Dr Deirdre Connolly , Trinity College Dublin (TCD)

Effectiveness of Occupational Therapy interventions for Homecare clients

Dr Deirdre Connolly & Ms. Carmel Cooney: Discipline of occupational Therapy, Trinity College Dublin Ms. Avril Carey, Ms. Sinead Crowe & Ms. Ellen O’Dea: Occupational Therapy, Dublin South Inner city Primary Care team

Trinity College Dublin, The University of Dublin

Background to the study

• Increase in ageing population nationally and internationally

• By 2041, there will be 1.4 million people in the Republic of Ireland aged 65 and over

• Increased incidence of chronic diseases as people age

• Ageing and presence of chronic diseases result in reduced physical, mental and cognitive functioning.

Subtitle – Calibri Regular 14pt


ADL/IADL difficulties

• 13% had difficulty with ADL

• Most difficulty in dressing and bathing

• 11% difficulty with IADL

• Most difficulty with household chores and grocery shopping

• Over 80 years: 32% difficulty with ADL and 25% difficulty with IADL

• Risk factors for ADL/IADL (after age) were pain, taking five or more medications and depression

Connolly et al., 2016


Homecare support scheme • Introduced to reduce risk of admission to long term care for older

adults and latterly to assist in hospital discharge to home.

• Reduce the proportion of older adults in institutional care; to provide a greater quality of life for older adults living at home

• Intended for people with medium to high care support needs

• Budgets range from €55m in 2007 to €120m in 2008

• Administered by HSE through local health offices

• Funding reduced and ceased on several occasions over the past 8 years.


Homecare support scheme

• Support needs are assessed through a care needs assessment carried out by Public Health Nurses.

• Provides a range of services but most frequently provides personal care assistance and home help.

• Initially provided a sum of money for the person to employ their carer, now carers are provided through nominated private home help companies.


Occupational Therapy Intervention

• Funding obtained for one-year pilot project of home-based occupational therapy in Dublin-South inner city area

• Occupational therapy aims to improve functional abilities in self-care, productive and/or leisure-based activities that people want to, or need to, do over the course of their day.


Study aims

• To explore the impact of a dedicated home-based occupational therapy service on:

• functional abilities of older adults in receipt of HCP

• On allocation of HCP hours

• To explore perceptions of those receiving the service, their families and other stakeholders involved in the delivery of HCP, on their perspectives of a home-based occupational therapy service


Study methodology

• Mixed methods exploratory study

• Sample:

• 15 people receiving home care services

• Family members

• HCP coordinator

• HCP occupational therapist

• University ethical approval


Study measures • Quantitative

• FIM+FAM (Functional Independence Measure + Functional Assessment Measure) (Keith, Granger, Hamilton, & Sherwin, 1987)

• Montreal Cognitive Assessment (MoCA) (Nasreddine et al., 2005)

• Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983)

• EQ-5D (Euroqol) (EuroQol-Group, 1990) Health-related quality of life

• Goal Attainment Scale (GAS) (Kiresuk & Sherman, 1968)

• Qualitative interviews with all stakeholders

• Chart audit of nature and duration of occupational therapy interventions.


Inclusion/exclusion criteria Inclusion Criteria Exclusion Criteria

Over 65

Recently allocated a home care package

Have rehabilitation potential as confirmed

by chart review and/or discussion with

primary care team members

Significant cognitive impairment as

measured by the MoCA: a score < 10/30

Visual impairment impacting on ADL

safety

Chronic respiratory issues that are

impacting on ADL participation

Palliative condition: cancer, COPD, CCF,

renal failure.

Home care package recently increased or

decreased in the past 3-6 months


Participants’ profile Characteristics Participants (N= 15)

Mean Age: 86 (range 82-91 years) Females 14; Males 1

Marital status

- Single - Widow

4

11

Living situation

- Alone - With family

14

1

Education Status

- Attended University - Attended secondary school

4

11

Median no. of homecare hours pre intervention

(range)

5 (2.5 - 12)

Median no. of health conditions (range)

3 (2-6)

Median no. of medications (range)

8 (5-19)


Interventions Type of goal

No. of participants Total no. of goals set per category

Bathing practice 9 13

Use of Equipment 8 19

Meal Preparation 8 11

Transfer practice 7 11

Community mobility 7 8

Community involvement 6 7

Dressing practice 5 8

Fall prevention education 5 5

Self-advocacy 4 5

Memory strategies 4 5

Stair Mobility 4 4

Pressure Care 3 3


Functional Independence measure scores FIM+FAM Item

(Max. Score)

Time 1

Median

(Range)

Time 2

Median

(Range)

Time 3

Median

(Range)

Change

Time1/2

(Sig.)

Change

Time 2/3

(Sig.)

Change

Time 1/3

(Sig.)

