Australian Occupational Therapy Journal (2014) 61, 187–193

doi: 10.1111/1440-1630.12105

Research Article

Implementation of an advanced occupational therapy assistant-led groups programme in aged care rehabilitation Ruth J. Cox,1 Vickie J. Mills,1 Jennifer Fleming1,2 and Emily Nalder1,2 1 Occupational Therapy Department, Princess Alexandra Hospital, Woolloongabba, and 2School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia

Background/aim: The use of support workers such as occupational therapy assistants is emerging as a strategy to enhance the health workforce, but there has been little evaluation of the feasibility of expanding support worker roles and responsibilities. This study aimed to implement an advanced occupational therapy assistant-led groups programme in a subacute aged care rehabilitation setting and to evaluate the impact on the clinical outcomes of group participants. Method: A prospective quasi-experimental cohort study was conducted comparing outcomes of 30 patients receiving a groups programme led by an advanced occupational therapy assistant with a historical control group of 40 patients receiving the groups programme led by an occupational therapist. The groups programme comprised up to six groups per week and included meal preparation groups and domestic training groups. Outcomes were Functional Independence Measure scores, Australian Therapy Outcome Measures, discharge destination, length of stay and patient satisfaction. Results: Discharge outcomes of patients participating in the assistant-led groups programme were not significantly different to patients who participated in the therapist-led groups programme. Patient satisfaction levels were not significantly different between groups. Conclusion: The introduction of an advanced occupational therapy assistant to replace an occupational therapist in facilitating a groups programme in aged care

Ruth J. Cox MBA, BOccThy (Hons); Acting Director of Occupational Therapy (Job Share). Vickie J. Mills BOccThy; Advanced Occupational Therapist. Jennifer Fleming PhD, BOccThy (Hons); Conjoint Associate Professor in Occupational Therapy. Emily Nalder PhD, BOccThy (Hons); Research Assistant. Correspondence: Ruth J. Cox, Occupational Therapy Department, Princess Alexandra Hospital, Woolloongabba, Brisbane, Qld 4102, Australia. Email: [email protected]. gov.au Accepted for publication 8 November 2013. © 2013 Occupational Therapy Australia

rehabilitation did not result in a decline in patient outcomes. However, the results should be interpreted tentatively given the study limitations and the advanced skills of the assistant involved. Further more rigorous longer term research with a larger sample is required. KEY WORDS rehabilitation services, workforce.

Introduction Internationally there are current and escalating issues in meeting patient demand for aged care rehabilitation services due to the increasing ageing population; increases in the prevalence of chronic disease; skills shortages, including in occupational therapy; funding restrictions; and rising consumer expectations (Lizarondo, Kumar, Hyde & Skidmore, 2010; Mackey, 2004; Nancarrow & Mackey, 2005; Powell, Griffith & Kanny, 2005; Wood, Schuurs & Amsters, 2011). Increased utilisation of support worker roles, including occupational therapy assistants, has been identified as one strategy to manage rising demand and limited workforce supply (Buchan & Dal Poz, 2002; Centre for Allied Health Evidence, 2008; Lizarondo et al.; Nancarrow & Mackey; Wood et al.). Although these organisational imperatives exist to manage resources more efficiently, including the use of support workers, it remains important that the quality of service provision to patients is not compromised by such initiatives. Therefore, their introduction should be accompanied by an evaluation of any impact on patients of aged care rehabilitation. This study describes the evaluation of an initiative directed at reducing workforce costs by utilising an advanced occupational therapy assistant to run a group therapy programme which had traditionally been run by an occupational therapist. Occupational therapy assistants have played an important role in contributing to occupational therapy services both in Australia (Ford & McIntyre, 2004) and internationally (Mackey, 2004; Nancarrow & Mackey, 2005; Powell et al., 2005) for many years. However, there are contradictory opinions within the occupational therapy

