Interprofessional primary care: the value of occupational therapy.
The Role of Occupational Therapy in PC
An occupational therapist is one potential team member who can contribute significant value to the health care team. Occupational therapists are skilled in addressing physical dysfunction and behavioral and mental health issues and in working with individuals across the lifespan to maximize function and participation. The role of occupational therapy (OT) in PC is not yet well defined and is dependent on such factors as the business model of the setting, the requirements of the interprofessional team, the patients' needs, and the awareness that the other team members have the skill set that OT contributes to the interprofessional PC team (American Occupational Therapy Association [AOTA], 2013; Donnelly, Brenchley, Crawford, & Letts, 2013). However, because the role of OT is frequently misunderstood, occupational therapists are often overlooked and underused as members of the interprofessional PC team (AOTA, 2013; Dahl-Popolizio, Manson, Muir, & Rogers, 2016; Donnelly et al., 2013; Donnelly, Brenchley, Crawford, & Letts, 2014). Table 1 provides brief, illustrative vignettes demonstrating what occupational therapists can do with complicated patient issues in the PC setting. Table 2 provides examples of common conditions where occupational therapists can be a primary or supplemental provider in PC.
Over the recent decades, most occupational therapists have pursued specialized positions in mental health or rehabilitative settings, despite their broad training. Reimbursement guidelines and the demands and requirements of the practice settings where occupational therapists work were the primary influences of this trend toward specialization. This narrowed focus has resulted in a lack of understanding by the medical community regarding occupational therapists' broad scope of training and their qualifications for the many clinical services they provide. With the expansion of integrated care, reimbursement opportunities, and the focus on value-based quality care, occupational therapists are increasingly becoming members of the PC workforce and interprofessional care team. The OT assessment focuses on how each patient's complaints or symptoms affect his or her ability to complete daily activities, or how his or her daily activities influence one's health (AOTA, 2010a). Health problems often result from these habitual daily activities. Occupational therapists identify barriers, both internal and external, to optimal function (Metzler et al., 2012), which equates to identification of barriers to optimal health. Occupational therapists' training and philosophy enables them to provide clinical services to improve self-management of health conditions and independence with activities of daily living, including those activities that affect health and adherence to medical instruction (Dahl-Popolizio et al., 2016).
When a patient requires additional assistance beyond the traditional medical visit for issues such as coping skills to deal with anxiety, exercises to address an acute musculoskeletal injury, or developmental screening to identify developmental delays, they typically receive a referral to an outside clinic or another provider. Occupational therapists on the interprofessional PC team immediately address these issues. This results in increased access to care and facilitates cost containment, as the referral to an outside provider may not be necessary and more patient needs can be immediately and collaboratively addressed in house (Dahl-Popolizio et al., 2016).
How OT Can Contribute to the Interprofessional PC Team
Interprofessional teams are typically comprised of multiple health care disciplines applying their unique skill sets and attitudes to supplement the contributions of the other team members (Hall & Weaver, 2001). Occupational therapists, with their broad skill set, contribute to the coordination of care and provide patient care to meet the needs of the patients in their most meaningful context, such as work, home, family, or community. Occupations, as defined by the AOTA, include any activity in which people engage throughout the day (Roberts, Farmer, Lamb, Muir, & Siebert, 2014). These actions and activities are the occupations addressed by an occupational therapist (AOTA, 2010a). The Manitoba Society of Occupational Therapists (2005) discusses the unique role of OT in individual health:
How people perform their occupations is believed to be an important determinant of health and is influenced by personal factors, environments and the occupations that people do. Occupational therapy is the only health profession whose education is entirely devoted to the study of occupational performance and its impact on people's health and wellness, (p. 3)
This approach of addressing patient motivation in relation to functional activities has been the basis of OT for nearly 100 years and aligns with the World Health Organization's International Classification of Functioning (2014).
The occupational therapist on the interprofessional PC team is an additional professional who assists with many issues that complicate health and increase health care costs. For this reason, an occupational therapist is a benefit to the collaborative interprofessional PC team and the patients. With the top of the license principle, using their full skill set, occupational therapists provide whole-person care for populations, groups, and individuals in the PC setting, especially for those with or at risk of developing chronic illnesses (Roberts et al., 2014). This care is continuous, comprehensive, and coordinated over the lifespan and across all elements and levels of the health care system and includes collaboration with other team members, patients, caregivers, and families to make optimal decisions regarding overall health. With an emphasis on quality improvement and management of chronic conditions, costs will be reduced and the health of the population will improve (AOTA, 2013).
