsidised, Singapore’s reliance on client co-payments has been a key factor for containing national and public health spending (Lee, 2020).

Providing affordable health care has become increasingly complicated with rising demands from an ageing population and prevalence of chronic disease (Lim, 2017). This echoes the increasing healthcare expenditure in many countries, causing national healthcare affordability to become a topic of importance worldwide (Fantini and Vaccaro, 2019). It has been argued that the inability of organisations to effectively measure and manage the true costs and value of health care has contributed to escalating costs (Fantini and Vaccaro, 2019).

VBHC was first introduced as a way to support the sustainability of healthcare systems (Porter and Teisberg, 2006). The authors advocated for a ‘patient-centric’ (p. 158) system organised around the person’s needs; a move away from the traditional volume-based approach centred around health professionals’ priorities. The main concept of value has been defined initially as health outcomes achieved per US dollar spent (Porter and Teisberg, 2006). As VBHC has been adopted into healthcare systems funded mainly through taxation, such as the United Kingdom, the definition has evolved to contextualise value as health outcomes based on ‘equitable, sustainable and transparent use of available resources’ (Hurst et al., 2019: 8). Important principles in implementing VBHC include engaging and activating people throughout their care journey, ensuring person-centred goals and preferences in treatment via shared decision making, and empowering all staff to perform empathetic listening and communication skills to enhance client self-efficacy (Keswani et al., 2016). The focus is on improving experiences and outcomes that matter most to people, rather than on cost reduction or health professionals’ valued outcomes (Porter, 2010).

Although the goal of VBHC is optimising population health, utilitarian societies (e.g. the United Kingdom and Singapore) are varied in their methods to achieve this goal. Different models have been proposed, reflecting the healthcare systems’ social values and funding structure. In a recent report by an expert panel (European Commission, 2019), four pillars of value, namely personal value, societal value, allocative value and technical value were identified. Personal value is value as perceived by the client, which includes health benefits as well as process elements including personal experience. Societal value reflects the need to consider how health care can contribute to the society’s goals which may include inclusivity, connectedness and participation. Allocative value refers to how equitable resources are distributed across groups, and technical value is the achievement of best possible outcomes with available resources.

Despite VBHC being a forward-looking approach to manage the rising costs of health care, little has been discussed within allied health literature. Few commentaries from physical therapy (Lentz et al., 2020) and radiotherapy (Lievens et al., 2019) have suggested that these professions are well positioned to implement VBHC but urged more needed to be done in developing a team-based approach, defining person-centred outcomes and embracing rigorous research study designs to better understand how value can be delivered. They warned that while opportunities exist, value and growth of their professions can be threatened if existing practice and research standards do not evolve and embrace VBHC principles (Lentz et al., 2020; Lievens et al., 2019).

Similar discussions have occurred in occupational therapy. Occupational therapy’s expertise in engagement in meaningful occupations reflects several of the ‘patient-centred’ VBHC outcomes proposed by Porter and Teisberg (2006: 158). There is also increasing evidence of the potential of occupational therapy in bringing about cost savings and improvements in quality of care for older adults and the management of various illnesses and chronic conditions (e.g. Nagayama et al., 2016; Rexe et al., 2013). Despite advances towards VBHC in occupational therapy, it is imperative that the profession further demonstrates its contribution to value-based outcomes or risk becoming marginalised in the rapidly changing healthcare environment (Leland et al., 2015).

Defining value and translating it into service delivery is not straightforward. Various stakeholders such as clients, managers and practitioners may have differing perceptions of what value is in occupational therapy services (Porter, 2010; Schapira et al., 2020). For example, some studies have observed that while clients valued participation-based goals, occupational therapists tended to set impairment- or activity-based goals that were achievable, measurable, and in line with organisational expectations and resource constraints (Leach et al., 2010; Rosewilliam et al., 2011). Additionally, perspectives of value are usually explored with different protocols and usually do not include perspectives of multiple stakeholders within a single study (e.g. Pendleton, 2018; World Economic Forum and Boston Consulting Group, 2017). Lack of clarity and consensus among the stakeholders can lead to a failure to implement VBHC, while continuing to drive up costs with mediocre care (Fantini and Vaccaro, 2019; Porter, 2010).

