Linking Occupation, Health, and OT through Outcomes Research

1. Linking Occupation, Health, and OT through Outcomes Research Matthew Geddie, OTR, PhD. Rachel Kahlig, MOTS

2. Objectives • Identify the need for a more complete research process • Discuss a four step Outcomes Research Plan • Use a Needs Assessment to identify treatment possibilities • Create a manualized treatment

3. OT in the 1900’s (Occupational Therapy, 2008)

4. “That occupation is necessary to life as food and drink. That every human being should have both physical and mental occupation….that sick minds, sick bodies, sick souls, may be healed thru occupation” William Rush Dunton, MD (Knowles, 1995)

5. “To help patients to readjust themselves, both socially and industrially, through organized occupation” Eleanor Clarke Slagle (100 Influential People, 2017)

6. Within 100 years, have we successfully articulated that occupation is linked to health? (OT Centennial, 2017)

7. (Durham, 2016) “A deep commitment to the growth of the profession and maintenance of the identity of the profession.” Gail Fidler

8. We are here to reinforce and demonstrate to others that being OCCUPIED allows individuals to be healthy!

9. Objective #1Identify the need for a more Complete Research Process

10. What does Research need? • Had students review a Systematic Review of Community Dwelling Older Adults (Stav, W, Hallenen, T, Lane, J, Arbesman, M, 2012) • Results indicate generally good results for Occupation • However, there were important details missing about what leads to a person being successfully Occupied

11. Occupation influences health • The article suggested that better health was linked to all of the following Occupations (Stav, et al., 2012): • Physical activity • Work • IADL’s • Religious activity • Social participation • Leisure activities • Sleep

12. Occupation influences health • Those occupations were measured in a variety of ways (Stav, et al., 2012): • Mortality • BMI • Self-ratings, Interviews and questionnaires • Regression analysis • Mental health, Anxiety and Depression scales • Functional Capacity scales • Mini-mental Status Exam

13. Occupation influences health • Weakness of these findings included (Stav, et al., 2012): • Types of occupation or activities were not clearly defined • Levels of intensity and duration were not clear • Optimal dose and frequency not known • Needs Assessment was not performed (so how important were these occupations to people?) • Components of occupation were poorly defined

14. Defining treatment/occupation used in OT • Random check of five articles

15. Need for Change to Research Process • (Hart, 2009) • Rehabilitation treatments are often described with ‘face validity’ • We know ‘it’ works because we see improvements in our clients • But… We need more knowledge about HOW and WHY things work • We need better research on efficacy and effectiveness

16. Need for Change to Research Process • Difficulties in OT/Rehabilitation Research (Hart, 2009) • Treatment is not consistently defined by therapists • There is a lack of Common Language that limits the ability to specify critical contents of the treatment process by which we think treatments exert their effects on the targeted outcomes • A diversity of settings, populations, and targeted outcomes decreases the chance of having uniform language/definitions • Treatments are COMPLEX • OT’s address behavior, learning, adaptation, coping, feedback loops, and other constructs that likely have both independent effects and interdependent effects on the targeted outcomes • Our treatments are often individually focused limiting the ability to track things repeatedly • Additional “synergy” effects from other disciplines that are difficult to isolate

17. Need for Change to Research Process (Hart, 2009) • Theory • Should start your treatment • Theories suggest Active Ingredients • Active Ingredients • This is what you say or do as an OT • Identification of Active Ingredients leads to Fidelity (the degree to which something is exact when copied or reproduced) • External rater watches or listens or evaluates against some type of checklist of treatment concepts or processes • Operationalize • Translates Active Ingredients into actions • Uses some form of treatment manual (these don’t have to be “cookie-cutter”)

18. Need for Change to Research Process Hart, Tsaousides, Zanca, Whyte, Packel, Ferraro, Dijkers (2014) • Rehabilitation Treatment Taxonomy (RTT) • Theory • Treatment theory • Common language • Taxonomies • Targets • Mechanisms of Action • Active Ingredients

19. Need for Change to Research Process • Rehabilitation Treatment Taxonomy (RTT) (Hart, et al., 2014) • Targets • Targeted Outcomes • Measurable • Mechanism of Action • The actual reason it is believed that the treatment works (e.g. neuroplasticity, strengthening, etc.) • Caused by what the therapist does or says (active ingredients) • Mostly unobservable and must be inferred