188 profession and elsewhere regarding the effectiveness of increased use of support workers due to concerns regarding efficiency and therefore cost effectiveness (Buchan & Dal Poz, 2002); unclear accountability and supervisory requirements (Lizarondo et al., 2010; Nancarrow & Mackey); lack of competency standards (Ford & McIntyre); limited formal qualifications (Lizarondo et al.; Wood et al., 2011); and role threat to the occupational therapy profession (Lizarondo et al.; Powell et al.). Notwithstanding these concerns, support workers may represent a relatively untapped resource for meeting some of the demands associated with stretched staffing in rehabilitation. Research examining outcomes following the use of occupational therapy assistants in expanded roles is very limited (Lizarondo et al., 2010). Nancarrow and Mackey (2005) used a qualitative approach to gain an understanding of roles of ‘assistant practitioner’ occupational therapy assistants in the United Kingdom. The authors reported positive findings about their ability to work autonomously and take on similar responsibilities to occupational therapists except for in a few key areas such as home visiting and management duties. These encouraging findings, combined with the need to provide sufficient therapy to patients in our aged care rehabilitation setting with relatively low staff to patient ratios, led to the current study examining the feasibility of expanding the role of an advanced occupational therapy assistant. Groups programmes are one area of rehabilitation practice which has the potential to be effectively managed by occupational therapy assistants. This is due to the fact that groups usually follow a structured and prescribed format, have documented aims and objectives and have eligibility criteria which often exclude complex cases. Groups programmes also have distinct costefficiency advantages as multiple patients can be seen at once, making group work a viable way to increase the intensity of practice for patients in neurological rehabilitation which is essential in improving outcomes (Kwakkel et al., 2004; Van Peppen et al., 2004). Groups also enhance opportunities for observational learning (Ertelt et al., 2007) and peer support (English, 2008) among participants. The efficiencies created through rehabilitation groups pointed to this being a feasible area to target in terms of further maximising resource use by piloting an advanced occupational therapy assistant-led groups programme in occupational therapy. The aim of the current study was to determine whether clinical outcomes differed when a groups programme in an aged care rehabilitation unit was conducted by an occupational therapist vs. an advanced occupational therapy assistant. It was hypothesised that the patient outcomes on discharge from rehabilitation would be similar between patients receiving a therapistled groups programme and patients receiving an assistant-led groups programme. The study also aimed to examine patient levels of satisfaction with both © 2013 Occupational Therapy Australia

R. J. COX ET AL.

programmes. This study reports on patient outcomes and was part of a larger study which also examined organisational impacts of introduction of the role of an advanced occupational therapy assistant.

Method Design A prospective quasi-experimental cohort study was conducted using historical controls comparing participant outcomes of an advanced occupational therapy assistant-led groups programme (intervention group) with those of the occupational therapist-led group programme (historical control group). Ethics approval was granted by Metro South Health Service District Human Research Ethics Committee.

Participants To be eligible for inclusion in this study, participants were required to be inpatients at the Geriatric and Rehabilitation Unit which is a 76 bed-unit in a large tertiary level hospital located in a metropolitan area in Brisbane, Australia. All patients referred to the groups programme during the study period were consecutively recruited. Suitability to participate in the groups programme includes the following criteria: (i) patient rehabilitation goals are able to be addressed by attending the programme; (ii) patient will benefit from increased opportunities to practice instrumental activities of daily living; (iii) patient is able to follow simple verbal commands/instructions in English; and (iv) patient is able to complete meal preparation/domestic tasks with provision of minimal assistance only. In addition, patients needed to be able to understand and respond to questions in a client satisfaction survey to be included. Informed written consent was obtained from the participants via the treating therapist or researcher.

Procedure Traditionally the group therapy programme was coordinated and led by an occupational therapist. The groups programme comprised up to six groups per week. Patients admitted to the Geriatric and Rehabilitation Unit were referred by their treating therapists to relevant groups as appropriate. Groups included but were not necessarily limited to breakfast, lunch and afternoon tea preparation groups, and domestic training groups (including cleaning, laundry, etc.). Groups were typically one to two hours in duration and followed a standard procedure. Emphasis was placed on providing opportunities for practice of activities of daily living in a supportive social situation. The number of patients in each group varied depending on referrals but ranged from 2 to 6. All groups were conducted in the occupational therapy department. Facilitating the groups programme also involved some organisational responsi-