Ultimately, it is important for outcome measures to demonstrate the value of occupational therapy to enable service comparisons and facilitate resource allocation (Leland et al., 2015). Evidence-based medicine now accepts that outcomes must be meaningful and valuable to the person accessing the service (Epstein and Street, 2011). However, outcomes valued by people often differ from those of health professionals, and many services do not routinely or systematically collect information on outcomes and costing to assess value accurately (Elf et al., 2017). Thus, clarification of the perception of value of occupational therapy services by different stakeholders can potentially better inform the interdisciplinary healthcare team about the unique responsibilities of occupational therapists. The challenge remains to develop a practical understanding of value in occupational therapy services that stakeholders can agree on to inform the development of appropriate measures. As such, this research aimed to explore how clients of occupational therapy services, occupational therapy managers and occupational therapists in an acute hospital in Singapore perceive value in occupational therapy services.

Methods

Study design

This study employed a qualitative design guided by social constructionist perspectives (Patton, 2015) and appreciative inquiry (AI; Cooperrider et al., 2008; Figure 1). To understand what VBHC is, social constructionism enabled multiple perspectives of value to be recognised and meaningful features understood (Patton, 2015).

Figure 1.

Four stages of appreciative inquiry conducted in two phases.

Appreciative inquiry was selected as it is a strength-based approach which capitalises on existing and past positive experiences to facilitate the generation of ideas that might contribute to our understanding of value-based occupational therapy and what to build upon in future services (Cooperrider et al., 2008). AI proposes that instead of solving problems, emphasis is placed on what is going well. The use of AI has been gaining traction in health care in a bid to depart from the conventional focus on the drawbacks of the current services to focus instead on its merits (Wright and Baker, 2005). AI was therefore deemed a suitable framework for exploring the concept of value in occupational therapy services.

Ethical approval

This study was carried out in a public tertiary hospital in Singapore, and ethical approval was obtained from National Healthcare Group Domain Specific Review Board (NHG DSRB Ref: 2018/01382) and Singapore Institute of Technology (SIT Ref: 2019127). All participants were provided with a written participant information sheet outlining the study aims and procedures and that they would be able to withdraw from the study at any point without adversely impacting their employment or therapy sessions, whichever was relevant to them. Written informed consent was gathered from all participants. Each participant was given a $SGD20 voucher at the end of each focus group or interview as a token reimbursement for their time.

Sampling and recruitment

Purposive sampling was used to recruit clients (i.e. patients and caregivers) of occupational therapy services, occupational therapy managers and occupational therapists. All clients were recruited from the outpatient occupational therapy waiting areas at the hospital (e.g. hand therapy, paediatrics, mental health and community mobility). Thus, at time of the research, participants had experience of occupational therapy services, but were not in an acute phase of healthcare need. To focus on family caregivers, paid and formal caregivers were excluded. Eleven clients participated (Table 1), with six additional clients recruited but who withdrew prior to any data collection due to scheduling and/or commuting inconveniences (n = 4) and inability to be contacted (n = 2).

Table 1.

Demographics of clients.

Participant code	Gender	Age	Occupational therapy service received	Number of sessions in preceding 12 months (x)	Frequency of sessions
Client-A	Female	65	Hand therapy	≤ 5	Monthly
Client-B	Female	22	Hand therapy, mental health	6 to 10	Monthly
Client-C	Female	22	Hand therapy, neurorehabilitation, paediatrics	≥ 10	Fortnightly
Client-D	Male	25	Mental health	6 to 10	Quarterly
Client-E	Male	75	Community mobility	≥ 10	Monthly
Client-F	Male	34	Hand therapy	6 to 10	Monthly
Client-G	Female	44	Hand therapy	≤ 5	Bi-monthly
Client-H	Male	41	Low vision	≤ 5	Monthly
Caregiver-A	Female	36	Paediatrics	≤ 5	Monthly
Caregiver-B	Female	47	Paediatrics, mental health, neurorehabilitation	≥ 10	Monthly
Caregiver-C	Male	56	Paediatrics	≤ 5	Monthly

Seven occupational therapists and seven managers were recruited following an information sharing session during a department staff meeting. The occupational therapists had a mean working experience of 4 years across specialisations of neurorehabilitation, orthopaedics, low vision, oncology, geriatrics, hand therapy and mental health. The managers had an average of 15 years of clinical and 7 years of managerial experience. Managers were recruited from occupational therapy specialisations of paediatrics, hand therapy, geriatrics and orthopaedics.

