Canadian Journal of Occupational Therapy 2014, Vol. 81(1) 51-61 DOI: 10.1177/0008417414520683

Article

The emerging role of occupational therapy in primary care

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Le nouveau roˆle de l’ergothe´rapie dans les soins primaires

Catherine A. Donnelly, Christie L. Brenchley, Candace N. Crawford, and Lori J. Letts

Key words: Family Health Teams; Integration; Interprofessional primary care; Primary health care. Mots cle´s : e´quipes de sante´ familiale; inte´gration; soins de sante´ primaires; soins primaires interprofessionnels.

Abstract Background. Few studies have examined the role of occupational therapy working in a primary care setting. Purpose. The objective of the study was to describe the emerging role of occupational therapy in Family Health Teams, a model of interprofessional primary care. Method. A multiple case study design was used to provide in-depth description of the occupational therapy role. Data collection included interviews, document analyses, and questionnaires. Each case was first analyzed individually, followed by cross-case analyses to determine common themes. Findings. The role of occupational therapy in Family Health Teams epitomizes that of a generalist, whose overarching focus is on function. Occupational therapists are working across the life span with a wide range of client populations. Older adults and individuals with complex chronic conditions are two prominent areas of occupational therapy focus. Implications. Understanding the impact of health conditions on daily function and enabling participation in activities are unique and important contributions of occupational therapy. Abre´ge´ Description. Peu d’e´tudes se sont penche´es sur le roˆle de l’ergothe´rapeute travaillant dans un milieu de soins primaires. But. L’objectif de l’e´tude e´tait de de´crire le nouveau roˆle de l’ergothe´rapie au sein des e´quipes de sante´ familiale, un mode`le de soins primaires interprofessionnels. Me´thodologie. Un devis d’e´tude de cas multiple a e´te´ utilise´ pour donner une description approfondie du roˆle de l’ergothe´rapie. La cueillette de donne´es comprenait des entrevues, des analyses de documents et des questionnaires. Chaque cas a d’abord e´te´ analyse´ de manie`re individuelle, puis a` partir d’analyses globales de cas, en vue de de´terminer des the`mes communs. Re´sultats. Le roˆle de l’ergothe´rapie dans les e´quipes de sante´ familiale est la parfaite illustration de celui d’un ge´ne´raliste qui met l’accent sur les capacite´s fonctionnelles. Les ergothe´rapeutes travaillent avec un large e´ventail de cliente`les, a` toutes les e´tapes de leur vie. Les personnes aˆge´es et les personnes ayant des proble`mes complexes et chroniques sont deux domaines sur lesquels l’ergothe´rapie met l’accent. Conse´quences. L’ergothe´rapie contribue de manie`re unique et de´terminante a` la compre´hension de l’impact des proble`mes de sante´ sur le fonctionnement quotidien et a` l’habilitation de la participation a` des activite´s.

Funding: This study was supported by Primary Health Care System seed funding. Corresponding author: Catherine Donnelly, Occupational Therapy Program, Queen’s University–School of Rehabilitation, 31 George Street, Kingston, Ontario, Canada, K7L 3N6. Telephone: 613-533-6385. E-mail: [email protected]

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or over a decade, Canadian documents and policy papers have emphasized the need for interprofessional primary care (Drummond, 2012; Romanow, 2002). Growing evidence suggests that primary care provided by a team of professionals results in better health outcomes and increased satisfaction with services (Russell et al., 2009). Primary care is described as the first point of contact with the health care system and is most often associated with family physician offices (Manitoba Society of Occupational Therapists, 2005). In contrast, the broader term of primary health care refers to a variety of services that address the broader determinants of health. Services within primary health care extend beyond what we often think of as ‘‘health care,’’ including services such as social services, housing assistance, legal aid, and education (World Health Organization, 1978). Primary care can be seen as a subset of primary health care. The focus of this paper is on primary care and the role of occupational therapy within this setting. The Canadian Association of Occupational Therapists (CAOT) position statement on primary health care states, ‘‘Canadians have a right to quality primary health care services available from collaborative interdisciplinary teams of health professionals that include occupational therapists’’ (CAOT, 2006, p. 122). Primary health care has been a priority for provincial and national occupational therapy associations for almost 10 years, and the associations have advocated for an increased occupational therapy presence in these settings (Klaiman, 2004). However, despite the interest in exploring the role of occupational therapy in primary care, there remains a glaring lack of information about occupational therapy in this setting. The paucity of research in primary care is reflective of occupational therapy practice in Canada. The Canadian Institute of Health Information (CIHI) reported only 1.5% of occupational therapists work in the area of health promotion and wellness. In the annual report of the Canadian occupational therapy workforce, primary care is not currently included on the list of potential employers of occupational therapists (CIHI, 2011). Primary care has remained an emerging area of practice for over two decades (see Bumphrey, 1989; Devereaux & Walker, 1995; Donnelly, Brenchley, Crawford, & Letts, 2013; Finlayson & Edwards, 1997; Metzler, Hartmann & Lowenthal, 2012; Muir, 2012; White, 1986). Letts (2011) encouraged the profession to tread cautiously when moving into emerging roles by considering three important questions: How proximal is occupation to the role, how strong is the evidence to support occupational therapy in the role, and is the timing right for change? In her 2011 Muriel Driver Lectureship, Letts provided ample evidence that occupational therapy fits with the philosophies and practices of primary care. Little research has been conducted in primary care settings. McColl and colleagues (2009) have outlined six different delivery models for occupational therapists to consider in a primary care setting: a traditional clinic model, chronic disease management, outreach, community-based rehabilitation, shared care, and case management. While these models can provide a Canadian Journal of Occupational Therapy