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bilities, including receiving referrals, allocating patients to groups and providing feedback to referring occupational therapists in the team meeting. Comparison data were first collected over an initial five-month period (July to November 2010), when the groups programme was led and run by an occupational therapist. During this time, the advanced occupational therapy assistant was being trained to facilitate the groups programme. The selected assistant had already been working as a full scope assistant in the aged care team for more than 10 years and had attained the Certificate IV in Allied Health Assistance and Certificate IV in Training and Assessment. The assistant also completed an extensive training programme and competency assessment designed specifically for the role. Once the advanced occupational therapy assistant was deemed competent in these areas, the assistant began facilitation of the groups programme adhering to written guidelines regarding group procedures (available from the authors). Participant data were then collected for a further five months (January to May 2011), when the groups programme was administered by the assistant. During the course of the trial, the assistant received regular formal supervision sessions from a researcher (V. M.) and a proportion of groups were observed by an occupational therapist to maximise treatment fidelity. Throughout both phases of data collection, participants received usual care from other rehabilitation therapies, including physiotherapy and speech pathology, as well as individual therapy sessions with their occupational therapist. All data were collected either by the treating therapist or by a researcher who was also involved in treating patients at the time of the study. It was not possible to blind the researcher to the intervention phase (therapist-led or assistant-led) or the hypothesis of the study.

Data collection/Measures Participant demographic information was obtained by accessing the local ward database system. Demographic information collected included age, gender, marital status and diagnosis. Admission and discharge measures were selected to represent global functional outcomes which are the target of rehabilitation, including the Functional Independence Measure (FIM) (Wright, 2000) and the Australian Therapy Outcome Measures (AusTOMs) (Unsworth & Duncombe, 2007). The Client Satisfaction Questionnaire (CSQ-8) (Larsen, Attkisson, Hargreaves & Nguyen, 1979) was used to measure patient satisfaction levels. Additional discharge outputs collected from the ward database system included length of rehabilitation stay and discharge destination. The FIM is a functional assessment measure widely used in rehabilitation. The FIM instrument comprises 18 items assessed, of which 13 items are physical domains and 5 items are cognition items. Each item is scored from 1 to 7 based on level of independence, where 1

represents total dependence and 7 indicates complete independence. It is viewed as most useful for assessment of progress during inpatient rehabilitation. The FIM has clinically appropriate validity and inter-rater agreement (Wright, 2000). The FIM was administered by the participant’s treating therapist on admission and discharge from the inpatient rehabilitation unit. All therapists were trained and accredited to score the FIM. The AusTOMs were developed to measure therapy outcomes for Occupational Therapy, Physiotherapy and Speech Pathology. The AusTOMs for Occupational Therapy consists of 12 scales of measurement with a focus on everyday activities and participation. Scales to be used are selected on the basis of assessment findings and goals of therapy. Scales used in this study included Upper Limb Use (Scale 3), Carry Out Daily Life Tasks (Scale 4), Domestic Life – Home (Scale 8), Participation Restriction Scale and Distress/Wellbeing Scale. Each of the domains is rated by therapists on an 11-point ordinal scale, including six defined points from 0 [most severe] to 5 [normal function], and five undefined half points. These scales were administered by the participant’s treating therapist on admission and discharge from the inpatient rehabilitation unit. Initial testing of the AusTOMs for Occupational Therapy Scales indicates that they are sufficiently reliable, valid and sensitive for clinicians to use them with adult patients (Unsworth & Duncombe, 2007). All therapists were trained in the use of the AusTOMs prior to the commencement of the study. The CSQ-8 is an 8-item, easily scored and administered measurement designed to measure client satisfaction with services. It was contextualised for use in this study as per the administration guidelines (i.e. the specific programme being evaluated (Occupational Therapy Group Programme) was named). The CSQ-8 has been extensively studied, and while it is not necessarily a measure of a patient’s perceptions of gain from treatment, or outcome, it does elicit the patient’s perspective on the value of services received (Larsen et al., 1979). Participants completed this survey independently or with the assistance of the researcher at the end of their participation in the groups programme.