Occupational Therapist Education and Training
The American Occupational Therapy Association (AOTA) is the national professional organization of OT and provides accreditation and academic program consistency through the Accreditation Council for Occupational Therapy Education (ACOTE). The AOTA (2010b) outlines minimum standards that an occupational therapist must have to safely and effectively provide OT services to individuals, groups, and populations. An occupational therapist enters the field after earning either a master's or clinical doctoral degree in OT, passing a national certification examination, and obtaining licensure through the state in which they intend to practice. Core curriculum comprises biological and physical sciences, including anatomy, physiology, neuroscience, kinesiology, and biomechanics. Core content of OT educational programs also includes knowledge and understanding of human behavior and analysis of how disease, disability, trauma, and injury impact an individual's physical and mental health. Occupational therapists learn about the physiological process of diseases as well as the psychological and physical implications to function and quality of life that diseases impose. Through their training, OT practitioners deliver services to promote health and wellness, prevent disease and disability, develop skills not yet obtained, and provide compensatory or remedial strategies to improve an individual's function with his or her everyday living skills (ACOTE, 2011).
Integrating behavioral health into PC is cost-effective, and it is critical to address frequently co-occurring medical and behavioral health issues (National Association of State Mental Health Program Directors, 2012). It is not widely understood that occupational therapists receive training in mental and behavioral health and have a unique skill set focusing on roles, habits, and routines that can add to the expertise and effectiveness of the interprofessional PC team (AOTA, 2010a). The profession's educational standards related to behavioral health include knowledge of the current Diagnostic and Statistical Manual of Mental Disorders (DSM) relating to "psychiatric diagnoses, etiology, symptoms, impairments, clinical course, and prognosis" (AOTA, 2010a, p. S35; ACOTE, 2011). Further, OT educational standards include, but are not limited to, the ability to effectively evaluate and provide appropriate clinical care for patients with common comorbidities of mental illness and chronic medical conditions, such as diabetes, obesity, substance abuse, chronic obstructive pulmonary disease, attention deficit hyperactivity disorder, and autism. Occupational therapists are educated in multiple models of evidence-based group and individual approaches to provide clinical care effectively, including cognitive behavior therapy, psychoeducation, behavioral approaches, motivational stages of change, social and emotional learning, and more (AOTA, 2010a). Furthermore, in the last 5 years, the ACOTE (2011) mandated that all OT educational programs require at least one of the student's clinical rotations to focus on "psychological and social factors that influence engagement in occupation" (p. 34).
After graduation, an occupational therapist may practice as a generalist in a variety of settings or complete additional training and earn a board certification in one of several specialty areas. Depending on the needs of the specific PC setting, these specialist skills can complement the general OT training and meet the needs of the patient population (see Table 3).
What Occupational Therapists Currently Contribute to PC
As a generalist working in PC, the occupational therapist's clinical care strategies focus on improving overall function and self-management of health (Donnelly et al., 2014). The PC setting has required a renewed focus on the generalist approach to OT practice. In this model of care, occupational therapists provide rapid, targeted evaluations and brief, evidence-based clinical care strategies consistent with the pace of the PC clinic. An occupational therapist in PC practice does not negate the need for referrals to specialized OT services, such as neurological rehabilitation, certified hand therapy, and developmental rehabilitation, when patients need more involved clinical care than can be provided in the PC setting. They do, however, address issues that do not require the acute medical expertise of the physician and other non-physician providers (Dahl-Popolizio et al., 2016).
Occupational therapists use evidence-based strategies and assessments to identify and address a wide variety of client needs. Occupational therapists in PC can provide individual and group treatment for behavioral activation, patient engagement, and psychoeducation regarding symptom and disease self-management. In addition, occupational therapists can provide population health management using risk stratification to place patients in appropriate individual and/or group programs for the most efficient use of resources. Population health management strategies focus on preventative care, chronic disease management, and management of behavioral health issues, as well as behaviors affecting health. Occupational therapists evaluate for adaptive equipment when it is necessary to maximize function and safety and minimize pain.