Data collection

Appreciative inquiry guided the semi-structured interviews (n = 5) and focus groups (n = 6) (see Table 2 for the interview questions). AI includes four stages of Discover, Dream, Design and Destiny. The first stage, Discovery, focuses on what is working well. Questions in this phase were designed to illicit success stories that help bring positive attributes to the fore. The second stage, Dream, encourages exploration of what might be. Questions encouraged participants to think of what a ‘better’ situation would look like, beyond what has been experienced in the past. In the third stage, Design, decisions and choices are made about what should be. Questions in this stage help to begin to form an action plan for change. In the final, Destiny, the plan is to generate commitment to change. Questions encourage participants to consider what they can do to contribute to desired change.

Table 2.

Interview guide for focus group and interviews.

Phase 1 guide for interview/focus groups – discovery and dream
Clients	Occupational therapists and managers
Discover	Discover
Quality	Quality
1. How would you describe an experience that you had that you felt was quality occupational therapy? What do you think made it a positive experience for you?	1. How would you describe your experience as an occupational therapist/manager in ensuring quality occupational therapy services? What do you think made it positive for you?
2. What was important for you to achieve out of your occupational therapy sessions?	2. What outcomes/quality indicators helped inform you that your practice was successful in improving quality of occupational therapy services?
Cost	Cost
3. What were some of the direct and indirect costs that you considered when you attended occupational therapy sessions?	3. What are the steps that you have taken to address the direct and indirect cost of services you provide?
4. How and when do you decide if it is still worth it to attend therapy sessions?	4. What were the most important cost considerations you were trying to manage?
Dream	Dream
1. Based on your sharing so far, what do you think you would notice and experience in an ideal situation where the value of occupational therapy services is the highest possible level?	1. Based on your sharing so far, what do you think you would observe in an ideal situation where the value of occupational therapy services is maximised?
2. What would you notice or experience in your therapy experience that was different from the usual sessions that you have had so far? What will you see more of or less of?	2. What are some outcomes which indicate that things are moving in the right direction?
3. How do you think the direct and indirect costs of therapy in this ideal situation differ compared to your usual sessions?	3. How do you think the direct and indirect costs of therapy in this ideal situation differ compared to usual sessions?
4. What will you be able to achieve out of your therapy sessions you receive in this ideal situation?	4. What would clients see that is different in this ideal situation?

Phase 2 guide for interview/focus groups – design and destiny
Clients	Occupational therapists and managers
1. As you think about the ideal future, how do you think you can play a role or who else do you think will play a role in enabling this change? How will you/they go about doing it?	1. With a better understanding of what value in occupational therapy looks like currently and ideally, what do you think needs to be done in order to achieve the changes?
2. How will the results/outcomes of this ideal situation be measured?	2. How might you play a role in bringing about this change?
3. Based on the ideas you have shared, what do you think are steps that can be taken in the near future to achieve them?	3. Based on the ideas you have shared, what do you think are steps that can be taken in the near future to achieve them?

The focus groups addressed the Discover and Dream stages in phase one, and Design and Destiny in later phase two focus groups. Consistent with social constructionist perspectives (Patton, 2015), focus groups were chosen to enable participants to build on ideas and clarify perspectives with others (Nyumba et al., 2018). Therefore, separate focus groups were conducted for occupational therapy managers, occupational therapists and clients to allow for sharing of similar experiences. However, in the second phase focus groups, to encourage discussion of different perspectives, combined results from all participant groups (from phase one) were shared as the basis for the Design and Destiny conversation.

Single individual interviews, covering both phases of AI were separately held for participants (n = 5) who were unable to attend any of the scheduled focus group sessions: three occupational therapy managers, one occupational therapist and one client. These interviews occurred after the focus group discussions. Thus, data from the focus groups were able to be shared during the interview, after the views of the participant were explored, so they could also comment on the different perspectives. Each focus group or interview lasted 60–90 min.

Data analysis

All sessions were audio and video recorded, enabling transcription and observation of verbal and non-verbal interactions between the participants (Patton, 2015). Thematic analysis was carried out using NVivo 12 software (QSR International, 2018). Four researchers independently coded the data using inductive and deductive methods to establish themes which helped understand the perceived value of occupational therapy services (Fereday and Muir-Cochrane, 2006). Twenty percent of each transcript was then independently coded by another researcher and compared through discussions until agreement was reached (Syed and Nelson, 2015).