Data analysis Stata Data Analysis and Statistical Software version 11 (StataCorp, College Station, TX, USA) was used to analyse the data. Demographic characteristics of the participants in the two groups were compared using independent sample t-tests and Pearson chi-square tests. The Mann–Whitney U-test was used to compare length of stay and client satisfaction ratings between groups, as these variables contained ordinal data or did not meet the assumption for normal distribution. A two-way analysis of variance was used to analyse FIM and AusTOMs data, with time (admission and discharge measurements) being the within-group factor, and intervention (therapist- vs. assistant-led group programme) being the © 2013 Occupational Therapy Australia

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between-groups factor (Tabachnick & Fidell, 2007). Comparison between the groups with regard to the discharge destination was made using the Pearson chi-squared test. We considered P ≤ 0.05 to be statistically significant.

Results The study included 40 participants in the therapist-led group (20 women and 20 men) with a mean age of 63.43 years, and 30 participants in the assistant-led group (20 women and, 10 men) with a mean age of 70.2 years. Table 1 provides a summary of participant characteristics. There was a statistically significant difference between the groups for marital status (Pearson chi2(1) = 5.15; P = 0.02) with participants in the therapist-led group more likely to be married. There were no statistically significant differences between the groups for other variables, including age, gender, diagnosis, length of stay and discharge destination, although there was a non-significant trend towards the assistant-led group being older. Table 2 provides FIM and AusTOMs data for the therapist-led group and the assistant-led group in addition to results of the two-way analysis of variance tests. The TABLE 1: Characteristics of participants

Characteristic Age (years) Gender Female Male Marital status Married/ defacto Other marital status Diagnosis Neurological Orthopaedic Lower limb amputation Other Length of stay (days) Discharge destination Home Residential facility (low care) Residential facility (high care)

Therapist-led group (n = 40) M (SD) or n (%)

Assistant-led group (n = 30) M (SD) or n (%)

63.43 (12.71)

70.2 (15.46)

20 (50) 20 (50)

20 (66.7) 10 (33.3)

20 (50)

7 (23.3)

20 (50)

23 (76.7)

17 (42.5) 7 (17.5) 6 (15)

18 (60) 5 (16.7) 2 (6.6)

10 (25) 54.08 (30.37)

5 (16.7) 58.6 (39.97)

37 (92.5) 2 (5)

27 (90) 2 (6.7)

1 (2.5)

1 (3.3)

M, mean; SD, standard deviation. © 2013 Occupational Therapy Australia

interaction effect between time and intervention group was not significant for FIM total scores (F(1,136) = 0.53, P = 0.47). However, there was a significant main effect for time (F(1) = 79.56, P < 0.001). Thus, participants on average improved on FIM scores between admission and discharge regardless of whether they participated in a therapist or an assistant-led groups programme. For all AusTOMs scales, there were no significant interaction effects between time and treatment group. A significant main effect was observed for time on all scales except impairment of the upper limb, indicating participants in both groups improved between admission and discharge on the AusTOMs. For the upper limb impairment scale, a significant group effect was observed such that the therapist-led group had a higher upper limb impairment (median = 4) on discharge compared with the intervention group (median = 5). Table 3 presents summarised data on the client satisfaction for each group on the CSQ-8. No significant differences were observed between the two groups for all eight dimensions of client satisfaction (P > 0.05 for all CSQ-8 items). For both groups, at least 90% of the participants reported a satisfaction rating of ‘good’ or ‘excellent’ for the overall quality of the groups programme. Qualitative information was also collected by way of ‘other comments’ at the end of the survey where participants reported feedback that was positive, neutral or not relevant.

Discussion The results of this research indicate that the introduction of an advanced occupational therapy assistant to replace an occupational therapist in leading a groups programme in aged care rehabilitation did not result in a decline in patient outcomes. The discharge outcomes, including the FIM; AusTOMs – Upper Limb Use, Carry Out Daily Tasks, Domestic Life – Home, Participation Restriction and Distress and Wellbeing scales; discharge destination; and length of stay of patients participating in assistant-led groups programme remained equivalent when compared with patients who participated in the therapist-led groups programme. Under both the intervention and historical control conditions, the samples showed statistically significant improvements in FIM and AusTOMS scores between admission and discharge. These improvements of 25–30 points on the FIM and on average of half to one point on the AusTOMS could also be considered to represent a clinically significant improvement. However, the findings must be interpreted with caution given that the outcomes were not specifically linked to the groups intervention and participants were receiving other rehabilitation therapies at the same time. An assumption of the research was that occupational therapy groups are effective but further research is required to establish the efficacy of different types of