20. Need for change to research process • Rehabilitation Treatment Taxonomy (RTT) (Hart et al., 2014) • Active Ingredients • Attributes of the treatment that effect a desired change (targets) • Serve to define and organize treatments and distinguish them from each other • Essential Ingredients • Ingredients may need to be considered along selected continua • Most Ingredients are ‘Behavioral’ in Rehabilitation • Measurable • Delivered through devices, training in tasks and strategies, and other specific clinician behaviors

21. Need for change in research process (Kielhofner, Hammel, Finlayson, Helfrichj, Taylor, 2004) • Researchers must specify a theory • What is being targeted? (Targeted outcomes) • How the change will lead to the outcome? (Mechanism of change) • What ‘service’ will cause the change? (Active Ingredients)

22. Need for Change to Research Process AOTA & AOTF Research Agenda - Optimal dose - Frequency - Duration - Location - Active ingredients - Efficacy and effectiveness (AOTA & AOTF, 2011)

23. Objective # 2:Discuss a four step outcomes research plan

24. Outcomes Research Process (Kielhofner, et al., 2004)

25. Change Needed • So what is the change that is needed? • A continued better understanding of what the client needs and wants • A more accurate and consistent way to discuss and report treatments and treatment techniques believed to make changes that lead to the outcomes that clients want and need • More experiments with the ‘groundwork’ noted above • Dissemination of that evidence

26. Objective #3use a needs assessment to identify treatment possibilities

27. Research Process • What does the client value? • What is the client’s perspective? • What is the client’s self perception? • What roles does the client identify with? (Kielhofner, et al., 2004)

28. (Casper, n.d.)

29. Needs assessment • Needs Assessment • Individual level with each client • This way every treatment is as individualized as possible • Group level • This allows therapist to organize treatment thoughts about certain populations, settings, and diagnoses • This is a large task and needs some sort of coordination

30. What can Be used as a needs assessment? • There are options, but… there is a down side to allowing for more choice. • Some possible options include: • Your own set of interview questions • COPM • Occupational Profile (1 page from AOTA)

31. AOTA’s Occupational Profile (AOTA, 2017) • How can we ask these questions and get the information needed? • Note the page numbers of the OT Framework that can help you organize your questions • You might even use a checklist system to help you and your client identify issues • Therapists can ask • Students can ask

32. Needs assessment in the literature • Examples

33. Needs assessment Important Question… • How can you begin to systematically document the needs of your client/s in a way that the profession can identify “group” needs? • How do you share what you may already do (needs assessment) with others? • At your facility/institution • Within similar settings or practice areas • Within towns or cities • Within TOTA districts

34. Needs assessment • Without better Needs identified, OT’s may be working on issues of less or little importance to clients. • With needs identified, OT’s can do a better job of treating what is most critical • They can do this because they can now link theory and treatment to the actual concern in a more targeted manner, which leads us to our next topic: treatment manualization.

35. Objective #4Create a manualized treatment

36. Research Process • Theory based interventions • Describing process (Kielhofner, et al., 2004)

37. (otstudent, 2011)

38. Real Time Action - http://www.screencast.com/t/cYjjjiwBEdN

39. Taxonomies and Treatment Manuals • Taxonomies – a categorization system that allows for common language to be used • Treatment manuals – Allow for treatments to be usable and reproducible given various characteristics of the client (diagnosis, severity, interests, etc.). • Treatment manuals may run a continuum from fairly rigid to very flexible in nature.

40. RTT (Rehabilitation Treatment Taxonomy) (Hart, et al, 2014)

41. RTT (rehabilitation treatment taxonomy) (Hart et al, 2014) • Table 1 from RTT

42. (Whisner, 2014)

43. (Whisner, 2014)

44. Taxonomies • Taxonomies help define what is involved in our complex treatments • As a profession, we need more guidance on what makes up Active Ingredients in various treatment situations

45. What are your Active Ingredients? • Break into groups • Discuss some patient/client characteristics (come to consensus on a type of client) • Identify targeted outcomes of this client • Brainstorm possible treatments for these targeted outcomes. You may want to consider what type of theory is driving your treatment choices. • What are the active ingredients that allow for the mechanisms of change to alter the targeted outcomes?

46. Treatment manuals (Hart, 2009)

47. Make an abbreviated treatment manual • Now write up a treatment. • Consider that these treatment write ups may be very specific (probably less behavioral) or can be broad overarching suggestions (probably more behavioral)

48. Treatment manual examples • Discuss Treatment Manual Ideas

49. Research Process (Back to Objective #2) (Kielhofner, et al., 2004)

50. Research Process (Kielhofner, et al., 2004)