To increase rigour, codes and themes were continuously refined as each transcript was analysed and cross checked with the video recordings (to observe non-verbal communication) (Patton, 2015). Retrospective reflexivity was also employed as codes and themes were refined with the entire research team, informed by field notes (Patton, 2015). Additionally, after phase one focus groups, infographic summaries were provided for member checking in phase two focus groups (and interviews). After phase two, further member checking was sought through a sharing session of the findings with occupational therapists and occupational therapy managers.

Findings

Three themes encompassed the participants’ perceived value of occupational therapy services: (1) outcomes which are meaningful to daily life, (2) a constructive client–therapist relationship and (3) affordable, coordinated and understandable therapy. As this study was conducted in a large acute hospital, the terms ‘patient’ and ‘caregiver’ were used by participants to describe clients using the occupational therapy services.

Outcomes which are meaningful to daily life

Outcomes, or the meaningful difference therapy sessions made to the person’s life, were considered a marker of a quality occupational therapy service and indicator of value. Meaningful outcomes were defined through the achievement of the goals which were set during therapy. These goals needed to be clear for the client and relate to something which was important for their, or their family members’ lives:

“At the end of each session, [the occupational therapist] will go through [the plan]… And she would emphasise on what other things I should do before I meet her again for the next session, and that works. Yeah. It brings more quality because we have that goal to achieve” (Client-B)

“To provide a better service and better-quality service to the patient, [the service needs to] make sure that the patient knows what the goals is… If you achieve the goal that is set for you, then you will feel the sense of achievement. Then you will work harder towards the next goal. As compared to when you have no goal, no target, nothing, you just go and see therapist again and again” (Client-F)

The expertise of both the client’s and therapist’s opinions were appreciated in the goal-setting process. While the clients wanted to be involved in establishing their own goals, they also saw that the therapist’s contribution could add value as they could break down the goal into smaller tasks and offer encouragement as to what might be possible:

“Client: I would prefer [the occupational therapist] set goals that are important to me, so I have the motivation to do the therapy. But I feel that sometimes when they set goals that they think is beneficial for me, it’s like something that I can work towards also, ... that means they think that I can do it and that’s why they set the goal for me.

Facilitator: So, in some sense you do value the therapist’s input in setting your goals?

Client: Yeah” (Client-C)

“Goal setting is not a therapist-set goal [but] a discussion between the patient and therapist...I think it’s a way of patient-centredness for patients to tell us what they think is important, and what they want to achieve” (Manager-X)

Goal setting tended to happen at the start of the therapy process and was monitored in subsequent sessions. While some objective measures of goal achievement were discussed, the participants suggested that subjective measures such as the client’s opinion were more commonly used for short-term progress checks. It was suggested that a longer-term measure of impact on quality of life was more difficult to measure and that a structured system for that was not yet in place:

“It’s quite difficult to measure, or maybe we’re not sure or not aware of what are some of the long-term measures that what we do impacts on the patient’s life or the family’s life. But we do get quite a lot of subjective feedback from the parents telling us… but we don’t really have a score to measure the impact on the family’s life and the patient’s life” (Manager-T)

Therapists discussed how setting goals and achieving meaningful outcomes was a marker of a quality service and indicator of value. There was some debate, however, as to what was considered meaningful and to whom. Therapists who encouraged clients to set goals related to their participation in life situations were challenged when some clients or the governing body of the hospital wanted to see measurable improvements in a client’s impairment or disability.

“How [therapists] measure the outcome is [that] we look at [the patient’s] overall eventual participation in their activities, whether [they have] managed to achieve their goal of returning to [a] particular activity or occupation; which is still quite different from what some of our [patients] perceive as the goal of therapy because… to them, the disability is there, then they just focus on reducing or improving the [impairment]” (Occupational Therapist-R)

“What we see as outcomes is very different … We might look into quality of life and how they cope with their life, but they [healthcare systems] are looking at significant changes, numbers or things that are very different from our perspective” (Manager-X)

A constructive client–therapist relationship

Participants frequently spoke about how the perceived quality of the service was influenced by the client–therapist relationship. Clients described positive relationships using phrases such as ‘putting herself in my shoes’, ‘comfortable’, ‘really listen’, ‘understand what I was going through’, ‘motivate’, ‘encouraging’ and ‘caring’. Being listened to and understood were suggested as markers of quality and strength of occupational therapists:

“I am still facing difficulties in my daily life, so like I feel that occupational therapists are still the ones that listen, yeah… in comparison to the other like healthcare professionals like doctors” (Client-C)

“We have [a good relationship] I think. [The occupational therapist] understands me yah there’s really like no communication breakdown. She really understands what I was going through and then I feel that I can really understand her too” (Caregiver-A)

Clients placed value on the relationship they had with their therapist and appreciated consistency when seeing the same therapist over time. Some described how changing therapists or seeing more than one therapist for their problems could be challenging as they needed to re-invest their energy in creating a new working relationship:

“It’s fragmentation…I have to see different occupational therapists because of different problems. It will be better if there is one therapist with general skills, then refer me to a specialist… If I have to switch again…I have to build rapport again…The therapist-patient relationship is very important” (Client-C)

Communication skills were highlighted as vital to developing constructive relationships by therapists. They did, however, express that the advanced communication skills required to develop rapport with some clients could be further enhanced. Quality professional development opportunities focusing on communication, along with experience were suggested as ways to advance these skills:

“When it comes to patients with a bit more complex care or if they have more emotional needs, sometimes we do not really have the skills… sometimes we feel like we are lacking in the communication skills to really communicate with them to go into like a deeper level to understand them. So that might also affect the rapport with some of these groups of patients as well” (Occupational Therapist-R)

Along with communication skills, therapists and managers reflected that constructive relationships required time with the client to develop. Time was often a challenge for therapists in the acute setting and proposed as a potentially limiting factor in developing these relationships:

“I resonate with the idea about having the time to see patients, to build the relationship, [and] the rapport… I think having that time to build rapport and for [patients] to understand what you do, for them to understand what we can offer to them, would make a difference” (Occupational Therapist-M)

“The dream that we have is [to] not [be] restricted by time. I think outpatients is a very complex setting, and that is the time we get in touch with the patient, we understand the patient, but we are also [bound by] productivity” (Manager-Z)

Affordable, coordinated and understandable therapy

Costs were discussed by all participants when they considered the value of the occupational therapy service. Some clients found the costs of occupational therapy reasonable when compared to other services previously received. Therapists also considered costs and found ways to keep them to a minimum by scheduling sessions when they could provide therapy to the person and educate the caregiver simultaneously. Self-management strategies were another common approach advocated to reduce the cost of therapy:

“Cheap in terms of 1-to-1 coach, anywhere in Singapore, 1-to-1 coaching is really expensive. A personal trainer like that. This is like my personal trainer. So, I find [the cost of therapy] like reasonable. Very reasonable” (Client-H)

“I think in terms of direct costs… we will wait until the caregiver comes in so that it will be one session and that we don’t need to charge the patient so many times” (Occupational Therapist-P)

“We really hope that patients and family members … take up the role of self-management and reduce long term costs” (Manager-L)

The cost of therapy went beyond money. Participants spoke of the indirect costs associated with therapy, including the time for the appointment itself, the travel time to the hospital and inconvenience associated with scheduling appointments around work or other commitments. Clients also discussed the time required for carrying out the therapy at home, which sometimes prevented them from doing other meaningful activities.

“I feel I’m losing out to my friends in terms of how they have more time to study...I have less time because I have to spend time exercising at home, and I have to travel down to the hospital” (Client-C)

“We don’t really have a lot of choice [of therapy time slots], so if it’s like smack in the middle of the day, I also have to take leave because [the occupational therapist] only has this slot. It’s either I take it or don’t, you know?” (Caregiver-A)

In view of managing these costs, participants described how the coordination of therapy services was another marker of a quality service and represented value. Scheduling appointments so that the client could see other health professionals on the same day and good communication between health professionals was critical:

“They [the speech therapist and occupational therapist] have to share information about my daughter…if both therapists know what’s going on, they can help my child” (Caregiver-C)

“Working closely with other healthcare professionals is really important… [In the] acute setting, [therapists] need to know what are the investigation results, … communicate with the team [to know] what are the discharge plans, and [work] together with the physiotherapist, speech therapist, psychologist” (Manager-L)