Business Case for OT in PC
To fully demonstrate the benefit and sustainability of OT in PC, a business case must be built, as uncertainty about funding an OT position and reimbursement for services have been identified as barriers to inclusion of occupational therapists on the interprofessional PC team (Donnelly et al., 2013; Muir, Henderson-Kalb, Eichler, Serfas, & Jennison, 2014). In addition to explaining the services occupational therapists provide, it is critical to convey that they are not simply an additional expense, but a billable service (Dahl-Popolizio et al., 2016). Occupational therapists are able to use current procedural terminology (CPT) codes commonly billed in PC. They also provide services reimbursed under the CPT codes of physical medicine and rehabilitation, tests and measurements, therapeutic procedures, orthotic and prosthetic management, evaluation and therapeutic services, muscle and range of motion testing, and special otorhinolaryngologic services (American Medical Association [AMA], 2017; Dahl-Popolizio et al., 2016). It is common knowledge that when patients are unable to access in-house services, they often have difficulty obtaining these services elsewhere due to system and patient barriers to referral completion. As members of the PC interprofessional team, occupational therapists are available to address these patient needs immediately. This facilitates the cost- effectiveness (cost minimization and cost utility) of care teams. Tables 4 provides an example of OT CPT coding and billing in a typical day and demonstrates the potential revenue generation that offsets the cost of providing OT in PC. Table 5 demonstrates possible billing in a typical day and the potential increased revenue obtained by PC providers when an occupational therapist is treating patients with behavioral or rehabilitative needs, allowing the PC provider to see patients with more immediate medical needs. The AOTA is actively working to increase the number of insurers that accept behavioral health and case management codes for OT services. Limitations on the use, frequency, classification, and reimbursement of CPT codes in PC are controlled by payor (insurer), license, federal, and state regulations and policies. Regulatory guidelines must be thoroughly reviewed for sustainable cost control implementation.
Reform is leading us to view health care economics, sustainability, and PC services implementation differently. Medical practices are assuming the risk for their patients' health and the cost of care. In this changing environment, PC practices must consider all aspects of providing patient care, including the management of whole-patient care, ensuring optimal health outcomes, and injury and illness prevention, while providing all services in the most cost-effective and efficient manner. Quality care and outcomes are critical to economics and financial practice management. Including occupational therapists on the interprofessional PC team improves quality of care and efficiency in PC settings and specialty practice screening, intervention, and productivity (Dahl-Popolizio et al., 2016; Hart, Elizabeth, & Parsons, 2015; Macdonald, 2006; Metzler et al., 2012; Rexe et al., 2013; Waite, 2014).
To further address the barriers of lack of understanding of the potential contribution of occupational therapists in PC and current reimbursement strategies for sustainability of occupational therapists in PC outlined in this article, future research is necessary to ascertain the receptiveness of PC physicians to the inclusion of OT in PC. Although OT is not named in its report on the integration of physical and behavioral health care, the American Medical Association (AMA) supports the integration efforts of interdisciplinary teams providing team-based care to address the medical and behavioral needs of patients in PC (McIntyre, 2015). The authors recommend further research into and advocacy with the AMA and other interdisciplinary health care guilds to overcome these barriers to OT in this setting, as the educational background and skill set of occupational therapists offer significant value and complement the skills currently available on the interprofessional PC team.
Sue Dahl-Popolizio: Doctor of Behavioral Health, Clinical Assistant Professor and Occupational Therapist/Certified Hand Therapist with the Arizona State University Doctor of Behavioral Health Program, College of Health Solutions. Practice Scholar Affiliate Northern Arizona University Doctor of Occupational Therapy Program.
Oaklee Rogers: Doctor of Occupational Therapy, Academic Fieldwork Coordinator & Assistant Clinical Professor, and Occupational Therapist, Department of Occupational Therapy, Phoenix Biomedical Campus, Northern Arizona University.
Sherry Muir Doctor of Philosophy, Administrator; Faculty Practice & MOT Program, Associate Professor Occupational Science & Occupational Therapy, Doisy College of Health Sciences and Family & Community Medicine, School of Medicine, Saint Louis University.
Jennifer K. Carroll: Medical Doctor, Master of Public Health, University of Colorado Department of Family Medicine, Director, American Academy of Family Physicians National Research Network.
Lesley Manson: Doctor of Clinical Psychology, Clinical Assistant Professor, Assistant Chair of Integrated Initiatives, Consultant for PCBH Implementation and Auditing, Doctor of Behavioral Health Program, College of Health Solutions, Arizona State University.
