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HCCIntelligence™ Webinar Recording: Integrating Oc ...
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Hello, and welcome to the monthly HCC Intelligence Webinar and Virtual Office Hours. Today's webinar is entitled Integrating Occupational Therapy into Home-Based Primary Care. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research. I will be your moderator for this event. Before we begin, I'd like to cover just a few housekeeping items with you. All participants are muted, but please use the chat or the questions boxes located on your screen to submit comments and questions. Questions that are submitted will be answered when we transition into the virtual office hours portion of the webinar. The recording of the webinar, slide presentation, and the transcribed Q&A will be made available on the HCC Intelligence page within several days following the webinar. Today we are joined by Monica Robinson, Partner at Living Fully at Home, LLC, and Assistant Professor at Midwestern University. Monica Robinson is an Assistant Professor of the Department of Occupational Therapy at Midwestern University in Downers Grove, Illinois. She's been practicing clinician for over 30 years with interest in community-based practices, including a small private practice she currently runs, focusing on increasing participation of individuals within their homes and community by providing home consultations. Monica has provided presentations at professional seminars on the occupational therapy practices using telehealth, implementing home modifications, and providing nontraditional community services. She has assumed numerous roles for the Illinois Occupational Therapy Association, authored chapters on primary care and home health practices. She currently serves on the National Home Safety and Home Modification Workgroup Subcommittee for Consumer and Professional Education and Training and on a local governance committee for aging in place. Sarah Zampton, Professor, Director, Center for Innovative Care in Aging at John Hopkins School of Nursing. Sarah Zampton is a Health Equity and Social Justice Endowed Professor and Director of the Center of Innovation, excuse me, for Innovative Care in Aging at the John Hopkins School of Nursing. She holds a joint appointment in the Department of Health Policy and Management at the John Hopkins Bloomberg School of Public Health. Sarah tests interventions to reduce health disparities among older adults. Her work particularly focuses on the way to help older adults age in place as they grow older. She co-developed the CAPABLE program, which has been tested in randomized trials and scaled to 31 new sites in 16 states. She was a 2019 HIDES Award winner for the Human Condition and is a PBS organization's Next Avenue Influencers in Aging. Sarah completed undergraduate work in African American Studies at Harvard University and earned a bachelor's degree from John Hopkins School of Nursing. She holds a nurse practitioner master's degree from the University of Maryland and a doctorate from John Hopkins University. She has core faculty at the Center on Aging and Health, the Hopkins Center for Health Disparity Solutions, and adjunct faculty with the Hopkins Center for Injury Research and Policy. She's been funded by the National Institutes of Health, the Center for Medicare and Medicaid Services Innovation Center, the Robert Wood Johnson Foundation, the John A. Hartford Foundation, the Rita and Alex Hillman Foundation, and the AARP Foundation. The objectives for today's webinar are understanding occupational therapy's role in home-based primary care, how to relate, I'm sorry, relate how occupational therapy addresses the geriatric five M's areas of care and quality metrics, and identify a home-based model of care such as the Community Aging in Place Advancing Better Living for Elders that improves evidence for positive outcomes using occupational therapy services. With that, I will transition it over to Monica. Well, thank you for the opportunity to present this material that I have now in front of you. I'm thrilled to be able to provide hopefully some additional insights and understanding as to how OT fits within a home-based primary care model. As such, I'm grateful to Dr. Sarah Zanton presenting with me about the CAPABLE program which encompasses some essential elements of OT practice. Next slide. Well, let me start by sharing an experience that I had shadowing with Dr. Ching on his home visits one day. This will help illustrate some of the unique aspects OT can bring to home-based primary care. There was a young man who had agoraphobia and other chronic conditions including extreme lower extremity lymphedema. He was morbidly obese and was homebound. It was evident that his physical appearance that he was not able to take good care of himself. He had difficulty performing more demanding instrumental ADLs, and he was limited in his ability to identify and problem-solve solutions to the challenges he was facing with his day-to-day routine. It was also apparent that he was depressed given his flat affect and poor ability to manage his symptoms. He had very limited social supports and faced physical challenges in being able to navigate his home effectively. So how could OT have helped this person? Well, next. To begin, we are very ecologically focused on the person and the environment fit. It's an essential for community-based and home practices. We do not address the person in isolation to what their impairment is as it relates to their medical condition, which in this case would have been the patient's lymphedema. Rather, we look to address the transactional nature of what occurs as they interact within their environment and how their functional performance is affected. We consider the social determinants of health that implicate a person's ability to maintain health and function because it's readily addressed in our practice as part of the person's environment. It was apparent that this patient had many physical barriers in his home, limiting his independence such as low seating height, the layout of the home, and the difficulty accessing necessary household items. Matter of fact, there are systematic reviews on OT interventions for community-dwelling older adults. And the key here in all of these is that OT identifies the mismatch between the environment and the performance to maximize someone's independence. Next. We have a unique skill set in addressing functional skills by performing detailed task analysis. For instance, if I had the opportunity to intervene with this patient, I would have evaluated him by observing his actual what we call occupational performance with his instrumental ADLs, asked him if he was able to manage his symptoms, and reviewed