All participants spoke about the lack of awareness and clarity about what occupational therapists can offer. Clients discussed how they did not always see the difference between a physiotherapist and occupational therapist, particularly when both professions were asking the client to complete exercises. Confusion arose in a few cases when clients were seeing hand therapists, who were also occupational therapists. Participants suggested that due to the complexity of understanding the profession, occupational therapists should better promote what they do, indicating that despite the confusion, they still valued the service:

"What’s the difference? ...From the laymen [perspective], people are asking me, ‘Are you going for [physiotherapy]?’. I [replied]: '[yes], some exercise'. To me, it’s the same but now you keep using the word occupational therapist… [whereas] in the centre, they use ‘hand therapist’ so to me I thought it’s under the umbrella of physiotherapy... For your sake as...professionals, you should tell people [what occupational therapy does]. I think you all should champion what you all do" (Client-G)

“I think in the ideal world, OT [occupational therapists] needs to be better publicised or positioned to know what we can give and offer…to outside people – the doctors, families, [and] caregivers” (Manager-T)

"[The patients] value the impact of improving their everyday activities. So, it does show that actually [patients] value the role of OTs, [although] maybe they don’t know the term is OT, but they...value the overall goal that everyone is working towards improving their overall health and wellbeing" (Therapist-O)

Discussion and implications

The value of occupational therapy services in this study was considered primarily reflecting personal and societal value, according to the European Commission’s (2019) four pillars of value. Personal value was expressed in the participants’ focus on setting meaningful goals and the achievement of outcomes that made a difference to the client’s life, while managing personal costs. The therapeutic process during service delivery emphasised the personal value placed on the relationship between the client and therapist, as well as the connectedness associated with societal value (European Commission, 2019).

Personal value expressed through goal setting

VBHC signifies a shift towards a more client-centred approach, with client-centred goals being key in operationalising value (European Commission, 2019). One of the primary ways of increasing personal value highlighted in this study was the importance of collaborative goal setting to align goals of different stakeholders. The occupational therapy profession has long upheld the importance of client-centred practice at the core of the profession (American Occupational Therapy Association; AOTA, 2020). However, goal setting is a complex process requiring an understanding of the values of the client, considering what therapy has to offer, within the constraints of the system. Challenges are seen when stakeholders have differing or conflicting goals (Brewer et al., 2014), which was also reflected in this study.

For example, clients proposed goals which related to both occupational performance or participation improvements and a reduction of impairment or disability. For occupational therapists working from an occupation-centred perspective (AOTA, 2020), goals which focused primarily on reduction of impairment or disability presented a challenge to their own perceived value of occupational therapy as making a difference to people’s lives through engagement in occupation and participation in life roles. This was further complicated when healthcare systems also valued quantifiable targets which often reflected a measurable reduction in impairment or disability. It is possible that these different views contributed to the confusion expressed by clients as to the role of occupational therapy. Therefore, collaborative goal setting could be problematic for therapists to facilitate. Given the potentially differing perspectives of stakeholders and lack of clarity in the occupational therapy role, more may need to be done to enhance the goal-setting skills of therapists (Brewer et al., 2014).

Personal value expressed through outcomes

In recent years, there has been a call from various organisations and regulatory authorities to consider if outcome measures are meaningful to the individual (European Commission, 2019). Like previous studies, managers and therapists in this study highlighted the current gap in existing outcome measures used and challenges in selecting outcome measures that accurately reflected goals within their practice (Bowman, 2006). Patient-reported outcome measures and patient-reported experience measures were used by therapists in this study and have been suggested as important ways to capture what is meaningful to clients (European Commission, 2019).

Findings from the study, however, also suggest that we should strive to use outcome measures that are flexible enough to account for individualised goals but produce results that can be aggregated and generalised for service-level reporting, in an attempt to meet the needs of different stakeholders. This may be supported by using the International Classification of Functioning, Disability and Health Framework (ICF; World Health Organization, 2003) as a way of categorising goals which can reflect both body functions and structures’ improvements and changes to activity and participation (Powrie and Dancza, 2018). For example, if a person wanted to cook a meal but was limited by pain, goals could be set and categorised around the reduction of pain (body functions ICF code b280) and preparation of meals (activity and participation ICF code d640). Outcomes would reflect goal achievement (or not) which could be collated for service-level analysis based on the ICF codes.