framework to support the development occupational therapy roles and services in primary care, no published data have compared the efficacy of these models or offered practice examples (McColl et al., 2009). Bumphrey (1989) provided one of the first examples of occupational therapy in primary care. The study took place in England and described the role of occupational therapy in a community care group, an interprofessional primary care service. The mandate of the service was to provide accessible, collaborative health care with a focus on health promotion. Bumphrey reported that occupational therapists worked as generalists and provided services primarily to older adults within their homes. No description was provided on the type or nature of occupational therapy assessments used or how these services were evaluated. While the study offers one of the first descriptions of occupational therapy in primary care, it has been almost 25 years since its publication, and no physicians worked directly within the community care group. Given that primary care is largely delivered by family physicians, it is important to understand the role of occupational therapists in the primary care context that includes physicians as team members. Only two studies were identified that included occupational therapy in a Canadian primary care context. Richardson and colleagues (2010) conducted a randomized controlled study to examine the impact of occupational therapy and physical therapy services for adults with chronic illness at an interprofessional primary care centre in Ontario, Canada. Clients who received primary care occupational therapy and physical therapy reported significantly higher satisfaction with services and had significantly fewer planned hospital days than those who received routine rehabilitation services in the community. No difference in health status or emergency room visits was reported between the intervention and control group (Richardson et al., 2010). In the second study, a multicomponent intervention was delivered to individuals with chronic illness by an occupational therapist and physical therapist (Richardson et al., 2012). The study employed a two-group cohort design that was conducted at two primary care sites. The intervention consisted of a function-based individual assessment designed to identify individual goals, a 5-week self-management program, and an online personal record system to promote selfmonitoring. Richardson and colleagues (2012) found significant differences in the patients’ reported physical functioning and physical performance measures (grip strength); however, there were no significant differences between groups in health utilization, self-rated health, or self-efficacy. Both of these studies offer preliminary evidence to support the role of occupational therapy and physical therapy with individuals living with chronic conditions in a primary care setting. However, no conclusions could be made about the impact of occupational therapy services alone, as the interventions in both studies involved multicomponent occupational therapy and physical therapy interventions. Limited descriptions of the specific role of occupational therapy were provided, and only broad details were offered on the nature of the service delivery models used.

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Canadian Journal of Occupational Therapy 81(1) In 2010, the Ontario provincial government approved funding for occupational therapists as interdisciplinary health providers in Ontario’s Family Health Teams (FHTs). FHTs are health care organizations with an interprofessional team of providers. The focus of care involves both acute illness and health promotion and prevention activities. FHTs were initially created in 2005, and there are currently 200 teams serving approximately 25% of Ontarians (Rosser, Colwill, Kasperski, & Wilson, 2011). As this new funding opportunity represents the first large-scale expansion of occupational therapy into primary health care in Ontario, it is critical to document the emerging roles of occupational therapists from the early stages to inform both policy and practice. Therefore, the purpose of this study was to understand how the emerging role of occupational therapy in FHTs was being implemented and evaluated. The study sought to answer two questions: (a) How and why is occupational therapy within a FHT being delivered? and (b) How are occupational therapy services within an FHT being documented and evaluated?

Method Study Design A multiple case study design (Yin, 2009) was conducted with four FHT sites within the province of Ontario, Canada. The unit of analysis was occupational therapy services. Case study research is used to ‘‘explore real life experiences and situations, when the researcher is interested in both the phenomenon and the context in which it occurs’’ (Salminen, Harra, & Lautamo, 2006, p. 3). Case study research uses multiple sources of evidence and is best suited to answer ‘‘how’’ and ‘‘why’’ questions (Stake, 1995; Yin, 2009). Three types of case studies have been described: exploratory, explanatory, and descriptive (Yin, 2009). As there are few documented examples of occupational therapists working in primary care, a descriptive case study design enabled an in-depth picture of the early implementation of occupational therapy in FHTs. As per multiple case study methodology (Yin, 2009), each case provided the opportunity for replication of the outlined methods. Replication, as viewed from case study design, is ‘‘analogous to that used in multiple experiments’’ (Yin, 2009, p. 54), and as a result, multiple case study designs are considered to be more robust than single case designs. While there are few examples of case study research in occupational therapy, Salminen and collegues (2006) have argued that case study methodology is ideally suited to develop and inform occupational therapy practice.

53 organizational elements that have been found to support the provision of interprofessional care, including (a) electronic medical record (EMR), (b) team size, and (c) co-location of health professionals (Bradley et al., 2008; McColl et al., 2009). Each element was thought to influence the occupational therapy role and was considered in the identification of the cases. The literature has described occupational therapists working in primary care with a wide range of client populations and conditions (Bumphrey, 1989). Therefore, the nature and duration of the occupational therapists’ clinical experience and the full-time equivalency (FTE) were also thought to be important elements to consider in the identification of cases. Two further dimensions were considered in the case selection: academic versus community and rural versus urban. Purposeful sampling of cases was used with the intent to sample breadth of communities, teams, and occupational therapists. A fifth case was included in the initial recruitment of cases as it represented the only FHT to use contracted occupational therapy services. Multiple communication attempts with both the occupational therapists and the executive director (ED) were unsuccessful; thus the FHT did not participate in the study. While no formal analysis can be included, the recruitment process provides some interesting insights into the barriers that contractual services may have on the roles of occupational therapy in FHTs, primarily the issue of engaging in nonclinical, nonbillable activities, such as meetings and research.

Participants An information letter was sent to the ED for each case FHT describing the study and seeking approval for participation. EDs were also asked to identify and recruit members of the FHT staff to participate in data collection. Because the study focus was on the role of occupational therapy, all occupational therapists working at the FHT were included. Each FHT has one ED responsible for overseeing and managing the team. Because of their instrumental role in the processes and operations of the FHT, the ED for each case FHT was also included in the study, as was each lead physician due to his or her leadership role. Finally, any member of the team who provided collaborative patient care with the occupational therapist was also considered to be eligible for the study. An occupational therapist at each FHT acted as the main contact for liaising and coordinating interviews with the staff. Ethics approval was received by the university’s Health Science and Research Ethics Review Board. During the onsite visit, consent forms were provided to each of the participants. All consent forms were signed and copies were provided to each participant prior to the start of the interviews and completion of any questionnaires.