his self-management skills. Our interventions typically focus on compensatory or adaptive strategies that match the individual's levels of function, whether that be behaviorally or physically. Next. We work as generalists with a focus on function and participation. OT's practice is generalist, and we look at the participation levels and function as the primary means to treatment. That's what we do. We actually use the function as the intervention. And we use it as outcome measures. For this patient, I would have asked him about his social supports and determined what his psychosocial coping abilities were and how this affected his routines and self-efficacy. We would have discussed simple tasks to incorporate in daily routines to improve self-care and allowed him to generate these solutions through client-identified goals and strategies that are important to him. I could have utilized a norm-referenced criterion assessment tool to measure the outcomes then and show demonstration in improved metrics. Next. So the concept in OT in primary care is not new. It exists in outpatient clinics and throughout the VA system in terms of the home-based primary care model. In Canada, the results of a national survey from an article published in 2016 found that 45% of primary care OT practices are in a clinic setting and 35% are in the home. Most often, the role in that country is prescribing equipment and providing health promotion and prevention activities. Next. Here is some evidence on the effectiveness of primary care OT in improving outcomes for the health and function of older adults with chronic conditions using interventions that focus on health promotion, mental health, falls prevention, chronic pain, and diabetes management. There were two large random controlled trials, they were published some time ago, involving actually in JAMA, an OT lifestyle intervention focusing on wellness and health promotion for an ethnically diverse older adult population. The results of those studies revealed reduced pain, improved social participation, mental health, improved cognition, life satisfaction, and reduced depression. Next. There have been cost savings of OTs implementing pain management techniques to reduce costs for dependence on prescription medications using other alternative pain relieving strategies, including fall risk reduction and addressing supports for Alzheimer patients and their families. And there'll be more to come on this in an upcoming slide. Consider the fact that this is the one message I could drive home, that as you see your patients, you may not have the time or the resources to address all the nuances of the person's environment and ensure that they are following through on the day to day self management tasks. OTs can assist in addressing these aspects, which can ultimately affect your quality metrics. Next slide. The focus of rehab is on addressing the medical condition or impairment, such as what you would likely consider in skilled home health agency rehab professionals when you've worked with skilled home health agencies. But within primary care, the difference is there's a focus largely on prevention and health promotion. Next. Whether it is addressing self-management or symptom control at the tertiary level of prevention, focusing on lifestyle modification on the primary level, OT applies wellness approaches looking at all three tiers of prevention. Next. Therefore, care is not episodic, rather it considers to be longitudinal and it follows the patient with their ongoing health needs because we focus on performance at different life stages across all contexts and address challenging health needs. Next. So you're probably very familiar with OT being part of primary care team through the VA's home-based primary care services. So I won't go into much description this year. Next. There are models of OT primary care within the patient-centered medical homes. The home-based primary care OT is an extension of the patient-centered medical home in some states. There is also a federally qualified healthcare center affiliated with USC and LA where services are being built as a single unit of care and not built separately. And then the funding is split between USC and the federally qualified health center. Next. So where do I see the potential for future growth and how would OT fit in other alternative payment models? Well, first and foremost, I think the independence at home demonstration is a natural fit when evaluating and addressing the functional limitations that patients exhibit in order to even qualify for these services. I will discuss in the upcoming slides what metrics could be addressed to demonstrate the feasibility of how OT services could support the IHA demonstration. Next, when reviewing the primary care first model, OT has been considered an asset to primary care teams as part of the interprofessional collaboration. Since the goal of primary care model is to enhance care for patients with complex chronic diseases and seriously ill patients, OT interventions have proven to reduce hospital readmissions and therefore can contribute to improving the days at home metric for these types of models. And there will be more on this to come as well. Another viable option is for OT to be utilized as part of the primary care team. But as a Medicare Part B provider, one factor to consider I will mention is that you do need to coordinate the care when the patient is receiving skilled home health services at the same time, given that a patient cannot concurrently receive Medicare Part A and Medicare Part B services. And lastly next is the ACOs had a survey through the National Association of ACOs and the Institute for Accountable Care and West Health Institute. And they looked at 163 ACOs that participated in Medicare Shared Savings Program. And there were also a few next generation ACOs. 265 said they have home visit programs. So of those, 25% said they conduct visits but don't have a formal program, 17 are in development and 32 had no plans to start a home visit program. This trend is demonstrating the value of home-based visits and could create more opportunities for primary care services in the home to be conducted in partnership with the ACOs. Next. So now I'll briefly go over how OT can relate to the geriatric five M's. Next. The OT profession has standardized assessments to measure the effectiveness for all of these areas. Some of the assessments that I will be presenting are norm reference criterion and would meet the eligibility to become recognized as a potential quality metric assessment tool. The goal here is to present feasible methods in which OT practices can support better outcomes for physician home-based primary care practices, particularly under the alternative payment models. So for mind, we