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TABLE 2: AusTOMs and FIM data and between-group comparisons

Outcome Measure FIM* AusTOMs – Impairment Upper limb use Carry out daily tasks* Domestic life* AusTOMs – Activity limitation Upper limb use* Carry out daily tasks* Domestic life* AusTOMs – Participation restriction* AusTOMs – Distress/wellbeing*

Therapist-led group (n = 40)

Assistant-led group (n = 30)

Time group interaction

Admission M (SD)

Discharge M (SD)

Admission M (SD)

Discharge M (SD)

df

F

P-value

83.05 (20.99)

108.45 (13.66)

81.93 (25.30)

111.87 (7.95)

1, 136

0.53

0.47

3.73 (1.24) 2.75 (0.98) 2.60 (1.01)

3.98 (1.07) 3.38 (0.98) 3.30 (0.91)

4.03 (1.38) 2.57 (0.73) 2.57 (0.77)

4.43 (0.94) 3.60 (0.67) 3.57 (0.68)

1, 136 1, 136 1, 136

0.14 1.88 1.02

0.71 0.17 0.31

3.78 2.98 2.58 2.95 3.55

4.28 3.98 3.53 3.68 4.30

4.17 2.53 2.43 2.63 3.37

4.63 3.80 3.53 3.83 4.33

1, 1, 1, 1, 1,

0.01 1.09 0.24 2.86 0.55

0.93 0.30 0.63 0.09 0.46

(1.31) (0.86) (1.08) (0.96) (1.04)

(1.06) (0.77) (0.88) (0.76) (0.72)

(1.26) (0.73) (0.86) (0.86) (0.93)

(0.72) (0.55) (0.68) (0.59) (0.66)

136 136 136 136 136

*Denotes significant improvement between admission and discharge (i.e. significant main effect for time P < 0.05). FIM, Functional Independence Measure; AusTOMs, Australian Therapy Outcome Measures; M, mean; SD, standard deviation.

group interventions separate to individual therapy. It is not clear given the design of the study to what extent either the assistant-led or therapist-led group programme actually contributed to patient outcomes, although we infer that the contribution was equivalent. Patient satisfaction data were also collected and unlike the other outcome measures, this was specifically targeted to the groups intervention. Patients rated both groups programmes highly, indicating that they found the groups helpful and of good or excellent quality, and were mostly or very satisfied with the programme. Patients also unanimously indicated that they would recommend the programme to others or would come back to the programme themselves if needed. These findings suggest that regardless of the qualification of the group facilitator, the occupational therapy groups programme offered a valued service to aged care rehabilitation patients and met their needs. Similar to the findings of Nancarrow and Mackey (2005), it is speculated that patients did not distinguish between the occupational therapist and the advanced occupational therapy assistant. Although further research into the efficacy of groups programmes is needed, these results add to the literature as they suggest that a more cost-efficient skill mix can maintain patient outcomes across a variety of measures. A strength of this study is that a range of measures was used that included personal activities of daily living, length of stay and discharge destination which are key outcome measures in rehabilitation. In addition, more holistic outcomes such as participation restriction and wellbeing were also examined. The AusTOMs was specifically chosen as it incorporates the International

Classification of Functioning, Disability and Health (ICF) domains, including impairment, activity limitation and participation restriction (Unsworth & Duncombe, 2007). Thus, this outcome measure incorporates the ICF focus on the impact rather than just the cause of disability and also takes into account the role of contextual factors, including the environment (World Health Organisation, 2012). However, a limitation of the study design is that the outcome measures did not specifically target the goals of the group interventions and therefore the significant gains on the measures could not be attributed directly to this intervention. Inclusion of specific goal-based outcomes linked to the group interventions is recommended in future research of this type. It is encouraging that patient outcomes were maintained when utilising an advanced occupational therapy assistant but it should be noted that the advanced occupational therapy assistant had over 10-years experience as a base level occupational therapy assistant and had formal qualifications in Allied Health Assistance. It may be that experienced occupational therapy assistants use similar clinical reasoning strategies to occupational therapists (Lyons & Crepeau, 2001) resulting in high-quality patient care. The potential importance of formal qualifications along with local training programmes and supervision must be emphasised (Mackey, 2004; Nancarrow & Mackey, 2005). Therefore, it is questionable whether the results can be generalised to less experienced occupational therapy assistants and other settings where the level of support and expertise is not as high as in a large tertiary teaching hospital. It should also be noted that only a proportion (approximately 20%) of © 2013 Occupational Therapy Australia