Case Identification Four FHTs were identified from the approximately 20 FHTs employing occupational therapists at the time of the study. The cases were chosen to reflect different dimensions that were thought to influence the role of occupational therapy. The literature on interprofessional primary care has identified certain

Data Collection To ensure triangulation, data were collected through different methods, including semi-structured interviews, program documents, and questionnaires. The principal investigator (CD)

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Table 1 Number of Participants Across Professions by Case

Executive director Occupational therapist Nurse practitioner Social worker Physician Dietician Diabetes educator

Case 1

Case 2

Case 3

Case 4

1 2 0 2 1 0 1

1 1 1 1 1 0 0

1 1 0 1 1 1 0

1 2 1 1 2 0 0

visited each FHT to retrieve documents for analyses, distribute questionnaires, and conduct interviews with key informants and additional health care providers. Key informants were the occupational therapist(s), lead physician, and ED for each case FHT. Two to three additional interdisciplinary health care providers for each case FHT also participated in interviews to provide a further description of the role of occupational therapy from the perspective of an interprofessional team member. Twenty-four individuals were interviewed from seven different disciplines (see Table 1). Interview data were digitally recorded and transcribed verbatim by a research assistant. All interviews were conducted between February and May 2012 using a semi-structured interview guide. Questions were asked about the role of occupational therapy from each disciplinary perspective. Program documents, including job descriptions, occupational therapy assessments, and FHT mission and vision statements, were obtained during the onsite visits. Further extraction of program and FHT descriptions from webpages was completed after the onsite visit, and case FHTs were contacted if further questions about the nature of occupational therapy services were identified. A FHT profile questionnaire was completed by the ED to obtain descriptive information about the team, including the type of EMR system, number of rostered patients, and health professional makeup. Finally, an occupational therapy profile was completed by the occupational therapists during the onsite visit to obtain descriptive information about the educational and work experiences of the occupational therapists.

Data Analyses Analyses involved both within-case and cross-case analyses (Stake, 1995; Yin, 2009). Pattern matching was used as the overall analytic strategy. This approach ‘‘compares an empirically based pattern with a predicted one’’ (Yin, 2009, p. 106), where propositions are developed prior to data collection to identify a predicted pattern of variables. Propositions for this study were derived from the literature. This study drew on three bodies of research: interprofessional collaborative practice, occupational therapy, and primary care. While there is limited research on occupational therapy in primary care settings, the literature suggests the role is that of a generalist (Bumphrey, 1989). As a result, it was considered to be important to examine the educational and work backgrounds of the occupational Canadian Journal of Occupational Therapy

therapists to determine if previous professional experiences influenced the emerging role within the FHT. FHTs are independent health organizations designed to meet the health needs of the local population (Rosser et al., 2011). Each FHT varies in size, program delivery models, and professional compositions. Both the organizational dimensions and patient characteristics were felt to have possible influence on the role of occupational therapists. The use of EMRs has become standard in FHTs and has been found to support internal communication (Howard, Brazil, Akhatar-Densh, & Agarwal, 2011). It was felt that the EMR would be an important element to examine in the documentation and evaluation of occupational therapy services. Two study propositions were formulated: 1. The nature of occupational therapy services provided will be influenced by the structure of the FHT, patient rosters, and educational and work history of the occupational therapist(s). 2. The EMR will be pivotal in documenting and evaluating occupational therapy services. Each case was first analyzed individually, followed by cross-case analyses to determine common themes. Data obtained from documents were extracted using a priori document analysis forms. A separate document analysis form was developed for each set of documents analyzed: (a) EMR documentation review form, (b) occupational therapy assessment review form, (c) occupational therapist job description review form, and (d) FHT program description review form (i.e., mission and vision statements). Data were entered into Excel (Version 4.3.8) spreadsheets, and tables were created to visually examine the data on a case-by-case basis and across cases. The qualitative analysis software program ATLAS.ti was used to organize coded data and themes both within and across cases. All transcripts were read and reread by the primary author, and preliminary codes were established. Selected transcripts were read and independently coded by a second investigator (LL) using the preliminary coding structure. Any discrepancies in coding were discussed by CD and LL until consensus was reached. Member checking was performed to enhance validity of the findings. Occupational therapists were provided with preliminary summary of their own case and were asked to inform the investigators if any errors were noted. None of the participants reported any errors.

Findings Within-Case Analysis The four case FHTs in the study had patient rosters ranging from 7,200 to 42,000 patients and were located in both rural and urban centres. Three cases were community FHTs and one was academic. Occupational therapists were all relatively new to their positions with a range of 3 months to 18 months. Table 2 provides a summary of the four case FHTs. Each case had a unique complement of health providers: chiropodists, psychologists, social workers, dieticians, physician assistants, pharmacists,

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Table 2 Profiles by Case

Urban/rural Academic/community Number of occupational therapists  full-time equivalency Occupational therapy experience (years) Area of previous occupational therapy clinical experience Time in current position (months) Rostered patients (n) Sites covered by FHT (n) Occupational therapist onsite with physicians EMR used across sites Occupational therapist access to EMR

Case 1

Case 2

Case 3

Case 4

Rural Community 2  0.5

Urban Community 1  1.0

Rural Community 1  1.0

Urban Academic 2  1.0

16/15

4

2

24/23

Community paediatrics/ General inpatient General inpatient Chronic pain, inpatient and private Community adults rehabilitation rehabilitation practice/ General inpatient rehabilitation 7/7 18 3 18/13 46,000 22 No

7,200 4 No

26,468 4 No

28,000 2 Yes

Yes Yes

No (3 of 4) Yes (3 of 4)

No No

Yes Yes

Note. FHT ¼ Family Health Team; EMR ¼ electronic medical record.