address this as functional cognition, meaning you're viewing the patient as a whole, looking at all aspects of the client's abilities, which involves their strategies, their habits, their routines, that are used specifically within their context and environment that they exist in. Because of this, functional cognition can only be evaluated within the actual task performance. And since it's functional, unlike impairment individual assessments of cognitive skills, such as attention, executive function, and memory, you achieve a much more reliable outcome. Next. OT uses strategies to address psychiatric and behavioral conditions. As we know that it is very challenging to deal with behaviors associated with cognitive decline, such as Alzheimer's, there are evidence-based interventions, such as the skills to care program. It involves five 90-minute OT sessions in the home. They look at the functional performance of the individual with dementia, as well as the caregiving communication style of the caregiver, and they assess the physical and social environment. The OT provides suggestions focusing on problem-solving and stress-managing techniques. The program has been effective in improving caregivers' self-efficacy, reducing caregiver upset, and notes continued improvement in everyday task performance for up to six to 12 months after the conclusion of the program from the study. The caregivers have found their family members with dementia to have less upset memory-related behaviors, as well as need for less assistance and overall better affect. Next. It's been proven effective because it's using this competence environmental press framework and a personal control theory. Again, the focus is on that person-environment fit. Next. Examples of formal assessments that can be utilized are the performance assessment of self-care skills, otherwise known as the PASS. It's a criterion reference, and it comes in two versions. It looks at a multitude of tasks, 26 of them, looking at self-care, IADLs, and they focus on cognitive as well as physical performance. The scoring is based on the levels of assistance of what someone needs to do and looks at the independence and their safety performance. Another assessment tool is the executive function performance measure, and it measures the IADL by looking also at the levels of assistance. They break down the cognition as terms of problem-solving, safety judgment, organization, et cetera. But both of these assessments are performance-based and therefore are ecologically valid assessment tools. Next. So, for mobility, when OTs address mobility, they're largely considering the functional mobility within the home via the use of adaptive devices or techniques to improve safety and reduce falls. Fall risk assessments, next, are effective in reducing falls when they focus specifically on individually tailored fall prevention assessments and interventions that target a patient's multiple fall risk factors, and these could be low vision, medication use, environment balance, balance confidence, postural hypotension, fear of falling, mobility skills, and footwear. OTs address these areas. Next. A recent systematic review on home modifications showed strong evidence for both single and multi-component interventions to reduce risk of falls in older adults and improve caregiving for people with dementia. Know that comprehensive and intensive interventions demonstrate greater effectiveness in improving functional performance. Home modifications provided by OTs reduce falls by 39%, and these are from studies that were conducted in Europe and Australia. What you see now, the last point, is the Home Hazards Removal Program, otherwise known as HARP, and it demonstrated improved outcomes as well. Some of the measurements they were looking at were the first fall over 12 months, ADL performance, falls self-efficacy, and health-related quality of life. The current protocol involves one to three visits from OT over a month period, with an average modification of the cost about $200. This is just another example, similar to the CAPABLE Program, which Dr. Zanton is going to talk about, that OTs' role in home modifications can provide to improve safety and mobility of older adults. The examples of the formal assessments that can address the home safety are the in-home occupational performance evaluation that actually looks at the patient's desired activities, they identify them, that they have difficulty performing. It's an observational performance assessment, and you look at the pre- and post-intervention performance scores to determine effectiveness. The WEST-ME home safety assessment has been more widely utilized. It was also utilized in the HARP protocol. It's a home safety checklist that identifies fall hazards, looking at all areas of the home, and focuses solely on risks related to fall. Next. Medication adherence is an important aspect to symptom control for chronic diseases. When it comes to medication management, OTs focus on the routine and habits a person utilizes in taking their medication, not on educating them on the medications. Rather, we emphasize on how they can be successful in adhering to their medication regimen. One study demonstrated the effectiveness of OTs collaborating with patients to develop individualized medication routines to promote medication adherence. I think the success of all of this really relies on the communication and collaboration between primary care team members in identifying areas that may not always be apparent because they're secondary symptoms to their primary condition, such that they might have cognitive issues, which we know are well associated with chronic diseases, low vision, and dexterity factors. I have often, during my home health experience, come across patients who are not able to effectively manage taking their diabetic medications due to these secondary symptoms and was able to problem solve with the medical staff members on strategies that promote successful ways for alternative methods of medication administration. One of the formal assessments that can measure are the In-Home Medication Management Performance Evaluation, known as the HOME-Rx. It's a performance-based medication management assessment tool, just similar to what I described earlier in the I-HOPE, but this one has three parts. It has an interview. It looks at the actual medication list and the medication management assessment. Each part has a subscale that provides scores on safety, performance, capacity, and severity of the environmental barriers, so looking at that transactional relationship. Another assessment is the Cognitive Performance Test, which is standardized, and it addresses independence with IADLs within the patient's typical context. It uses seven subtasks, and it actually