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TABLE 3: Client satisfaction rating frequencies for each group using the CSQ-8

CSQ-8 item

Therapist-led group (n = 40)

Assistant-led group (n = 30)

Q1 How would you rate the quality of the Occupational Therapy Group Programme? Fair 2.5 0 Good/Excellent 97.5 100 Q2 Did you get to work on the things you wanted? No 5 0 Yes 95 100 Q3 To what extent has our programme helped you to meet your rehabilitation goals? None/few needs met 7.5 0 Most/all needs met 92.5 100 Q4 If a friend were in need of similar help, would you recommend our programme to them? Yes 100% 100% Q5 How satisfied are you with the amount of therapy you have received? Dissatisfied 5 0 Satisfied 95 100 Q6 Has attending the groups programme helped you to deal more effectively with your problems? No 10 0 Yes 90 100 Q7 In an overall, general sense, how satisfied are you with the service you have received? Satisfied 100 100 Q8 If you were to seek help again, would you come back to our program? Yes 100 100 CSQ-8, Client Satisfaction Questionnaire. Values are expressed in percentage (%).

patients admitted to the aged care rehabilitation were referred to the groups programme, and the eligibility criteria meant that patients who have lower levels of functioning with rehabilitation goals that require one-toone intervention are not referred. Consequently, the findings only suggest limited scope for occupational therapist responsibilities to be successfully carried out by an advanced occupational therapy assistant. Other organisational issues such as staff satisfaction, acceptance of the role by staff, supervision and training resources required and knock on impacts for other team members and occupational therapists should also be considered (Buchan & Dal Poz, 2002; Mackey, 2004; Wood et al., 2011) but are not addressed in this component of the study. Knight, Larner and Waters (2004) argued that patients and teams may benefit from a more generic patient-focussed support worker role which is multidis© 2013 Occupational Therapy Australia

ciplinary rather than one which is discipline and task specific. This might be more appropriate in smaller facilities, but the challenges of shared supervision, learning and development would also need to be addressed. Powell et al. (2005) speculated that the role of occupational therapy assistants in acute care may be limited by high patient acuity and short lengths of stay which reduce opportunity for occupational therapists to develop a treatment plan for occupational therapy assistants to implement. This suggests that there may be a more positive impact from the contribution of occupational therapy assistants in subacute care as found in the current study.

Limitations and future research This study constituted a trial to examine feasibility and global impact on patient outcomes in one rehabilitation setting and clearly more robust, longer term research with larger sample sizes is required. The 12-month project timeframe limited the amount of time the assistant could operate at advanced scope prior to the evaluation being completed. Similarly, these timeframes limited sample size with a smaller intervention group (n = 30) compared to the historical control group (n = 40). Only one advanced occupational therapy assistant led the groups programme so it remains unclear whether these results can be generalised to other assistants with less skill and experience. Further research is required to examine outcomes when occupational therapy assistants with different skill levels and training are involved. Use of a historical control group for comparison is another limitation, as is the fact that participants were receiving other therapies at the time of the study which could not be controlled. As previously discussed, the study outcome measures could not separate the effects of the groups from the effects of other interventions. Finally, this project was based in an aged care rehabilitation service of a large metropolitan teaching hospital in Brisbane, Australia. As Buchan and Dal Poz (2002) pointed out, results of studies which examine the impacts of skill mix are not necessarily generalisable to other health systems or countries. Local context is an essential factor when considering support worker roles (Lizarondo et al., 2010). Even in the Australian context, it is unknown whether these findings can be generalised to rural, remote and smaller, non-teaching hospital settings. Research has indicted that therapy assistant demographics, employment characteristics, supervision arrangements and roles in rural and remote areas are greatly different to ‘traditional’ roles of assistants in larger centres (Lin, Goodale, Villanueva & Sptiz, 2007).