patient educators, mental health workers, health promoters, respiratory therapists, case managers, nurses, nurse practitioners, and physicians. Case 1: Large rural FHT, two occupational therapists. Two occupational therapists shared one FTE position, creating two 0.5 FTEs. One occupational therapist focused primarily on paediatrics, working closely with the paediatric mental health team. The other occupational therapist concentrated on older adults with an emphasis on home safety and cognitive screening. Their clinical foci reflected previous employment experiences. Occupational therapy services were primarily one-onone, with a large focus on home and community-based assessments and interventions. Both therapists had plans to develop groups to address the high demand for occupational therapy services. With no occupational therapy services at the community hospital and limited access to rehabilitation in the community, the FHT was seen as an important resource in offering access to occupational therapy services. Case 2: Small urban FHT. The occupational therapist saw a wide range of clients over the life span but focused on chronic disease management and chronic pain. The occupational therapist was not linked to any specific programs (i.e., mental health program) within the FHT. One pilot chronic pain group had been implemented, and the development of further interprofessional groups was being planned. Situated in a large urban centre, clients had access to a range of occupational therapy services through the community and hospital. Case 3: Large rural FHT. The FHT was in the process of developing five clinical programs, each with a complement of interprofessional health providers, community partners/

services, and a physician lead. The occupational therapist was responsible for the development of the seniors’ program, which was her primary clinical focus. In addition, the occupational therapist worked with three of the other programs. Occupational therapy services consisted of a mix of one-on-one clinic-based appointments, groups, and home visits. Home visits were occasionally co-booked with a social worker. The region had limited access to specialized rehabilitation programs or outpatient services, and the FHT was seen as providing occupational therapy services to those who might not have had access otherwise. Case 4: Urban, academic FHT. Two occupational therapists worked closely together and loosely triaged the referrals based on previous clinical experience: chronic pain and older adults. Both occupational therapists reiterated their role was that of a generalist, working across diagnoses and age groups. As members of an academic FHT, both occupational therapists were responsible for supporting the education of medical residents with a secondary focus on educating occupational therapy students. The primary occupational therapy service delivery model was one-on-one, clinic-based encounters; however, home visits and groups were also part of the delivery model. Co-bookings were done with other team members and medical residents. There was an increased focus on developing groups and programs to address the high demand for occupational therapy services.

Cross-Case Analysis The occupational therapy role was unique to each case; however, there were a number of commonalities that were found between the cases. Six themes emerged from the data analysis

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Table 3 Occupational Therapy Role Interventions and activities Enable functiona Activity/exercise support Chronic disease management Chronic pain management Cognitive assessments Coordination of services Discharge support Driver screening Falls prevention and intervention Funding applications Home and safety assessments Linking to community programs and resources Paediatric screening Return-to-work planning and support Seating and equipment Sensory assessment

Clinical focus Acquired brain injury Chronic pain Complex chronic disease Dementia/Mild cognitive impairment Developmental disability Falls risk Mental health Sensory processing disorder

Client age span Infant Preschool School Adult Older adult

The focus on function transcended specific client diagnoses or populations and provided occupational therapists with the ability to address the daily issues and complexities faced by individuals. So I feel like the doctors don’t look at [the clients] and say, ‘‘This is a chronic disease management issue.’’ It is more what are the functioning daily issues. Sometimes it is about the complexities: ‘‘I don’t know what to do . . . help us figure it out.’’ (occupational therapist)

A functional perspective also served to provide a deeper understanding of patients: ‘‘We have that flexibility to really figure out what it is the [client] wants . . . the luxury and flexibility of really being able to work . . . in their environment with their occupational performance issues’’ (occupational therapist).

a Enable function was reported as the overall focus of occupational therapy interventions and activities.

and highlight the diversity and breadth of the occupational therapy role in a primary care context. The generalist. As an emerging area of practice, participants had to grapple with the breadth of occupational therapy in primary care. The role of occupational therapy in FHTs epitomizes that of a generalist. The occupational therapists in the study worked across the life span with a wide range of client populations providing many types of interventions (see Table 3). Older adults (focus on cognition, falls, and home safety), individuals with complex chronic conditions, and chronic pain were three prominent occupational therapy areas of focus. The generalist perspective was not viewed as unique to occupational therapy but seen as fundamental to primary care: ‘‘And that is what my friend said . . . welcome to primary health care’’ (occupational therapist). As generalists, the occupational therapists were able to work to their full scope; this broad role was felt to be both overwhelming and exciting: ‘‘One referral to the next is completely different which is exciting and a little bit scary’’ (occupational therapist). Focus on function. As generalists working with a diverse caseload, occupational therapists viewed function to be the common thread among clients. Both occupational therapists and team members used the term function to refer to the daily activities in which the clients needed and wanted to participate. There was a strong sense that occupational therapists’ focus on function was a unique and important contribution to primary care. Canadian Journal of Occupational Therapy

My primary role is to provide assessment and intervention or connect to the community and to help the family doctors managing their patients with functional challenges. . . . It is not all chronic disease; there are people who . . . just need a basic exercise and pain management program to the very chronically disabled and everything in between. (occupational therapist)

The challenge of managing caseloads. The ratio of occupational therapist per FHT roster ranged from 1 per 7,200 patients to 1 per 42,000 patients. Referrals to occupational therapy were slow at two case FHTs, and participants felt that this may have been due to the perceived lack of understanding of the role of occupational therapy in primary care: ‘‘It’s underused, because I don’t think everyone knows what the OT [occupational therapy] can do’’ (nurse practitioner). The need to educate the team and, in particular, physicians was felt to be an important step in enhancing the profile of occupational therapy: ‘‘What is OT? I’m working in trying to educate the team in what OTs can do. I just don’t think they knew what the role could be’’ (occupational therapist). However, given the ratios of occupational therapists, all respondents recognized the need to identify strategies to cope with the current and potential demand for occupational therapy services: ‘‘We have one OT, we could really use three . . . four’’ (ED). The need to prioritize referrals was identified as a critical strategy to managing referrals: ‘‘They are really busy and so I go back to the OTs and say . . . ‘You need to prioritize things that you are invested in’’’ (ED). Aligning occupational therapy services with programs of care (i.e., chronic pain, mental health, chronic disease) in the FHT was seen as a way to narrow the scope of services, focus on team priorities, and provide a health promotion and health management perspective: ‘‘She will become very program specific. She will be involved in delivering specific expertise, because I think that the role could become so broad, that you lose the effectiveness of it’’ (ED). The leading model of service delivery for occupational therapy was one-on-one, clinic-based encounters. However, group models were recognized as a strategy for providing services to a greater number of clients: ‘‘I’m slowly trying to