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Arizona State University, firstname.lastname@example.org
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Sue Dahl-Popolizio, DBH, OTR/L, CHT; Oaklee Rogers, OTD, OTR/L; Sherry Muir, PhD, OTR/L; Jennifer K. Carroll, MD, MPH; Lesley Manson, PsyD
Table 1 Brief, Illustrative Vignettes on Issues Addressed by Occupational Therapists in the PC Setting Examples of Occupational Case Description Therapy Clinical Care 45-year-old male presents with * Complete a postural complaints of wrist, hand, and assessment, develop a shoulder pain that worsens customized home exercise throughout the day, duration 6 program to improve postural weeks. Pain is significantly alignment, increase patient's limiting his ability to work at flexibility, and decrease his the computer, which he does at complaints of pain. least 8 hr-day. He is a college * Complete an office work professor, with teaching and space evaluation, make research responsibilities. He has specific ergonomie tried over-the-counter anti- recommendations, and educate inflammatory medication, but with regarding good body mechanics no real relief. for sitting and computer use. * Discuss how these principles apply to the home office space as well. * Educate natient on modifvine his routine to include short standing activity breaks and brief full body stretches to relieve muscle tension. * Instruct patient on median nerve glides to prevent further development of carpal tunnel syndrome. * Give handouts with visual cues to assist patient with carryover at home for all of the above information. Mom brings in 5-year-old male for * Educate parents on a prekindergarten physical with age-appropriate routines and no real concerns, other than he expectations, and discuss ways is a little overweight and likes to seamlessly implement them to play on the computer or watch into their daily lives. TV. With questioning, mom Provide handouts to improve explains that at daycare, he follow through. usually prefers crafts and * Establishing healthy tabletop games to more active routines (meal time, activity play. At home, he watches TV choices, and bed time while mom cooks dinner, which routines) to promote healthy they eat in front of the TV. physical activity levels and After dinner, he plays video improve healthy behaviors. games or watches TV with his * Provide suggestions on father. He goes to bed around 11 age-appropriate activities to p.m. after a big battle. He is improve hand function and fine very hard to wake up in the motor control in preparation morning, around 6 a.m., to go to for school activities, such as daycare. handwriting. * Discuss creating healthy habits and routines around physical activity/exercise, social interaction/participation, and screen time for electronic media (e.g., meals without TV). Nurse case manager identifies 10 Group education sessions people whose A1C has been high developed in collaboration for more than 6 months who have a with nurse and occupational BMI over 30 and have poor therapist, conducted 1 hr per medication compliance. Referred week for 6 weeks: to occupational therapist for * Establishing healthy group intervention. routines (meal time, activity choices, and bed-time routines). * Choosing healthy foods and label reading at the grocery store. * Time saving cooking tips. * Establishing a routine to increase physical activity and medication compliance. * Managing stress. * Thought and behavior modification strategies to improve mood and resulting behaviors. * Sleep hygiene. * PHQ-9, a depression assessment, can be administered to determine if depression is a factor in poor control of diabetes. 70-year-old woman with long * Administration of GAD-7 history of smoking, chronic (anxiety assessment). obstructive pulmonary disease, * Assist patient to tell the and anxiety presents to primary difference between symptoms care several times per year for of anxiety and inadequate air follow-up after repeated ED supply/exchange. visits. * Develop coping strategies to increase self-management of anxiety (guided imagery, cognitive behavioral therapy) and reduce risk of panic attack. * Pursed lip breathing strategies. * Appropriate exercise/activity to optimize health. * Group interventions for support and education. * Collaborate with medical clinician for behavioral/pharmacological strategies for smoking cessation. Note. ADLs = activities of daily living; PHQ-9 = Patient Health Questionnaire-9; GAD-7 = General Anxiety Disorder-7. Table