P/OTD 541 Critical Analysis of Occupational Therapy Practice OTD 601 Capstone CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET

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1 Occupational Therapy Department Creighton University P/OTD 541 Critical Analysis of Occupational Therapy Practice OTD 601 Capstone CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET Focused Question: What is the effectiveness of Programs of All-Inclusive Care for the Elderly (PACE) in decreasing hospital length of stay for frail elderly enrolled in a PACE program? Prepared By: Kayla Hoge, OTS (kaylahofstetter@creighton.edu) Department of Occupational Therapy School of Pharmacy and Health Professions Creighton University 2500 California Plaza Omaha, NE Supervised by René Padilla, PhD, OTR/L, FAOTA (repadilla@creighton.edu) Date Review Completed: December 6, 2013 Clinical Scenario: The older population (65+) numbered 41.4 million in 2011, an increase of 6.3 million or 18% since Over one in every eight, or 13.3%, of the population is an older American (Department of Health and Human Services, 2012 p.1). This growing number of older adults means an increased need for services that promote independence and home safety. According to the Department of Health and Human Services, Some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-care, or independent living) was reported by 35% of men and 38% of women age 65+ in Some of these disabilities may be relatively minor but others cause people to require assistance to meet important personal needs (2012 p.15). This demonstrates an immediate need for cost-effective and efficient medical care for these individuals. There are several facilities and resources such as nursing homes and home health programs that cater to the needs of the growing elderly population. However, with more recent changes in healthcare, the demand for cost-efficient programming is even greater. Programs of All- Inclusive Care for the Elderly (PACE) are geared toward providing centralized care in one location in order to address health care costs and effectiveness, and to provide quality care close to home. The very first PACE facility was developed in San Francisco in As of 2012, there are 88 PACE programs throughout 29 states (National PACE Association, 2013). In order to be eligible for a PACE program, individuals must be age 55 or older, certified by their state to need nursing home care, qualify for Medicare/Medicaid, and live within the service area of a PACE program. Individuals are then enrolled in this program which provides all medical needs including, but not limited to doctor visits, rehabilitation services, respite care, and home health services. In addition, individuals unable to remain at home without supervision for extended periods of time can be brought to the local PACE Center to participate in an adult day program tailored to their specific needs. All medical and supportive services are provided by PACE employees or by companies contracted through PACE. 1

2 Nursing home care can be costly for both the individual and their family. The mean cost of nursing home care in Nebraska can range from $64,000-$72,000 annually (Genworth Financial, Inc. 2013). According to the A Profile of Older Americans: 2012, in 2011 the median income reported for older persons was $19,939 (Administration on Aging, 2012). This leaves a significant gap in income versus cost of living. PACE programs can provide services to delay the need for nursing home care. One of the services provided within a PACE program is occupational therapy (OT). OT practitioners can address functional performance and provide recommendations for home modifications as well as provide therapy while the individual attends the adult day program. Providing this functional structure in a familiar and safe environment can delay the need for costly long-term nursing home care. OT s play a huge role in providing the individualized intervention needed to make PACE successful. According to Lohman, Spergel, and Pennington, OTRs and COTAs are important team members with their strong skills of prevention, adaptation, and restoration of function (2012, pp. 6). OT practitioners can incorporate elements from one s environment, personal motivation, social context, and individual abilities in order to promote wellness in the elderly population. Butin and Montgomery have referenced OT practitioners as experts in functional analysis and rehabilitation, have a role to play in the design and implementation of programs that enhance the confidence and function of older adults (as cited in Scott, Butin, Tewfik, Burkhardt, Mandel, Nelson 2001 p. 11). Older adults face an increased number of chronic health conditions as they age, with accompanying sequelae that include, but are not limited to, functional decline, reduced home safety, and increased fall risk (Sheffield, Smith, & Becker, 2012 p. 2). These factors can all contribute to a decline in independence and ability to remain in one s home. As individuals age, a decline in health is typically inevitable. PACE has resources available for numerous health professionals to address all medical needs of older adults. Summary of Key Findings: Summary of Levels I and II Trends in research have shown that PACE programs decrease the number of hospitalizations and the length of stay if a person is admitted to the hospital (Temkin-Greener, Bajorska, Mukamel, 2008, Level I; Kane, Homyak, Bershadsky, Flood, 2006, Level II; Meret-Hanke, 2011, Level II). PACE programs that have higher hospital admission rates have lower functional outcomes over time (Temkin-Greener, Bajorska, Mukamel, 2008, Level I). The number of hospital admissions per month was inconsistent across 29 PACE programs when adjusted for risks (Temkin-Greener, Bajorska, Mukamel, 2008, Level I). When compared to the Wisconsin Partnership Program, PACE enrollees have fewer hospital admissions, preventable admissions, hospital days, ER visits, and preventable ER visits (Kane, Homyak, Bershadsky, Flood, 2006, Level II). PACE programs demonstrated fewer hospitalizations per enrollee as well as a slightly shorter length of stay despite having a higher average age of enrollees (Kane, Homyak, Bershadsky, Flood, 2006, Level II). PACE enrollees had higher average hospital use in the initial 6 months of enrollment, but that number steadily decreased after that period of time (Meret- Hanke, 2011, Level II). PACE Programming allows individuals to reside longer in the community and to engage in their familiar community environment for longer periods of time (Kane, 2