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Canadian Journal of Occupational Therapy 81(1) integrate myself into some other groups . . . to further narrow down because we are swamped’’ (occupational therapist). Enhancing access to occupational therapy. Occupational therapy in the FHTs was seen to enhance access to services, particularly for those individuals who would not previously have been eligible through publicly funded community occupational therapy services: ‘‘I’m seeing a lot more of those people who haven’t accessed services in the past’’ (occupational therapist). We know it’s hard in this area, there wasn’t any easy access to outpatient occupational therapy assessment. . . . We know that there are clients, are patients that need to see OTs and we didn’t have access, so [what] we looked at is more so a part of the ability to provide services to patients. (physician)

Timely access to occupational therapy was seen as important in the primary care setting. The need for an FHT’s occupational therapists to link to and work with community occupational therapy and other community services was critical to both managing high volumes and supporting individuals functioning in their community: ‘‘Quick access to service. You know, they’re not waiting for months and months to see you. Just quickly see them, consult, do what you can do and link them’’ (occupational therapist). However, in some areas, long wait lists for community services and shortage of community occupational therapy services resulted in some tensions in the type of occupational therapy services provided in FHTs. Questions arose over what services are primary care in nature versus what services are provided to address unmet community needs. One particular FHT experienced long community wait lists: ‘‘The physicians are sort of fed up with that whole waiting list and the process, and they know that they have access to us with a quick little email and the people are seen’’ (occupational therapist). All participants spoke of the important role that occupational therapy has in connecting patients to community resources and services. What [community services] do we need to get in, what services do we need [for this client] . . . that is what being an OT is about, knowing what [service options are available] in health care and how to connect people. (occupational therapist)

In some cases, occupational therapists collaborated with other community organizations and services to enhance overall access to community services: ‘‘We have an OT from the Arthritis Society that consults here’’ (occupational therapist); ‘‘I’m working with the physio at the Community Health Centre . . . for building balance and fall prevention program’’ (occupational therapist). Multiple influences shape the occupational therapy role. The occupational therapy role was shaped by personal, organizational, and community factors. At a personal level, the occupational therapists’ clinical experiences and interests influenced the clients with whom they worked:

57 ‘‘Partly because I like the seniors, I love geriatrics, so I was really excited to jump into that and have that program going’’ (occupational therapist). In one case, an occupational therapist with a strong paediatric background worked closely with the paediatric mental health team. In another case, an occupational therapist with experience in chronic pain received frequent referrals for pain management: ‘‘They have done a nice job because one [occupational therapist] is really set on paeds and the other is geriatrics and that is her background’’ (ED). Flexibility and teamwork were viewed as critical personal characteristics that were considered in the hiring process. These personal characteristics enabled therapists to jump into emerging roles and promote occupational therapy in the FHT: ‘‘I think flexibility and a bit of assertiveness’’ (ED). A key informant commented, ‘‘I think it’s people’s personalities and backgrounds too’’ (occupational therapist). There was also recognition that each FHT is part of a unique community with its own specific needs that shape occupational therapy services. There is no scripted role. It really depends on the community you work in and the group of physicians you are with . . . and the Ministry [of Health and Long Term Care] seems to have set it up to be like that which is really nice that we can be creative and specific to the needs of your community. (occupational therapist)

The role of the occupational therapists at the academic FHT included the education of family medicine residents and other health professionals as well as participation in research: ‘‘We have two primary mandates of clinical care and education. And then scholarly work, which supports that’’ (physician). The programmatic nature of FHTs facilitated caseload management and also provided an overarching philosophy of care that reinforced program development. The programs in which an occupational therapist might work were also influenced by many factors, including professional interests, strategic direction of the FHTs, patient demographics, and wait lists. If you don’t have a program that’s developed and approved and implemented, then all visits are acute and episodic care. They’re not looking for Family Health Teams to be providing acute and episodic are. They want us to be providing programbased services that then allow the physicians to offload some of their acute and episodic care into program and therefore, move to a more open-access model and to also be able to roster new patients. So you’ll find with the development and the evolvement of the OT that programs will be their first priority within Family Health Team. (ED)

Ultimately, occupational therapy was funded to support physicians with patient care, and participants were cognizant of ensuring services helped support overall patient care and flow. ‘‘We clearly have a sense of what the physicians want us to do’’ (occupational therapist). Another participant stated, ‘‘We decided as a group what would be most valuable to the doctors’’ (ED).

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Table 4 Occupational Therapy Assessment Tools Reported by Participants Frequency of usea

Name of assessment by age span Paediatric

High

Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) Sensory Processing Measure Sensory Profile

Moderate

Behaviour Rating Inventory of Executive Function (BRIEF)

Low

Alberta Infant Motor-Scale Children’s Handwriting Evaluation Scale (CHES) Developmental Coordination Disorder Questionnaire Goodenough-Harris Draw-a-Person Test Movement ABC Peabody Development Motor Scales Test of Visual-Perceptual Skills

Adult/older adult Berg Balance Scale Brief Pain Inventory Canadian Occupational Performance Measure (COPM) Clock Drawing Montreal Cognitive Assessment (MOCA) Timed up and Go (TUGS) Trails A & B Cognitive Linguistic Quick Test (CLQT) Safety Assessment of Function and Environment for Rehabilitation (SAFER) 6 Minute Walk Test ABC Balance Confidence Scale Assessment of Motor and Process Skills McGill Pain Questionnaire Motor Free Visual Perceptual Test

a

Frequency of use as reported by occupational therapists.