Personal value expressed through managing personal cost

The focus on managing personal financial cost may have different applicability in healthcare contexts globally. Societies that rely on funding structures such as insurance providers or public funding may emphasise fair distribution of resources, efficiency and low waste (European Commission, 2019). In Singapore, healthcare financing requires client co-payment, reflecting the sociocultural belief that universal health care is one of shared responsibility (Lee, 2020). It was therefore no surprise that occupational therapists and managers were cognisant to manage the financial cost to the client. Managing the opportunity cost of investing time in receiving health care, and re-investing in multiple relationships when interacting with the healthcare team were also described as significant for clients.

The importance of self-management was identified in this study as both a valued outcome and a way to manage financial and opportunity costs. The idea of ‘coping’ or ‘managing’ appeared to be referred to as a satisfactory outcome. At the same time, it was suggested that encouraging self-management may also be an appropriate way to manage financial and opportunity costs of attending therapy sessions and reduce long-term reliance on the healthcare system. Occupational therapists are well-skilled to assess for and provide intervention for self-management (Leland et al., 2017). This may also reflect the need to measure outcomes not just at discharge but post-discharge when clients return to daily life in their homes and community.

Personal and societal value expressed through therapeutic relationships

Beyond client experience, investing in a therapeutic relationship with clients is key in the occupational therapy process (AOTA, 2020). It is, however, reassuring that the therapeutic relationship was similarly valued by clients in this study and perceived to be critical to their care. Therapeutic communication skills were particularly valued and desired. Similar to previous findings, occupational therapists expressed challenges in using therapeutic communication in complex situations and highlighted the need for continuing professional development (Solman and Clouston, 2016).

Interprofessional communication was also valued by clients. Although seamless coordination of care is often what hospitals aim to achieve, it is interesting to note that clients expressed perceived increased value when the interprofessional communication within the team was made explicit to them. Moreover, clients appeared to be understanding about costs when therapists communicated what services were for, how the services related to each other and reasons for possible constraints.

Limitations and further research

This study was limited by its small sample size and restricted demographics of the participants. Clients were recruited from outpatient settings and therapists who participated were mainly from the inpatient setting. From a macro-perspective, further research should be done to identify value from a range of allied health services. Within occupational therapy, further research should be done to identify suitable outcome measures to accurately reflect the unique value of occupational therapy.

Conclusion

This study is the first of its kind to explore the perceptions of value of occupational therapy services from different stakeholders’ perspectives in Singapore. VBHC literature often describes value in terms of medical services, with an implicit reference to the value of allied health services. Identifying value in relation to occupational therapy services means the profession can have a voice in how healthcare systems tailor their algorithms of value and allocate resources in healthcare transformation for the ultimate benefit of the people who access the services. In this study, value was attributed to personalised goal setting, achieving meaningful outcomes, managing personal costs and the extent of the therapeutic relationship. While not new concepts to occupational therapy, associating them with VBHC could assist in prioritising these areas in future service development. A starting focus could be placed in four key areas: (1) ensuring occupational therapists are skilled in collaborative goal setting; (2) determining suitable outcome measures which are meaningful for individualised goals, but can produce aggregated and generalised data for service-level reporting; (3) encouraging self-management strategies; and (4) emphasising the importance of the therapeutic relationship and supporting occupational therapists to continuously develop therapeutic communication skills. Further research is needed to explore how using VBHC concepts in service design can be used to enhance meaningful service provision.

Key findings

• Value in occupational therapy includes personalised goal setting, achieving meaningful outcomes, managing personal costs and positive therapeutic relationships

• Challenges exist in harmonising meaningful personal goals with organisational level outcomes

What the study has added

Understanding and emphasising the value of occupational therapy and aligning critical features with the concepts of value-based health care will ensure the profession remains contemporary and meaningful in a changing healthcare climate.

Footnotes

Acknowledgements

The research team wishes to acknowledge the contribution of staff, patients and caregivers who participated in this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Research ethics

Ethical approval was obtained from National Health Group Domain Specific Review Board (NHG DSRB #2018/01382) in 2019 and Singapore Institute of Technology’s Institutional Review Board (Project #2019127) in 2019.

Contributorship

SRW and KD conceived the study and developed the protocol. SRW and BXN were involved in literature review and gaining ethics approval. FYK, XTK and RJJC were involved in literature review, patient recruitment and data analysis. SRW, BXN and KD wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iD

Su Ren Wong

Karina Dancza

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