has something called the Med Box, and the patient is rated on a score using a five-point level of functional cognition, from intact to late-stage dementia. It has indicating corresponding levels of assistance that are required along all levels. It's even been recently utilized to test the sensitivity with fitness to drive for patients with neurocognitive disorders. Next. So, when it comes to matters most, our profession focuses on client-centered treatment. That's the hallmark of what we do. Patients identify their goals based on what are meaningful occupations that they wish to participate in. Goals are driven by the patient, and standardized assessments are utilized that are guided by those activities patients have identified as most important to them. It's how all our assessments and interventions are guided. Examples of some of these standardized assessments are client-centered, which is the Canadian Occupational Performance Measure. It's a client-reported outcome that's standardized and shows a statistical change by looking at a quantifiable number. The effectiveness of the interventions is determined by the pre-post-comparison scoring. The activity card sort is another client-centered assessment, and it looks to identify tasks ranging from low physical demand to high physical demand, as well as leisure activities and social activities. Both assessments provide these quantitative measures to determine change in functional performance. Next. OTs can facilitate implementation of self-care management skills for those patients that have multi-complexity chronic diseases. We assist to identify areas to problem-solve gaps in ability to follow through on medical management of symptoms, whether this has to do with addressing how the social and physical environment impact their ability to manage their care, or next. Another aspect we consider when it comes to chronic conditions, such as COPD and CHF, is how often secondary symptoms of cognitive changes are associated with these conditions, and how this has a direct impact on effective medication management and lifestyle adherence, such as proper nutrition. Next. OTs not only assist with addressing specific conditions-related symptoms and changes through lifestyle interventions, but also promote general health and wellness by ensuring they're able to engage in those activities that are meaningful for them to participate and address their overall quality of life through health behavior change. There are a few widely-researched and efficacious wellness approaches that are delivered through group interventions, but have been modified for individualized sessions. Recently, there was a hybrid model using a lifestyle redesign and a diabetes program that was OT-driven, demonstrated effectiveness in improving clinical outcomes. It was a random controlled trial for an ethnically diverse low-income group of patients with uncontrolled diabetes. They had an HbA1c score of more than 9%, and they were delivered in a safety and primary care setting. So, significant findings. Next. So, let's look at how OT and home-based primary care quality metrics can be applied. Well, if we look at the primary care first, and we look at the days at home, OT has the ability to reduce hospital readmissions, and this has been proven, next, through, have a direct impact on both of these two models. So, this is the primary care first model and the IHA demonstration. The study here was cited on a review of hospital spend for acute care services using Medicare claims and cost report data. They investigated the hospital spend for specific services and a 30-day readmission rate for congestive heart failure, pneumonia, and acute myocardial infarct, and found that OT was the only spending category where additional spending had a statistically significant association with lower readmission rates for all three medical conditions. This is the thought that OT focuses. The reason they thought it was so important is that it focuses on the patient's functional and social needs. Next slide. OT also has a role in hospice and palliative care with emphasis on caregiver education and support while promoting active engagement of patients by matching their abilities to their desired occupations and patient goals. OT's equip the family and patients to be able to deal with daily tasks and changing abilities by providing adaptive strategies for patient positioning, modification of activities, and to facilitate a good death experience. Focusing on these aspects supports home-based primary care and ensures the ability for family caregivers to be able to more effectively manage the care of their family member at home and avoid those hospital admissions and transfers to skilled nursing facilities. Next. When you review the MIPS metrics, you can see that we've covered these quality metrics during the review of the five areas of geriatric care. We reviewed the evidence-based effectiveness of these interventions along with a sample of assessment tools that could demonstrate the change. As mentioned previously, the intent here is to recognize that OT can have a direct impact on your quality metrics that you may be assessed for and therefore would make it beneficial for you to consider including OT services as part of your primary care treatment. Now I will turn it over to Sarah Tanton. Thanks so much. What a pleasure to follow you, Monica. You make all of the important points and I'll just have some kind of color commentary about our specific CAPABLE program. Next slide, please. Thanks. Next slide. Great. So we developed CAPABLE, me and collaborators, after I had done house calls as a primary care provider, as a nurse practitioner throughout West Baltimore. Next slide, please. And as I would do those visits, I was very kind of classically medically trained, so I'd be looking at their diabetes or their high blood pressure, their sedentariness. So I might approach someone like Mrs. B, who had congestive heart failure and diabetes and arthritis, about those conditions. But next slide, please. You'll see from this slide that she couldn't really get into her clothes, that's her closet, because her bed was in the dining room because she couldn't get up the stairs. Next slide. This is her floor after we had fixed it, and then she had holes throughout it. So it was actually really dangerous for her to walk around and it made sense in a way for her to sit in her chair all day. Next slide, please. And these are her stairs. So going outside was treacherous, would have been treacherous even if she had been a spry 50-year-old. So next slide, please. So we developed CAPABLE based upon the ABLE program that had been developed by Laura Gitlin, who Monica Robinson mentioned, that was occupational therapy and home modification. And we added nursing