Outcomes and evaluation. At this early stage, workload measurements were used to evaluate occupational therapy services in FHTs: ‘‘Right now the only measure that the Ministry [of Health and Long Term Care] is holding us accountable to is workload’’ (ED). The emphasis on workload was not unique to occupational therapy and reflects the complexities of evaluating services in an interprofessional environment and relative newness of the FHTs: ‘‘How do you tease out who’s doing what and the impact within the collaborative team?’’ (social worker). Program-based outcomes were described as a priority focus and were considered a requirement in the development of programs: ‘‘Where [the occupational therapist] will get measured is within her program; there’s the targeted outcomes and we will have to develop the evaluation tools to be able to measure these’’ (ED). A number of formalized assessments were identified and reflect the broad range of clients and interventions within primary care. Table 4 provides a list of assessments used across cases. Participants identified quality of life as an important outcome of occupational therapy services and recognized that the emphasis on biomedical benchmarks did not fit with the services being provided: ‘‘Quality of life and the ability to engage in the community’’ (social worker). The EMR was viewed as a potentially important element in collecting data and facilitating evaluation. However, not all FHTs have a common EMR, and the original function was to support client documentation, not evaluation of services: ‘‘But I think certainly an EMR system can do a really good job of helping to capture the data’’ (social worker). The usefulness of the EMR for evaluation purposes was seen as largely dependent on the data input and collection process: ‘‘It’s a whole Canadian Journal of Occupational Therapy

garbage in, garbage out thing. It’s only good at measuring that which we enter into it, in order to be measured’’ (ED). While all respondents saw evaluation as important, no formal structures or plans were in place to evaluate occupational therapy services. The need to evaluate occupational therapy services is seen as a priority, and external supports may be required to facilitate and support this.

Discussion The role of occupational therapists as generalists in primary care has been consistently presented in both the early and recent literature (Bumphrey, 1989; Devereaux & Walker, 1995; Metzler et al., 2012; Muir, 2012; Tse, Penman, & Simm, 2003). The notion of the generalist as an area of specialization was described by Devereaux and Walker (1995), who stated, ‘‘For the occupational therapy practitioner who practices in primary health care, continuing to strengthen generalist knowledge and skills becomes that therapist’s specialty’’ (p. 393). This current study offered clear support for the view of the occupational therapist as a generalist and also highlighted the flexibility required to work to the full scope of occupational therapy practice. Muir (2012) forecasts that a primary care occupational therapist will require ‘‘broad experience, advanced training and commitment to life-long learning’’ (p. 509). The overarching focus of occupational therapy was to support individuals to participate in meaningful and valued everyday activities within their community. The role was less about the clients’ conditions and more about the unique lens on function that occupational therapy brings to primary care. Richardson and colleagues (2012) proposed the inclusion of physical

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Canadian Journal of Occupational Therapy 81(1) function as the sixth vital sign for individuals with chronic illness and highlighted the expertise of occupational therapy and physical therapy in understanding the consequences of disease on function. Cook and Howe (2003) have described the role of occupational therapy in supporting social functioning for individuals with severe mental health conditions in a primary care context. Occupational therapists in this study focused more on the management of chronic conditions, including both physical health and mental health, and less on health promotion activities. While occupational therapists’ role in health promotion and prevention has been emphasized in the literature, there has been very little evidence of such roles being implemented in practice (see Bumphrey, 1989; CIHI, 2011; Tse et al., 2003). The lack of focus on health promotion can likely be attributed to a number of factors. The roles that were adopted in the FHTs were in part influenced by the occupational therapists’ previous experiences. Given the overall lack of educational background and work experience in health promotion, it is natural that health promotion was not the immediate focus of occupational therapy services. There is an increasing emphasis on chronic disease management both in the literature (see Richardson et al., 2010, 2012; Russell et al., 2009) and in policy documents, providing evidence and resources to draw on (see Drummond, 2012; Government of Ontario, 2012). Occupational therapists in primary care worked in what may be described as the grey zone, providing services to individuals who (a) might not otherwise have access to occupational therapy, (b) may be on long wait lists for community rehabilitation, or (c) may be eligible only to receive time-limited, community-based occupational therapy services. In this way, occupational therapy services often did not reflect primary health promotion or prevention but, rather, reflected secondary prevention and management of health as a means of preventing re-hospitalizations and referral to tertiary services. McColl and colleagues identified six possible service delivery models (McColl et al., 2009; McColl & Dickenson, 2008). Of these models, the one-on-one, clinic-based model was most predominant among the FHTs within the study. Given the dearth of documented roles for occupational therapy in primary care, emerging roles will naturally build on traditional service delivery frameworks (Tse et al., 2003). However, the ratio of occupational therapists to patients and emphasis on program-based approaches within the FHTs makes it critical for occupational therapists to consider their role both within existing programs and group interventions (Muir, 2012). While occupational therapists in each case were involved in the development or delivery of at least one group, their involvement in groups was expected to grow as their roles become more established. The ability to conduct community-based assessment and intervention was viewed as an important addition to the FHT. In the province of Ontario, there has been a recent emphasis on the provision of ‘‘house calls’’ for older adults (Sinha, 2013), and this study provides support for occupational therapists to nurture this role. In one of the original studies documenting the role of occupational therapy in primary care in England, over 80% of

59 occupational therapy sessions were conducted in clients’ homes. Muir (2012) highlighted the importance of not duplicating community services, which reinforces the need for primary care occupational therapists to be cognizant of community programs, helping clients to navigate and connect to available services and working collaboratively with community occupational therapists. It is important to note the difference between community-based, home care occupational therapy and primary care occupational therapy. The former offers services within the home that are time limited and focused on a specific issue(s), while the latter provides occupational therapy services to a set of rostered clients, who may receive services across their life span for a multitude of reasons and whose focus is health promotion and prevention. A number of recent reports have stressed the need to focus on outcomes and evaluation in primary care (Drummond, 2012; Glazier, Zagorski, Rayner, 2012) and, more specifically, the need to identify nonphysician indicators (Jaakkimainen et al., 2006). The early establishment of outcomes is critical to facilitate the integration of occupational therapy in FHTs and ensure consistent and appropriate data are collected. Outcome measures need to be able to capture outcomes from occupational therapy services that address the extensive physical and mental health issues identified by clients in a primary care practice. Occupational therapists have been shown to primarily rely on nonstandardized measures (Colquhoun, Letts, Law, MacDermid, & Edwards, 2010); it is critical to identify standardized outcome measures that are both meaningful to clients and therapists and feasible to use in a diverse primary care environment to gather evidence related to outcomes.