Self-Care

(49)

41

(35-48)

45

(33-48)

43

(33-48)

+3

(0.015)

-2

(0.234)

+2

(0.44)

Bladder/bowel (14)

13

(6-14)

13

(7-14)

13

(7-14)

0

(0.713)

0

(0.196)

0

(0.313)

Mobility

(49)

33

(27-45)

40

(27-45)

38

(24-46)

+7

(0.007)

-2

(0.228)

+5

(0.462)

Communication (35)

34

(28-35)

34

(28-35)

33

(27-35)

0

(0.317)

-1

(0.005)

-1

(0.003)

Psychosocial

(25)

26

(21-28)

26

(21-28)

27

(21-28)

0

(0.336)

+1

(0.084)

+1

(0.105)

Cognition (35)

32

(16-35)

32

(16-35)

33

(16-35)

0

(1.0)

+1

(0.438)

+1

(0.677)


Improved FIM scores

“The bar on the bed to help me to get out and to hold on to, that was the best thing” “I eased off my daughter doing the shopping, I started doing the shopping myself”. “I started going walking down the garden when I got my grab rail” “My mother announced to me one day that she went down to a centre to play bridge, so she must have heard about that from the OT”.


Changes in MoCA cognitive categories

MoCA Normal Mild Moderate

Time one 1 12 2

Time two 4 8 3

Time three 4 7 3


Anxiety and depression scores (HADS)

HADS

scores

N=15

Time 1

Median

Range

Time 2

Median

Range

Time 3

Median

Range

Time 1 /

Time 2

P value

Time 2 /

Time 3

P value

Time 1 /

Time 3

P value

HADS

Anxiety

5

(0-8)

3

(0-10)

3

(0-9)

0.858 0.503 0.069

HADS

Depression

6

(3-10)

6

(2-13)

5

(1-11)

0.951 0.501 0.874

“I suppose its because I don’t regard myself as an invalid anymore”.


Health-related Quality of Life

EQ-VAS

scores

N=15

Time 1

Median

(Range)

Time 2

Median

(Range)

Time 3

Median

(Range)

Time 1 /

Time 2

P value

Time 2 /

Time 3

P value

Time 1 /

Time 3

P value

EQ-VAS 70

(0-100)

80

(60-100)

70

(40-100)

0.05 0.02 0.92

“They went out on a day trip one day.. she really got a buzz out of it ..so it was like a little outing. The O.T. went on that trip with her and they got on and off the bus, and after that my mother felt that she was well capable of doing it. It was about giving my mother back her confidence.” (Family member)


Difference between under and over 85 year olds FIM scores

FIM+FAM

scores

Time 1 /2 Time 2/3 Time 1/3

85 and under

Mean change

Sig. (p value)

183/192

+9

p=0.03

192/187

-5

p=0.176

183/187

+4

p=0.344

86 and over

Mean change

Sig. (p value)

173/176

+3

p=0.553

176/174

-2

p=0.325

173/174

+1

p=0.726


Health-related Quality of Life: under and over 85 years

EQ-VAS scores Time 1 /2 Time 2/3 Time 1/3

85 and under

Change

Sig. (p value)

58.6/80

+21.4

0.038

80/61.5

-18.5

0.042

58.5/61.5

+3

0.58

86 and over

Mean change

Sig. (p value)

72.5/80

+7.5

0.50

80/73.75

-6.25

0.24

72.5/73.75

+1.25

0.87


Changes in Homecare hours Participant Care hours (per week)

before intervention

Care hours (per week)

post intervention

Reduction in care hours

(per week)

1 3 1 -2

2 4 2 -2

3 3.5 3.5 0

4 7 3.5 -3.5

5 9.5 7 -2.5

6 7.5 7.5 0

7 7 4 -3

8 12 8.5 -3.5

9 4 4 0

10 8.5 7 -1.5

11 3 2 -1

12 10.5 10.5 0

13 2.5 2.5 0

14 4.5 4.5 0

15 5 5 0

Total 91.5 73.5 19 (p=0.012)


Reactions to reduced hours P1: “I suppose you have to go and do it yourself, you have to clear up after your breakfast, whereas the carer would have done it. It was put upon me to do it and I did it. And got into it. I wasn’t complaining. ..you had to get out of that sick mode you were in and get on with it. My daughters are delighted with the way I have recovered.”

FM10: “I think The O.T. arrived on the basis of “lets have a good look at what the system is doing and see if we can tweek it” specific to my mother. My understanding was that OT intervention aimed to give my mother her life back before the fall and as quickly as possible, and to do it in an organised way and that we sit down and talk to her and say “what is it that you would you like the carers to do? Would you like them to put your to bed or not put you to bed?”. In the end, for me it was about her getting to the point where she didn’t need the carers”.


Costs of occupational therapy interventions

Costs

OT Salary € 50,134.00

Equipment provision € 3,757.59

Reduction in homecare

hours

- € 22,742.00

Total cost of OT service: €31,149.59


Conclusions and implications • Significant changes in self-care activities and mobility – identified as areas of highest

difficulty for Irish older adults

• Improved mood and quality of life: risk factors for functional decline

• Those under 85 years made more statistically significant gains than those over 85-years

• Significant gains not maintained at 3 month follow up assessment – indicates a need for ‘top-up’ interventions

• Rehabilitation is rated as a low priority for primary care teams – pressured with higher ranked priorities

• Intensive occupational therapy intervention reduced HCP hours: Eighteen hours reduced for eight participants = €22,742.00

• Need a larger study with a comparison group to validate these findings

Thank You

Healthcare

Dr Deirdre Connolly , Trinity College Dublin (TCD)