visits and home repair and also everyday items. So for example, for Mrs. B, we actually bought her a sliding closet from Ikea. And you don't necessarily think of that usually as a home modification. So we get sturdy step stools for people or closets. And of course, a lot of things that OTs know all about, like cutting boards specifically made for someone who's got one arm that doesn't work, for example. But the underlying thing is we address people's function by treating the whole person, modifying the environment, thinking about environmental press, as Monica mentioned. Next slide, please. And we can do this. So it ends up costing about $3,000 a person. But insurance companies are starting to invest in this because functional limitations are costly. And Monica mentioned the preventive aspect of primary care. It turns out you can really target who will be more expensive over time, next slide, based on their ADL and IODL limitations. So this slide is old data, but the pattern currently still exists, where you can see that people are much more likely to be what economists call high-care users if they need help with ADLs and IODLs. So occupational therapy is crucial in this prevention of spiraling into high-cost spending. Next slide, please. So because of this, older adults drive the population health outcomes for every insurance. In any insurance, about 10% of the people use about 60% to 70% of the health care dollar. And occupational therapists are really well-poised to pull that back. Next slide, please. So in CAPABLE, a couple of things are different about it than some other models. The older adult is the expert. And what we're going in there for is to find out what they would like to be able to do to age in place successfully. So it's not about controlling their diabetes or controlling their high blood pressure or anything that's medical. It is all about, what would you like to be able to do? Well, I would like to be able to get down my front steps and into my daughter's car. Or I would like to be able to garden that back. Or Monica talked about meaningful activity as the occupation part of occupational therapy. And it turns out that when you address what someone wants to be able to do, that the M that she mentioned of what matters most, and we do it with mobility and medication, that turns out you save enough money, CAPABLE saves seven times what it costs. And so all we are doing is supporting their goals by working on their home environment and their intrinsic, their pain, their mood, their strategies for accomplishing ADLs and IDLs. And it turns out we increase physical function and reduce depression enough that that impacts hospitalization and nursing home admissions. Next slide, please. So the M, it's four months. It's an occupational therapist, a nurse, and a handy worker. The OT has six visits, the nurse has four visits, and the handy worker has up to $1,300 budget. And as I mentioned, that includes home repair, medications, assistive devices, and everyday items. And in the question and the answer, we can get through into that more. It costs, as you can see, a little less than $3,000. And the main things are ADLs and IDLs, but we address other meaningful activity as well. Next slide, please. And so this is, the OTs on here are the heart-shaped hands holding each other. And the OT opens the case and has the first two visits, and where there's an assessment called the C-CAP, and then an assessment, a performance-based assessment. As Monica mentioned, that's where you see this personal environment fit. So if someone says, I'd like to be able to get in, out of the bath myself, rather than having to wait for my grandson to pick me up and put me in the bath, or I'd like to be able to get on my back stoop rather than waiting for my husband to be able to come home and lift me up over the step. OT actually observes this. What are they doing? Are they grabbing onto the soap dish, for example? The nurse is the logo up at the top with the medical bag with the heart. And the nurse addresses things like strength and balance, pain, mood, the medications, if there's too many, if there's too few, and primary care provider communication. So the nurse is kind of the contact for looping this person back into primary care and making sure that the primary care provider understands about the person's goals. And then the handiwork is represented on the bottom. The OT really makes up a work order based on the older adult's goals that include what I mentioned about home repairs, modifications, everyday items, and assistive devices. Next slide, please. And this is just a visual example of how important home mod can be. Next slide. So I'll talk to you about the data in a minute, but CAPABLE is now actually in 32 places in 17 states. We just added Alaska two weeks ago. And it has spread. It was started with research, NIH-funded research, and it's been spreading through philanthropy and also through policy. Next slide, please. And these are data from our, we had a CMS Innovation Center trial, and this was published in Health Affairs. And I know you can get the slides and you can find this article or I'm happy to send it. You can see that 75% of people improved in their ADLs and 65% in their IADLs. And this is over time, low income, dually eligible people who had Medicaid and Medicare. So, and the average reduction was cutting disability in half, which is really quite remarkable. And I think speaks to the combination of the disciplines and this like almost radically based older adult centric approach. Next slide, please. It also improved depressive symptoms and of course, home hazards. Next slide, please. These are the data from the first randomized control trial of CAPABLE where we had 30% reduction in ADLs from baseline to five-month ADL limitations. And even though the control group improved too, we had a control group that was attention-based. So people got as many visits and they were also goal-based and that the person derived, but they were sedentary goals. So people really liked it and they benefited from it. We were glad for that, but the benefit was stronger in the CAPABLE group. Next slide, please. And this is essentially the same data. Next slide, please. This is data from Dr. Ruiz published in Health Affairs showing that over a two-year period, Medicare saved per quarter, per patient on average, $2,700. And that's just about as much as CAPABLE costs one time. So you can see that over eight quarters, it saved each quarter what CAPABLE cost in one quarter, which is why we can say that it saves about seven times what it costs. And that's just in Medicare. It's saved an additional three times what it costs in Medicaid. Next slide, please. And this is showing you with the Medicaid and the biggest savings, you can see the biggest difference is that orange, that's inpatient savings. So the difference in the dark blue at the bottom is the nursing home savings. And that's what we expected to really make a difference. And it turns out that that difference between the dark blues is enough to pay for CAPABLE for that whole cohort, just that difference. But then the hospitalization really put it over the top in terms of savings. And it makes sense because if you think of some of the people, older adults you work with, they're much more likely to go into a hospital in a given year than go into skilled nursing care. Next slide, please. And as I mentioned, people in the control group loved CAPABLE. People in the CAPABLE group loved it even more. The green is the CAPABLE group. And you can see that, you know, almost 100% said overall benefit. 