Study Limitations The main limitation of this study was that it involved four cases. Given the variability in FHTs, it is anticipated that further insights could have been gleaned by the inclusion of additional cases. The perspectives shared provide a snapshot of the role of occupational therapy in primary care during the early phases of implementation; it is anticipated that these roles will continue to evolve and be shaped by personal growth and organizational development. The study was descriptive in nature, and while it provides insights into the emerging role of occupational therapy within a primary care context, readers need to take care in transferring the findings broadly.

Future Research Given the paucity of literature exploring occupational therapy and primary care, there are a number of key areas for future research. It is important to continue to conduct descriptive studies to understand the contextual issues and the development of the occupational therapy role within interprofessional primary care teams. Increasingly, funding is attached to outcomes (Drummond, 2012), making it critical to investigate outcome measures and examine the efficacy of specific occupational therapy interventions in primary care settings.

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Revue canadienne d’ergothe´rapie

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Donnelly et al.

Conclusion The study has described the valuable and unique contributions occupational therapy can make in a primary care setting. When occupational therapy is situated in primary care, there is enhanced access to occupational therapy services, particularly for individuals who might not otherwise have had access. Understanding the impact of health conditions on daily function and enabling participation in activities are unique and important contributions of occupational therapy.

Key Messages  



The role of occupational therapy in primary care epitomizes that of a generalist. Understanding the impact of health conditions on daily function and enabling participation in activities are unique and important contributions of occupational therapy in primary care. There is a need to identify outcomes to evaluate the effectiveness of occupational therapy services provided in primary care teams.

References Bradley, F., Elvey, R., Ashcroft, D. M., Hassell, K., Kendall, J., Sibbald, B., & Noyce, P. (2008). The challenge of integrating community pharmacists into the primary health care team: A case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration. Journal of Interprofessional Care, 22, 386–398. doi:10.1080/13561820802137005 Bumphrey, E. E. (1989). Occupational therapy within the primary health care team. British Journal of Occupational Therapy, 52, 251–255. Canadian Association of Occupational Therapists. (2006). CAOT position statement: Occupational therapy in primary care. Canadian Journal of Occupational Therapy, 73, 122. Canadian Institute of Health Information. (2011). Occupational therapists in Canada, 2010: National and jurisdictional highlights and profiles. Retrieved from http://www.cihi.ca/CIHI-ext-portal/pdf/ internet/OT2010_HIGHLIGHTS_PROFILES_EN Colquhoun, H., Letts, L., Law, M., MacDermid, J., & Edwards, M. (2010). Feasibility of the Canadian Occupational Performance Measure for routine use. British Journal of Occupational Therapy, 73, 48–54. doi:10.4276/030802210X12658062793726 Cook, S., & Howe, A. (2003). Engaging people with enduring psychotic conditions in primary mental heath care and occupational therapy. British Journal of Occupational Therapy, 66, 236–246. Devereaux, E. B., & Walker, R. B. (1995). Nationally speaking: The role of occupational therapy in primary health care. American Journal of Occupational Therapy, 49, 391–396. doi:10.5014/ajot. 49.5.391 Donnelly, C., Brenchley, C., Crawford, C., & Letts, L. (2013). The integration of occupational therapy into primary care: A multiple Canadian Journal of Occupational Therapy

case study design. BMC Family Practice, 14, Article 60. doi:10. 1186/1471-2296-14-60 Drummond, D. (2012). Commission on the Reform of Ontario’s Public Services: Public service for Ontarians. A path to sustainability and excellence. Retrieved from http://www.fin.gov.on.ca/en/reformcommission/chapters/report.pdf Finlayson, M., & Edwards, J. (1997). Evolving health environments and occupational therapy: Definitions, descriptions and opportunities. British Journal of Occupational Therapy, 60, 456–460. Glazier, R., Zagorski, B. M., & Rayner, J. (2012). Comparison of primary care models in Ontario. Toronto, ON:Institute for Clinical Evaluation Sciences. Government of Ontario. (2012). Ontario’s action plan for health care: Better patient care through better value from our health care dollars. Retrieved from http://health.gov.on.ca/en/ms/ecfa/healthy_ change/docs/rep_healthychange.pdf Howard, M., Brazil, K., Akhtar-Danesh, N., & Agarwal, G. (2011). Self-reported teamwork in family health team practices in Ontario: Organizational and cultural predictors of team climate. Canadian Family Physician, 57, e185–e191. Jaakkimainen, L., Upshur, R., Klein-Geltink, J., Leong, A., Maaten, S., Schultz, S., & Wang, L. (2006). Primary care in Ontario. Toronto, ON: Institute for Clinical Evaluative Sciences. Retrieved from http://www.ices.on.ca/file/PC_atlas_prelims_complete.pdf Klaiman, D. (2004). Increasing access to occupational therapy in primary health care. Occupational Therapy Now, 6(1). Retrieved from http://www.caot.ca/default.asp?pageid¼1031 Letts, L. J. (2011). Muriel Driver Lecture: Optimal positioning of occupational therapy. Canadian Journal of Occupational Therapy, 78, 209–219. doi:10.2182/cjot.2011.78.4.2 Manitoba Society of Occupational Therapists. (2005). Occupational therapists and primary health care. Winnipeg, MB: Author. Metzler, C. A., Hartmann, K. D., & Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy. American Journal of Occupational Therapy, 66, 266–269. doi: 10.5014/ajot.2010.663001 McColl, M. A., & Dickenson, J. (2008). Interprofessional primary health care: Assembling the pieces. Ottawa, ON: CAOT Publications ACE. McColl, M. A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O’Brien, P., & Donnelly, C. (2009). Models for integrating rehabilitation and primary care: A scoping study. Archives of Physical Medicine and Rehabilitation, 90, 1523–1531. doi:10.1016/j.apmr.2009.03. 017 Muir, S. (2012). Occupational therapy in primary health care: We should be there. American Journal of Occupational Therapy, 66, 506–510. doi:10.5014/ajot.2012.665001 Richardson, J., Letts, L., Chan, D., Officer, A., Wojkowski, S., Oliver, D., . . . Kinzie, S. (2012). Monitoring physical functioning as the sixth vital sign: Evaluating patient and practice engagement in chronic illness care in a primary care setting. A quasiexperimental design. BMC Family Practice, 13, Article 29. doi: 10.1186/1471-2296-13-29 Richardson, J., Letts, L., Chan, D., Stratford, P., Hand, C., Price, D., . . . Law, M. (2010). Rehabilitation in a primary care setting for persons with chronic illness: A randomized controlled