is adapted, with permission, from "Enhancing the Value of Integrated Primary Care: The Role of Occupational Therapy," by S. Dahl- Popolizio, L. Manson, S. Muir, and O. Rogers, 2016, Families, Systems, & Health, pp. 274-275. Copyright 2008 by the American Psychological Association. Table 2 Examples of What OT Can Contribute to the Team-Based Care with Common Conditions Seen in PC Occupational therapist can Occupational address medical/ therapists can rehabilitative address behavioral Diagnosis issues health issues * Diabetes * Medication * Coping strategies * Cardiac Diseases adherence * Adjustment * Hypertension strategies to illness * Depression * Diet * Family education * Anxiety modification around what to strategies expect and how to * Developing help family member schedules and succeed with plan habits to improve * Educate likelihood of regarding adherence community * Activity program resources that is consistent with patient goals and interests * Educate regarding self-management * Low Back Pain * Education * Coping * Shoulder Pain regarding postures strategies around * Tendinitis * Activity loss of function, modification loss of education employment, loss * General exercise of meaningful education recreation, change in family roles * Strategies to manage co/morbid depression and/or anxiety * Chronic pain Note. Table is adapted, with permission, from "Enhancing the Value of Integrated Primary Care: The Role of Occupational Therapy," by S. Dahl-Popolizio, L. Manson, S. Muir, and O. Rogers, 2016, Families, Systems, & Health, p. 273. Copyright 2008 by the American Psychological Association. Table 3 Current Recognized Specialty Certification Areas Board Certifications Specialty Areas * Hand Therapy (CHT--Certified Hand Therapist) * Gerontology (BCG) * Mental Health (BCMH) * Pediatrics (BCP) * Physical Rehabilitation (BCPR) * Driving and Community Mobility (SCDCM or SCDCM-A) * Environmental Modification (SCEM or SCEM-A) * Feeding, Eating, and Swallowing (SCFES or SCFES-A) * Low Vision (SCLV or SCLV-A) * School Systems (SCSS or SCSS-A) Table 4 A Typical Day with OT Available in PC CPT Code * Number of Minutes spent Per unit fee (visit type) patients with patient 97110 (ex) 2 30 $32.54/15 min 97535 (ADL) 4 30 $35.04/15 min 97530 (act) 5 30 $35.04/15 min 97150 (group) 10 60 $17.52 (untimed) 97003 (eval) 1 30 $85.45 (untimed) 97532 (cog tx) 2 30 $26.82/15 min Total net reimbursement for a typical 8 hr day Total net reimbursement per year based on this typical day (50 weeks) CPT Code * Billed/ Hours/ (visit type) day/code day/code 97110 (ex) $65.08 1 hr 97535 (ADL) $140.16 2 hr 97530 (act) $175.20 2.5 hr 97150 (group) $175.20 1 hr 97003 (eval) $85.45 .5 hr 97532 (cog tx) $53.64 1 hr Total net reimbursement for a typical 8 hr day $694.73 Total net reimbursement per year based on this typical day (50 weeks) $173,682.50 Note. * CPT codes (all modifiers) retrieved from the Centers for Medicare & Medicaid Services (2015). Salaries vary greatly and are dictated by setting and region. Current salary range across the nation according to the Bureau of Labor and Statistics (http://www-bls-gov) is approximately $50-$98,000 per year, with 114,600 jobs in 2014, which is expected to increase by 27% by 2024. As PC is an emerging practice setting, there are no current statistics regarding salaries in this setting. Table 5 Potential PCP Reimbursement With and Without OT A. Typical Day Without OT CPT Codes * Number of Total (visit type) patients revenue 99213 (basic) 16 $1,167.04 $72.94 99214 (moderate) 2 $216.68 $108.34 99203 (new basic) 2 $218.10 $109.05 Total Revenue: $1,601.82 B. Typical Day With OT CPT Codes * Number of Total (visit type) patients revenue 99213 (basic) 4 $291.76 $72.94 99214 (moderate) 12 $1,300.08 $108.34 99203 (new basic) 2 $218.10 $109.05 99204 (new moderate) 1 $165.90 $165.90 99205 (new ill) 1 $208.45 $208.45 Total Revenue: $2,184.29 Table includes typical PCP schedule of billable visits (A) versus using OT as part of the PC interprofessional team and (B) increasing PCP availability to see new and established high-need patients Note. * CPT codes (all modifiers) retrieved from the Centers for Medicare & Medicaid Services (2015). See Table 4 for potential OT billing.
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|Author:||Dahl-Popolizio, Sue; Rogers, Oaklee; Muir, Sherry Lynne; Carroll, Jennifer; Manson, Lesley|
|Publication:||Open Journal of Occupational Therapy|
|Date:||Jun 22, 2017|
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