Implications for practice This study provides preliminary evidence that occupational therapy assistants can play a significant role in the provision of occupational therapy services to patients in aged care rehabilitation. In particular,

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advanced occupational therapy assistants with a large number of years experience in the role, an appropriate qualification, a tailored training and competency programme and support and supervision from an occupational therapist may be able to take on advanced scope of practice in a subacute setting.

Conclusion The results of this research indicated that the introduction of an advanced occupational therapy assistant to replace an occupational therapist in leading a groups programme in aged care rehabilitation did not result in a decline in patient outcomes. This result is encouraging as there is an international trend towards the increased utilisation of occupational therapy assistants. Further research is recommended to rigorously explore the patient and organisational outcomes of utilising occupational therapy assistants and advanced occupational therapy assistants both for individual and group therapy, across diagnostic groups and across the continuum of care. Factors such as the specific role, qualifications, level of experience, supervision and scope of the assistant role need to be examined in this future research.

Acknowledgements This project was in part funded by Health Workforce Australia under the Workforce Innovation: Caring for Older People Program grants. The material in this study does not necessarily represent the view of Health Workforce Australia. This project was also partially funded through the Department of Health Allied Health Professions’ Office of Queensland, Models of Care Project Grants. Thanks also to Julie Connell, Angela Wood, Leah Clements and Anna Wiemers for their support of the project.

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193 ment process and applications. Australian Occupational Therapy Journal, 51, 49–52. Knight, K., Larner, S. & Waters, K.. (2004). Evaluation of the role of the rehabilitation assistant. International Journal of Therapy and Rehabilitation, 11, 311–317. Kwakkel, G., van Peppen, R., Wagenaar, R. C., Wood-Dauphinee, S., Richards, C., Ashburn, A. et al. (2004). Effects of augmented exercise therapy time after stroke: A meta-analysis. Stroke, 35, 2529–2539. Larsen, D. L., Attkisson, C. C., Hargreaves, W. A. & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197–207. Lin, I., Goodale, B., Villanueva, K. & Sptiz, S. (2007). Supporting an emerging workforce: Characteristics of rural and remote therapy assistants in Western Australia. Australian Journal of Rural Health, 15, 334–339. Lizarondo, L., Kumar, S., Hyde, L. & Skidmore, D. (2010). Allied health assistants and what they do: A systematic review of the literature. Journal of Multidisciplinary Healthcare, 3, 143–153. Lyons, K. D. & Crepeau, E. B. (2001). Case report- the clinical reasoning of an occupational therapy assistant. American Journal of Occupational Therapy, 55, 577–581. Mackey, H. (2004). An extended role for support workers: The views of occupational therapists. International Journal of Therapy and Rehabilitation, 11, 259–266. Nancarrow, S. & Mackey, H. (2005). The introduction and evaluation of an occupational therapy assistant practitioner. Australian Occupational Therapy Journal, 52, 293– 301. Powell, J. M., Griffith, S. L. & Kanny, E. M. (2005). Occupational therapy workforce needs: A model for demand-based studies. American Journal of Occupational Therapy, 59, 467–474. Tabachnick, B. & Fidell, L. (2007). Using multivariate statistics (5th ed.). Boston, MA: Pearson Allyn and Bacon. Unsworth, C. & Duncombe, D. (2007). AusTOMs for occupational therapy (2nd ed.). Melbourne, Vic.: La Trobe University. Van Peppen, R. P. S., Kwakkel, G., Wood-Dauphinee, S., Hendriks, H. J. M., Van der Wees, P. J. & Dekker, J.. (2004). The impact of physical therapy on functional outcomes after stroke: What’s the evidence? Clinical Rehabilitation, 18, 833–862. Wood, A. J., Schuurs, S. B. & Amsters, D. J. (2011). Evaluating new roles for the support workforce in community rehabilitation settings in Queensland. Australian Health Review, 35, 86–91. World Health Organisation (2012). International classification of functioning, disability and health. Retrieved July 9, 2012, from http://www.who.int/classifications/icf/en/ Wright, J. (2000). The FIM (TM). The centre for outcome measurement in brain injury. Retrieved July 9, 2012, from http://www.tbims.org/combi/FIM

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Implementation of an advanced occupational therapy assistant-led groups programme in aged care rehabilitation.

The use of support workers such as occupational therapy assistants is emerging as a strategy to enhance the health workforce, but there has been littl...
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