3 Homyak, Bershadsky, Flood, 2006, Level II; Meret-Hanke, 2011, Level II). Summary of Level III and IV Not included in review. Contributions of Qualitative Studies: Not included in review. Bottom Line for Occupational Therapy Practice: The clinical and community-based practice of OT: PACE allows individuals to age in an environment they are familiar with and comfortable with. Individuals are able to continue to participate in their community and maintain dignity. OT practitioners can provide recommendations to make one s home setting safer as they age. Education can be provided on fall prevention and the use of adaptive equipment and durable medical equipment to provide assistance with daily activities. In addition, OT practitioners have the opportunity to be involved in the continuum of care for each PACE participant. Interdisciplinary teamwork provides opportunities to consult directly with other medical professionals regarding individual participant needs. The results of the studies reviewed demonstrate that PACE programs contribute to decreased hospitalization and reduce the amount of time spent in the hospital. This demonstrates the effectiveness of proactive intervention in keeping individuals safe and healthy in their home environment. Program development: The results of these studies show that even though all PACE programs are based upon the same framework, there is still variation among participant outcomes. By examining the causes of the variation, changes can be made in various areas of service delivery to improve participant outcomes. OT practitioners can provide assistance to improve various areas of programming such as memory support needs, home modifications, and day center programming. The role of OT can vary within different PACE centers. Therefore, it is important to determine the primary need of each individual population in order to most effectively allocate OT resources. Societal needs: As stated previously Over one in every eight, or 13.3%, of the population is an older American. (Department of Health and Human Services, 2012 p.1). There is a growing need for services to support the aging population. The studies reviewed demonstrated that overall, PACE programming does reduce hospitalizations for enrollees. PACE provides a service that allows individuals to engage in community living for longer periods of time. Healthcare delivery and health policy: Recent changes in healthcare policies have created a push for more affordable healthcare for all individuals. One of the goals of PACE is to reduce costly hospital admissions in order to reduce healthcare spending. Programs like PACE are motivated to keep participants healthy in order to be profitable. PACE programs can be considered a financial risk as the financial success of the program depends upon the ability to maintain the health and wellness of the participants. This is an encouraging factor to produce positive outcomes on a consistent basis. The studies reviewed provided varied evidence as to whether or not PACE programs consistently prevent or limit hospitalizations. With the wide variability within programming, it is difficult to determine what factors within PACE are actually impacting hospital lengths of stay. Further research is warranted to determine what specific factors within PACE contribute to hospitalizations among participants. Education and training of OT student: The PACE setting allows for a less structured OT protocol. The entry level OT practitioner 3

4 4 must learn to prioritize individual needs based upon safety and medical necessity. In addition, elderly participants may have several medical needs. It must be determined whether the needs can be remediated or if a compensatory approach is more appropriate. PACE is a unique model in which individuals would most benefit from first-hand experience. It is focused on an interdisciplinary approach to participant intervention. Practitioners must keep in mind how their interventions may affect the other members of the interdisciplinary team. Formal training and education would be beneficial to develop this type of multi-dimensional clinical judgment. Refinement, revision, and advancement of factual knowledge or theory: While reviewing the available research on PACE programming it became evident that several factors contribute to the overall effectiveness of each program. It is difficult to determine specific causes of variability amongst sites. For example, the involvement of the primary care physician can significantly impact participant outcomes and can vary considerably between sites. Further research is needed to determine why certain programs have specific positive outcomes and why others do not. This type of outcomes based research could add further credibility to this model of elderly care. Review Process A focused question based on PACE programming was devised. The focused question was further defined to specify an identifiable population and a measureable outcome. Articles were gathered for potential review from several databases. Several online databases were searched individually until new results were no longer found. Article abstracts were reviewed to determine if further review was warranted. Full text versions of eight potential articles were collected and printed. Thorough review of each article was done and articles that did not directly relate to the population, intervention, or outcome were eliminated. One of the final articles chosen to review was originally part of a systematic review. The systematic review was eliminated, but the individual article was still found to be appropriate. Three articles met the criteria for inclusion. These articles were then reviewed and synthesized in an evidence table. Procedures for the selection and appraisal of articles Inclusion Criteria: The population chosen was frail elderly. The intervention was specifically PACE. The outcome measure included the length of hospital stay. Articles published after the year Level I, II, and III articles. Exclusion Criteria: The study was not outcomes based research. The intervention was a program similar to PACE, but not the exact same program. The outcomes measure did not include hospital length of stay. The study did not directly contribute to the relevance of the focused question. Level IV and Level V studies. Published prior to 2000.