90% made life easier, made their home safer, keep them living at home, gain confidence. People love CAPABLE. So it's four months. And actually in OTs and nurses love providing CAPABLE after they get used to the idea of putting the older adult in charge. It is a little bit of a learning curve. But to be able to see someone go from not being able to get off the couch, from not being able to take a bath, from not being able to get outside, to be able to do those things, someone just affect lifts a partway through CAPABLE. And it's like they're a new person. Next slide, please. So I think I'll save the story. I know we wanna get to questions and answers. I'll save some of the stories until the end if we have time. So we'll skip through. I think there's three slides of people's stories. So next one. And well, this is something one person said to me. She said, if I had 10,000 tongues and they could all speak at the same time, I couldn't praise the CAPABLE program enough. And she had gone from not being able to hear in church, not being able to get up off a chair herself, not being able to get in the bath, and being in pain and a little breathless. And she identified all those through the assessments and we were able to address all of those. And so she really found it life transforming. Next slide, please. So the reason it works, we ensure the person environment fit. We unleash their motivation, which is really key. It's not about what we want or what we think matters. It turns out the best way to target something is what they want for their own lives. We honor their strengths, not just think about their weaknesses. And then we are able to provide resources. So rather than saying, oh, you should really get that banister fixed, we fix that banister. Or we've put a second banister on most stairways if they're interested in fall prevention. And the program builds self-efficacy for new challenges. So people will often call us when they're done with CAPABLE and say, oh, I had a new challenge and I brainstormed it and I wanna tell you how that went. Next slide, please. So just to kind of recap, core function is costly. It's what older adults care about. It has been ignored, not by OTs, but in terms of prevention in regular medical care, it's generally been ignored and that's starting to shift as Monica is talking about with primary care first and ACOs and function can be modified. I think a lot of, certainly in medical training, people think, oh, once you're disabled, then you're disabled but we've shown that it can be cut about in half just with a pretty modest program. Next slide, please. Next slide again. Yeah, so just kind of a pitch for home-based care. And I know I'm singing to the choir here, but that hospital-based innovation is great. And so is clinic and outpatient care, but the new thrust is in home-based care and home-based primary care and hospital at home and what can we do to improve people's everyday environment to make it a great place to grow older. And certainly in COVID, that's even more important. Next slide, please. So I'm happy to talk in the questions and answers about the payer possibilities. And in fact, I know Monica talked about that some and just in March, CMS listed next generation ACO questions and answers. And one of them said that OTs could, that primary care practices could bill for OT services for non-traditionally home health care beneficiaries for services that would keep people out of the hospital. And we're in the middle of getting an answer from CMS about whether people could bill for capable. Next slide, please. Yeah, so this is just for those of you in the field, I just wanna put out there that any of you can come up with good ideas to change practice. I kind of had a aha moment when I was a nurse practitioner and I was seeing patients and you start with research funding. And then as you get bigger, you have philanthropy and then ideally you have fiscal incentives that are aligned in the policy environment, but your work can make that change. And that people sometimes credit capable for changing the way CMS is thinking about some of these issues. So I think just for everyone on the call, be thinking about your own insights and your own thoughts and what you could develop that could grow and help you make that change. Next slide. Yeah, and we can talk about this part in the questions and answers, but I'd love to get to your questions. So thank you very much. I guess there's one more slide. That just, you have great ideas grounded in reality, ready for change and you see what matters. And so I would encourage all of you to think about how you could change practice based on your insights. And that's it. Thank you so much. Thank you so much, Sarah. I really appreciate that. As we transition into our virtual office hours, we're joined today by Dr. Paul Chang, HCCI Senior Medical and Practice Advisor and Brianna Plintzner, HCCI's Manager of Practice Improvement. They're here if you have any questions that are not related to our topic today and are able to address those questions for you. We did receive a few questions ahead of time and we'll address those now. And then as we go through these, if they spark another question for you, by all means, please feel free to type those in. First question. Any tips for integrating OT into a palliative program? Are there any specific goals that you would recommend for OT in a palliative practice? Yes, absolutely. OT has been involved in hospice and palliative care. And we actually, as a profession, our National Association has a position paper on that. And so it ranges from anything having to do with caregiver education, very much many of the strategies that I mentioned in terms of what people deal with in terms of chronic disease management. The primary goal is to empower the individual to be able to be engaged as much as possible in whatever activity is important to them. We also look at strategies as far as adaptive techniques. So anything having to do