March 28, 2018

OT Reduces Hospital Re-admissions

The IMPACT Act was designed to improve healthcare by linking Medicare reimbursement to valuable outcomes.  Currently, value is crudely defined by outcomes that can be measured across multiple settings with many different medical conditions.  A basic outcome is the number of clients readmitted to the hospital within 30 days of discharge.  Medicare has begun to financially penalize hospitals with higher-than-average readmissions rates.  Hospital CEOs are very interested in finding out how to prevent these penalties.

Rogers and associates looked at what reduced hospital readmission in 7,174 people over 65 with pneumonia, heart failure, or a heart attack (1).  PT did not reduce readmissions for the three conditions.  An acute illness does not warrant a long hospital stay, but elderly people are often at greater risk because they more likely to have poor strength and endurance.  A short course of PT may not be enough to reverse physical deconditioning.  In addition, PTs are not trained to address the cognitive issues that some elderly clients have which makes it harder for them to follow medical instructions after they are discharged.

However, the study found that OT was associated with fewer readmissions in all three conditions.
OTs evaluate both physical and cognitive skills and can assess the match between a client's abilities, social resources, and physical environment at home.  OTs can recommend solutions when there is a mismatch between abilities and resources BEFORE the client goes home.  For example, there may be a need to train the caregiver or reduce fall hazards by installing grab rails.  The easiest way to quickly grasp an OT's ability to positively affect hospital readmission rates is to read a case study (2).

My Conclusions.
1. These findings apply only to clients with pneumonia, heart failure, or a heart attack.
2.  Lowering the costs is of value to hospitals but what about valued outcomes for the clients?
3.  This is a good start towards using value as a guideline for giving the healthcare system
     financial incentives to produce better results.

1. Rogers A, Bai G, Lavin R, Anderson G.  Higher hospital spending on occupational therapy is
    associated with lower readmission rates. Medical Care Research and Review. 2016;1-19.
2. Renda M, Lee S, Keglovits M, Somerville E. The role of occupational therapy in reducing
    hospital admissions. OT Practice. 2016:August: CE5-CE6.

March 19, 2018

Repeated Frustration Can Turn into Resentment

Able-bodied person cannot feel my pain unless you remember the frustration you feel when you looked for a parking space at a shopping mall a few days before Christmas.  Now imagine frustration escalating when this happens repeatedly.  Imagine having to wait for help thousands of times until caregivers can stop what they are doing.

Opening and refolding the plastic bag inside a cereal box is a two-handed task.  I would have to use my teeth and my sound hand while I am half awake.  Instead I take the bag out off the box, cut one side open with scissors (see arrow), and pour the cereal into the container.  Each morning my sound hand flips open the lid and pours.

I am not going to use my teeth to hold the end of the bread wrapper still so my sound hand can twist the end shut and attach the tie that holds the bag closed.  I fold the open end of the bag under the loaf (see arrow) and slide the loaf inside a bread container made by Rubbermaid.  When I turn the container upright, the weight of the bread keeps the folded end shut.  The next day my thumb flips the lid off, I put the container on its side, and slide the bread out of the container.  No swearing required.

March 11, 2018

I Am Passionate About Transporting Food

I am passionate about transporting food because paying an assisted living facility $60,000 a year is an expensive way to get 3 meals a day.  Meals on Wheels delivers a sandwich and a dinner meal to peoples' homes Monday to Friday so I would still need to prepare meals and buy groceries.

Transporting food begins with getting it into my house.  I make sure the cashier at the grocery store makes each shopping bag light.  I can safely carry two light bags from the car to the front porch.  However, I need my sound hand to hold onto the railing to climb the 4 stairs to my front door.
I was frightened when I started to fall backwards because I lifted my foot before I had hold of the railing.  The back of my head could have hit the concrete patio.  So I place the shopping bags on the 3rd step, hold onto the railing when I step up to the 2nd step, reach down to lift the bags to the top step, and hold onto the railing when I step up to the top step.  This process keeps me out of the emergency room - priceless.

Transporting food after it is prepared is a challenge.  I've dropped full glasses on the kitchen floor.  I live alone and had to clean up the mess with 1 hand.  So I "counter-hop" to get a glass to my kitchen table (on left).
I do not carry a glass across my carpeted living room when I want to drink while sitting on the couch to watch TV.  I place the glass on the far side of the kitchen counter, walk to the other side, pick up the glass, and take a step to place the glass on the end table.

Another food challenge is not making a mess a host has to clean up.  For example, filling a plate at a buffet brunch requires multiple strategies.  I have to set a plate on the table so my sound hand can serve the food.  A buffet table leaves only a small space for plates so one side of the plate hangs over the edge.  I place heavy food, like meatballs, on the side away from the edge to counteract the weight of light food, like salad.  I do not overload my plate and make a 2nd trip to transport a half-full glass.  Part of having a social life is not making people regret they invited you.
Rejecting help when I can do a task is not a matter of being ungrateful.  Unnecessary help
lowers the number of steps on my pedometer for the day.  Walking prevents a loss of endurance.
I live alone so there is no "Honey-do" at my house.  I must be able to walk until I get into bed.
Unnecessary help robs me of the opportunity to use problem solving skills to find solutions for each environment.  I cannot afford to let people feel good about helping me if it means gradually losing the skills I worked so hard to regain.  For me, maintaining skills by using them every day slows the decline that can send me to a nursing home.

March 3, 2018

OTs are Brainwashed and It's Not Their Fault

As an OT I did not know I was brainwashed by hand tests to think that only the dominant hand is important.  Hand tests ask either hand do what the dominant hand does, like use a spoon to scoop beans out of a bowl.  For 35 years Jebsen-inspired test items have been adopted by people who design hand tests.  It is time to stop asking the non-dominant hand to do tasks it never did when a person was well.  1)  Bimanual tasks are the only valid way to assess recovery of the non-dominant hand.  2)  Bimanual tasks can detect early recovery in the dominant hand when it functions as the assisting hand before it can function as the dominant hand once again.

I regret brainwashing hundreds of OT students by showing them this drawing of a palmar grasp that emerges at 6 months.  This grasp involves holding an object with the palm and sides of the fingers instead of the fingertips.  The drawing gives the impression that a palmar grasp is a primitive stage infants pass through on the way to something better.  It does not create an image of adults holding age-appropriate objects.  I wish I could have shown my students the four bimanual tasks below. 
A palmar grasp lets my non-dominant hand hold the watering can still while my other hand controls the garden hose.

A palmar grasp has allowed me to take the cap off the toothpaste tube 6,570 times in nine years.
A palmar grasp lets me hold the hair dryer while my sound hand fluffs my hair.

Notice that my fingertips are not in contact with the food scraper, the food, or each other.

Able-bodied adults use a palmar grasp thousands of times in a life time.  Helping a client gain this grasp is not a small thing.