Renee Kinder

Change is in the air, final prep is occurring, and we are all doing our best to keep calm leading into October and the start of the Patient-Driven Payment Model. 

Conversations across therapy teams should remain focused on ensuring care is uniquely skilled, and that therapists are practicing at the top of their clinical license.

Increasing functional based care.

Reducing non-purposeful interventions.

And sending all your unnecessary equipment which may lead to repetitive interventions to restorative and/or activities teams. 

One campaign, Choosing Wisely, which is an initiative of the ABIM Foundation, has promoted this level of focused based care since 2012.

The mission of Choosing Wisely is to promote conversations between clinicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.

This organization includes recommendations supported by our therapy organizations including specific guides from APTA and AOTA. Additional recommendations useful to teams serving the geriatric population can be found in guides supported by the American Geriatrics Society. 

Furthermore, direction provided by this group aligns very nicely with the messaging associated with the CMS Triple aim which includes the following:

  • Improving the overall quality of care by making healthcare more patient-centered, reliable, accessible and safe.
  • Improving the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care.
  • Reducing the cost of quality healthcare for individuals, families, employers and government.

What information should you share with your teams?

Complete guides from the groups can be located via hyperlinks here: AOTA , APTA, AGS with some of my personal favorites from the groups listed below. 

Don’t provide intervention activities that are non-purposeful (e.g., cones, pegs, shoulder arc, arm bike).

Purposeful activities — tasks that are part of daily routines and hold meaning, relevance, and perceived utility such as personal care, home management, school, and work — are a core premise of occupational therapy. Research shows that using purposeful activity (occupation) in interventions is an intrinsic motivator for patients. Such activities can increase attention, endurance, motor performance, pain tolerance and engagement, resulting in better patient outcomes. Purposeful activities build on a person’s ability and lead to achievement of personal functional goals. Conversely, non-purposeful activities do not stimulate interest or motivation, resulting in reduced patient participation a suboptimal outcomes.

Don’t use physical agent modalities (PAMs) without providing purposeful and occupation-based intervention activities.

The exclusive use of PAMs (e.g., superficial thermal agents, deep thermal agents, electrotherapeutic agents, mechanical devices) as a therapeutic intervention without direct application to occupational performance is not considered occupational therapy. PAMs provided with a functional component can lead to more positive health outcomes. PAMs should be integrated into a broader occupational therapy program and intervention plan in preparation for or concurrently with purposeful activities or interventions that ultimately enhance engagement in occupation.

Don’t provide cognitive-based interventions (e.g., paper-and-pencil tasks, table-top tasks, cognitive training software) without direct application to occupational performance.

To improve occupational performance, cognitive-based interventions should be embedded in an occupation relevant to the patient. Examples of cognitive-based interventions include awareness approaches, strategy training, task training, environmental modifications and assistive technology. The use of cognitive-based interventions not based on occupational performance will result in suboptimal patient outcomes.

Don’t prescribe underdosed strength training programs for older adults. Instead, match the frequency, intensity and duration of exercise to the individual’s abilities and goals.

Improved strength in older adults is associated with improved health, quality of life and functional capacity, and with a reduced risk of falls. Older adults are often prescribed low-dose exercise and physical activity that are physiologically inadequate to increase gains in muscle strength. Failure to establish accurate baseline levels of strength limits the adequacy of the strength training dosage and progression, and thus limits the benefits of the training. A carefully developed and individualized strength training program may have significant health benefits for older adults.

Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.

Careful hand feeding for patients with severe dementia is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers.

Here’s to Choosing Wisely, staying calm, and providing continued focused, purposeful based care!

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and 2019 APEX Award of Excellence winner in Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).