with fatigue management, which is oftentimes associated with conditions that require palliative care. There have been effectiveness and studies done where there's been a change in functional performance, patient satisfaction and quality of life for people living with cancer, congestive heart failure, respiratory diseases, neurodegenerative diseases, and even advanced dementia. So there is definitely a role for OT. It exists. Another question, where can we find more information about primary care OT for non-homebound patients? So I'm not sure if this question would really get at potentially being still delivered in the home. There are a few practices out there in terms of private practitioners that are doing what they're calling now mobile therapy. And they're essentially Medicare Part B providers. Depending on what state you live in and where you're calling from, there might be avenues for you to find out who those individuals are. But as was mentioned, for the non-homebound, there are also, as I mentioned, in the Southern state, there's an OT who provides these services through the patient-centered medical home and provides this for patients that are also non-homebound. So if I haven't answered that question as fully as I could, I'm hoping the person can reach out. Thank you. What are the environmental characteristics to observe for patients for their functional potential? Well, it's primarily to look and see what is it that they expect to be able to do. And so it's driven by the activity that is expected. If they are having difficulties with their self cares, we would obviously then go into the home environment and look at the bathroom, look at the actual transfers that someone is performing. We would look at where items are kept. Very much the principles that I utilize when I look at someone is very similar to what ergonomics is in terms of looking at their anthropometric measurements and looking to see what their endurance is like. So these are factors that we look at and we look at the home, looking to see, as I mentioned earlier, how it fits the individual. Perfect, thank you. How many staff are employed by the program? How are services tracked? Or how long are patients tracked after an intervention? And are patients able to have another intervention later if this destabilization comes back over time? Do we think that's a capable question? I'm thinking it is, Sarah. Okay, well, I'll just say that I'm thinking it is, Sarah. Okay, well, I'll just answer it as though it is and someone can ask again if it's not. So the question was about, I think there were three parts and maybe, Danielle, you could read each one. I think the third one was, can people have it again? And that's really up to the implementing site. We have certain guidelines that we require. For example, people can't drop out the OT for a PT or something, but there's a lot of stuff that's just up to the sites as they implement it. So some sites, someone could get it the next year, for example, or after a stroke, but that's really up to the implementing sites and what they think makes sense. We've also had a few sites that have implemented it as a prehab, if someone's going to have a planned surgery, like a hip or a heart valve or something, and where they fix up their house and look at their goals before a surgery. And so that's another way. But, Danielle, are you able to say what the other two parts of that question were? Absolutely. The second part of the question, how long are patients tracked after an initial intervention? Okay, so for our research, we did it up to 12 months, and the cost people did it up to two years. And for the tracking, if someone on this call implemented it in their own primary care practice, that would be just up to you, whatever made sense. As again, I said, we're very loose about the rules, about what people have to do. We figure it makes more sense for the local organizations to decide what matters for them. Okay, and then the first part of the question was, how many staff are employed by the program? And, I'm sorry, and how are savings tracked? So the staff, usually an OT and a nurse can each have about 35 participants at once, and they have them for about four months. So in a year, you can have 90 to 105 or so in a year caseload, if you're full-time. So the places tend to hire either part-time or full-time based around a caseload like that. And how are the savings tracked really depends on the organization. We had people's Medicare and Medicaid numbers because it was part of a research study, but as insurance companies, other places are starting to do this, they've got their ability to track through their own metrics. So if you were like a Habitat for Humanity or a local home health agency, you would have to work with the payers to be able to track the utilization, unless you just asked people if they'd been in a hospital or been in a nursing home. What is the most helpful to include in an order for home-based occupational therapy? As a practitioner, I would look for information, first of all, if there are any medical contraindications, what the medical diagnosis is, but primarily whatever it is that brings the person to OT. So if it's been identified that they're unsafe or if they're having difficulty performing certain ADLs, it isn't uncommon that an order could just be about evaluate and treat. It depends on the amount of information that the practitioner would have available about the patient as well. So, but the order itself, helpful for diagnosis, and if there are any specific functional limitations is what I would say. All right, thank you. As we continue, we have about eight more minutes, and I just want to remind everybody about our HCC Intelligence Resource Center. We do offer free technical assistance. You can either do it via the hotline, our webinars, excuse me, virtual office hours, or our tools and tip sheets. We do wanna take a moment too to thank Sarah Zanton and Monica Robinson for joining us today and sharing their expertise and answering our very challenging questions that our learners presented to us. There's also two more questions in the chat, looks like. Oh, there is, I apologize, I missed those. Thank you for catching those. Sure. A question, how is a handyman repair person vetted to make sure that the work is done in a quality fashion? So that's a great question. I'm sorry, I've got a tickle in my throat, one second. Typically what the capable sites do is they work with a separate organization that does its own licensing and bonding for the handy worker or it's a Habitat for Humanity that starts the project and then they have vetted everyone. But it is really important to work with reputable providers. We don't recommend, there's one project that tried to get three bids for every job and that just