5 Search Strategy Categories Patient/Client Population Intervention Outcomes Key Search Terms Aged, elderly, frail elderly, functionally impaired elderly, frail elders, frail older adults, frail seniors, geriatric, community dwelling older adult, aged 65 and over Programs of All-Inclusive Care for the Elderly, PACE, Adult Day Program, Health Services for the Aged, geriatric day hospital, day hospital decreas* hospitalization, hospital*, hospital use, length of stay, hospital length of stay Databases and Sites Searched The Cochrane Library; Ageline; OTSearch; JAMA Evidence; CINAHL; Google Scholar; Medline; MeSH Quality Control/Peer Review Process: A focused question was developed in collaboration with instructor, Dr. René Padilla An exhaustive literature search of 8 Databases was completed to collect possible research articles. The instructor reviewed the results of the search and provided additional feedback based upon search outcomes. After further review of 8 articles, the focused question was again refined to better identify a specific population and outcome. Articles were eliminated based upon listed inclusion/exclusion criteria. It was determined that 3 of the 8 original articles were appropriate for review and relevant to the specific focused question. The three articles were individually reviewed and summarized in an Evidence Table. The Evidence Table was reviewed by the instructor and feedback for clarity and thorough investigation was given. The information from the 3 articles was then assembled in a Critically Appraised Topic (CAT) to provide an overall representation of the research found. The CAT was then reviewed by the instructor and suggestions for additional clarification of findings were given. Results of Search Summary of Study Designs of Articles Selected for Appraisal 5 Level of Evidence Study Design/Methodology of Selected Articles Number of Articles Selected I Systematic reviews, meta-analysis, randomized 1 controlled trials II Two groups, nonrandomized studies (e.g., cohort, 2 case-control) III One group, nonrandomized (e.g., before and after, 0 pretest, and posttest) IV Descriptive studies that include analysis of 0

6 V outcomes (single subject design, case series) Case reports and expert opinion, which include 0 narrative literature reviews and consensus statements Qualitative Studies 0 TOTAL 3 Limitations of the Studies Appraised Levels I, II, and III PACE itself as an intervention is a broad assembly of several services. There is a high variability of service distribution within this model and further research is needed to determine specific factors contributing to participant outcomes. (Temkin- Greener, Bajorska, Mukamel, 2008, Level I). The data collected was from billing departments, which does not eliminate subjective influence (Kane, Homyak, Bershadsky, Flood, 2006, Level II). ADL s were counted as an aggregate number rather than indicating specific limitations. This neglects the impact of the severity of ADL impairment on hospitalization (Meret-Hanke, 2011, Level II). Many of the comparisons made were over a large geographic region, making it difficult to determine the demographic impact of health disparities among various populations (Meret-Hanke, 2011, Level II; Temkin-Greener, Bajorska, Mukamel, 2008, Level I). Levels IV and V Not included in review. Articles Selected for Appraisal Kane, R. L., Homyak, P., Bershadsky, B., & Flood, S. (2006). Variations on a theme called PACE. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 61A(7), Meret-Hanke, L. (2011). Effects of the program of all-inclusive care for the elderly on hospital use. The Gerontologist, 51(6), doi: /geront/gnr040. Temkin-Greener, H., Bajorska, A., & Mukamel, D. B. (2008). Variations in service use in the program of all-inclusive care for the elderly (PACE): Is more better? Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 63A(7), Other References Administration on Aging, Administration for Community Living, U.S. Department of Health and Human Services. (2012). A profile of older Americans: Retrieved August 29, 2013, from Genworth Financial, Inc. (2013). Compare cost of care across the United States. Retrieved September 1, 2013, from 6

7 National PACE Association. (n.d.). Who, what and where is PACE? Retrieved 2013, from CE? Lohman, H., Spergel, E., & Pennington, E. (2012). In Padilla, R., Occupational Therapy with elders: Strategies for the COTA (Third ed., pp. 1-18). Maryland Heights, MO: Elsevier Mosby. Scott, A. H., Butin, D. N., Tewfik, D., Burkhardt, A., Mandel, D., & Nelson, L. (2001). Occupational therapy as a means to wellness with the elderly. Physical & Occupational Therapy in Geriatrics, 18(4), doi: /j148v18n04_02. Sheffield, C., Smith, C. A., & Becker, M. (2012). Evaluation of an agency-based occupational therapy intervention to facilitate aging in place. The Gerontologist, 53 (6),