Downloaded from cjo.sagepub.com at IOWA TESTING PROGRAMS on March 18, 2015

Canadian Journal of Occupational Therapy 81(1) trial. Primary Health Care Research and Development, 11, 382–395. doi:10.1017/S1463423610000113 Romanow, R. J. (2002). Building on values: The future of health care in Canada. Commission on the Future of Health Care in Canada. Retrieved from http://publications.gc.ca/collections/Collection/ CP32-85-2002E.pdf Rosser, W. W., Colwill, J. M., Kasperski., J., & Wilson, L. (2011). Progress of Ontario’s family health team model: A patientcentred medical home. Annals of Family Medicine, 9, 165–171. doi:10.1370/afm.1228 Russell, F. M., Dabroughe, S., Hogg, W., Geneau, R., Muldoon, L., & Runa, M. (2009). Managing chronic disease in Ontario primary: The impact of organizational factors. Annals of Family Medicine, 7, 309–318. doi:10.1370/afm.982 Salminen, A. L., Harra, T., & Lautamo, T. (2006). Conducting case study research in occupational therapy. Australian Occupation Therapy Journal, 53, 3–8. doi:10.1111/j.1440-1630.2006.00540.x Sinha, S. K. (2013). Living longer, living well: Highlights and key recommendations from the report submitted to the Minister of Health and Long-Term Care and the Minister Responsible for Seniors on recommendations to inform a seniors strategy for Ontario. Retrieved from http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy.pdf Stake, R. (1995). The art of case study research. Thousand Oaks, CA: Sage. Tse, S., Penman, M., & Simms, F. (2003). Literature review: Occupational therapy and primary health care. New Zealand Journal of Occupational Therapy, 50(2), 17–23. Retrieved from http://www.nzaot. com/downloads/contribute/pagesfromnzjotsept200317to23.pdf

61 White, V. K. (1986). Promoting health and wellness: A theme for the eighties. American Journal of Occupational Therapy, 40, 743–748. doi:10.5014/ajot.40.11.743 World Health Organization. (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6– 12. Retrieved from http://www.who.int/publications/almaata_ declaration_en.pdf Yin, R. K. (2009). Case study research: Design and methods (3rd ed.). Thousand Oaks, CA: Sage.

Author Biographies Catherine A. Donnelly, PhD, OT Reg. (Ont.), is Assistant Professor, Occupational Therapy Program, Queen’s University, School of Rehabilitation Therapy, 31 George Street, Kingston, ON, Canada, K7L 3N6. Christie L. Brenchley, OT Reg. (Ont.), is Executive Director, Ontario Society of Occupational Therapists, 55 Eglinton Ave. E., Suite 210, Toronto, ON, Canada, M4P 1G8. Candace N. Crawford, OT Reg. (Ont.), is Occupational Therapist, Wise Elephant Family Health Team, 280 Main N, Brampton, ON, Canada, L6V 1P6. Lori J. Letts, PhD, OT Reg. (Ont.), is Assistant Dean, Occupational Therapy Program, and Associate Professor, School of Rehabilitation Science, McMaster University, 1400 Main St. W., Hamilton, ON, Canada, L8S 1C7.

Book Review Prager, Joshua. (2013). Half-life: Reflections from Jerusalem on a broken neck, Kindle ed. San Francisco, CA: Byliner. 132 pp. $3.99. ISBN: 978-1-61452-068-9 DOI: 10.1177/0008417413511433

Prager is a journalist and this slim book presents his musings on the half of his life lived since a traumatic spinal cord injury left him with Brown-Se´quard syndrome. However, the purpose and intended audience for this book are unclear. An estimated quarter of a million people in North America live with spinal cord injuries, thus the author’s injury is far from unique. Yet, Prager conveys so little of his daily life that it would be difficult for others to identify with or learn from his experiences. Seemingly preoccupied with the bus accident in which the injury occurred, the book returns continually to this event. Indeed, the book is framed around Prager’s return from the United States to Israel in an attempt to reconnect both with the landscape and location of the accident and with its victims and other survivors. Prager, who is Jewish, hints at a spiritual struggle following injury and his belief that ‘‘if you create the

world, you are responsible for its injustices’’ but does not elaborate on how this struggle impacts his ability to assimilate an injury he clearly perceives to be somehow ‘‘injust.’’ Prager is able to walk with a limp, and perhaps this is why he makes no mention of how physical access, stigma, disability rights, or experiences of social in/equality differ between the United States and Israel or how the experience of disability might be impacted by one’s dominant or subordinate religious and political status in Israel. The book is not always an easy read, sometimes employing a stream-of-consciousness style; referring to specific religious concepts, such as ‘‘Kiddush,’’ with which not all readers may be familiar (I was not); and employing a significant number of literary quotes—the relevance of which is not always apparent or explained. At one point, Prager sums up his perspective that ‘‘in the end, we are whom we love and what we do,’’ and the book would, I think, have been both more interesting and more valuable if he had focused more on this insight and less on the specific events surrounding one motor vehicle accident (among so many).

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Karen Whalley Hammell Revue canadienne d’ergothe´rapie