was exhausting for the older adult to have people come there that much. And it's much better either for the health place to hire their own handy worker or what's more usual is to contract with a nonprofit that either is already exists that works with making older adults' houses safer or for example, an AmeriCorps, sorry, an AmeriCorps site that trains people in carpentry. We do have lists and networks to hook people up with that. But yeah, you don't want just someone who drives by looks handy with a hammer. Understandable. The other question and before we go into it, we were hoping, some of our learners were hoping that they'd love to hear at least one of the patient stories that Dr. Zanton was mentioning. Sure. Let me just find those slides to tickle my memory. Would you like me to go back? No, I got it. It's okay. Right, well, so I'll tell you one. So we had one, she was actually the first, we'd already started, we'd done the pilot and we'd started our randomized control trial but she was our first CMS innovations. Participant. And when the, our OT, Alison Evelyn Gustav got there, she was, the person was like nodding off in a chair and the chair was a commode chair and her bedroom was only her bed and the commode chair. And she hadn't been downstairs in her house for two years. And she was, which took her 30 minutes to walk to her bathroom with the OT and that was about 30 feet away. So the, when the nurse started, she realized that the family was giving the participant 26 different medications all at once. And that they thought they were doing a good job with medication adherence. And it turned out a lot of them were for pain and were overlapping. And so she was really over medicated. And once she, once that was all straightened out and we do a really typical medication reconciliation. Once that was straightened out, she was more alert and she was excited. And she came up, her goals that the OT elicited were to be able to get downstairs. Remember, she hadn't been downstairs in two years. To get downstairs and wash her hair in the kitchen sink, which is such a good example of a person directed goals because there's no OT or nurse who would have walked in and said, I think you should wash your hair in the kitchen sink, right? But that's, that really, really motivated her. And she was really socially isolated up in that room because people would come to see her, but they would just say hi and go, like her grandchildren. So getting downstairs was also a way of her being kind of more included in the family. She also was unable to get out of bed herself and her husband who was quite frail, would have to lift her up out of the bed and then kind of drop her as gently as he could into this commode chair she sat in all day. So, you know, the OTs on the call will recognize we did some fairly standard things like bed risers and railings on both sides of the steps, but also crucially, she thought of in the brainstorming process, what about if we use part of the budget to buy a little plastic deck chairs that could go along the hallway from her to the bathroom, which was also the hallway to the stairs. And she would just practice in the month between one capable visit and another, she would just practice getting up from her chair and moving very slowly to the next one and sitting down. And so she actually made up her own exercise regimen, but we wouldn't have called it that. She didn't call it that, but it was figuring out for herself how to get that endurance. And with the bed risers and a grab bar inside of the bed, she was able to pull herself up out of the bed. And the first time she did that, her husband burst into tears at the idea, the dignity, the dignity difference for her. And she was able to get downstairs and actually at the two months after she finished capable, her granddaughter called and said the whole family was going to Atlantic City, including Mrs. D. And so she went from nodding off in a chair, unable to get out of the bed, unable to get downstairs to freely using the house, washing her hair herself and getting out of the bed. So that's just an example of targeting someone's goals with resources and clinician knowledge. That may hands down be one of my favorite stories ever. So as we wrap up, we have one minute left. I just want to remind everybody about our upcoming HCC event. There we go. Every Wednesday, excuse me, every third Wednesday of the month, we host a free webinar on clinical or practice management topics. Wednesday, September 16th, we'll be leading teams during the crisis, COVID-19 and beyond. And our presenter will be Cheryl Betting. We'd like to thank all of you for joining us today. Thank you so much again to Monica and Sarah, not only for the great stories, but for your expertise and just sharing background information on how OT can just over overarching in so many different areas that is really just great to learn about. And to Brianna and Dr. Paul Chang, thank you for being here in a supportive manner. If any questions did arise, we wish everyone all the best, stay safe and have a wonderful rest of your week. Thank you so much. Thank you again. Thank you.
Video Summary
Monica Robinson and Sarah Zanton discussed the integration of occupational therapy (OT) into home-based primary care. They shared insights on how OT can address the geriatric "5 M's" areas of care and improve outcomes for patients. They emphasized the importance of focusing on the person-environment fit and considering social determinants of health in order to maximize independence and functionality. OT interventions can address functional cognition, mobility, medication adherence, and matters most to patients. They provided examples of formal assessments that can be utilized to measure functional performance and track outcomes. Monica and Sarah also discussed the CAPABLE program, which combines OT, nursing, and home repair services to help older adults age in place. CAPABLE has been shown to improve physical function, reduce depression, and save costs for Medicare. They highlighted the importance of home-based care and the potential for OT to contribute to this growing field. Monica and Sarah answered questions about integrating OT into palliative care, the vetting process for repair workers, and the order for home-based OT services. They shared patient stories showcasing the impact of OT interventions on improving functional performance and quality of life. Overall, they emphasized the valuable role of OT in home-based primary care and its potential to improve outcomes for older adults.
Keywords
occupational therapy
home-based primary care
geriatric care
person-environment fit
functional cognition
mobility
Medicare
CAPABLE program
aging in place
functional performance
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