of occupational therapy in Canada.

Transcription

1 Occupational Therapy in Canada Economic evidence of the benefits of occupational therapy Kate Rexe, Brenda McGibbon Lammi and Claudia von Zweck 2012 Evidence shows occupational therapy interventions are cost-effective in treating or preventing injury and improving health outcomes in areas such as falls prevention, musculoskeletal injury, stroke rehabilitation, early intervention in developmental disabilities, respiratory rehabilitation and home care. Additional research indicates opportunities for occupational therapy to play an increased role in the management of health outcomes in complex and chronic diseases, pain management, nonpharmaceutical mental health interventions, dementia, end-of-life or palliative care and home care. This article aligns the discussion of health system transformation with literature identifying the costeffectiveness of occupational therapy in Canada.

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3 Table of Contents Introduction... 1 Overview of the Issue... 1 Health System Goals... 3 Aligning Occupational Therapy with Health System Goals... 4 Health Care in Canada... 6 Health System Transformation... 7 Public Health Care... 9 Shortening the length of hospital stays... 9 Increased effectiveness of community-based services Reducing costs of pharmaceutical intervention End of life care Private Sector Health Care Summary and Recommended Actions Table 1: Responding to Cost Drivers in the Health System Conclusion References... 18

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5 Canadian Association of Occupational Therapists The Canadian Association of Occupational Therapists (CAOT) is a national member-based organization representing over occupational therapists in Canada. With over 85 years of experience advocating on behalf of occupational therapists, CAOT provides services, products, events and networking opportunities to assist occupational therapists achieve excellence in their professional practice. In addition, CAOT provides national leadership to actively develop and promote the clientcentred profession of occupational therapy in Canada and internationally.

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7 Introduction In 2011, the CAOT Board of Directors conducted a strengths, opportunities, aspirations and results (SOAR) analysis whereby one of the outcomes was to collect economic evidence of the benefits of occupational therapy. While an environmental scan of the economic literature was conducted by CAOT in 2006, the purpose of this paper is not to reproduce the findings of the 2006 report, but rather build on its findings and put the issue of health spending decisions into the context of health system transformation in Canada today. In other words, this paper will explore the current economic situation in Canada impacting health systems chance, and provide evidence where occupational therapy has proven results related to cost-effectiveness. In so doing, this report will identify opportunities where occupational therapy can respond to emerging patient and caregiver needs while providing practical solutions to the concern of growing costs related to an aging population and limited resources available within Canada s health services system. The paper will begin with an overview of the issue of health system transformation and the current discussions at the federal, provincial and territorial levels regarding the renewal of the Canada Health Transfer. Based on the current context of financing and the desire for change which will better meet the health needs of Canadians, evidence will be presented to highlight how occupational therapy as a profession aligns with the stated goals of health system transformation in Canada. The paper will then review overall framework for the delivery of health care in Canada, identifying opportunities for transformation within the health services system. There will also be a discussion of public and private sector delivery of care, noting the connectedness of these two systems. Finally, the paper will summarize the evidence and offer recommendations for how occupational therapy can provide solutions in the advancement of cost-effective interventions that improve health, well-being and clientcentred practice. Overview of the Issue In 2012, the issue of health services funding renewal is high on the First Ministers agenda and there exists an intense interest in health economics as an influencing factor on health system transformation in Canada. Some of the key issues identified by public policy decision-makers and other key stakeholders in the health services system include how to manage or control rising health care costs, how to respond to changing demographics and the impact of an aging population, maximizing the efficiency of health services and the delivery of health care, balancing the fundamentals of an acute care system with health promotion and population health services, planning for an integrated system of health human resources, and maintaining quality care while undergoing health system transformation. An added challenge in the political sphere, however, is a unilateral decision of the federal government in December 2011 to provide funding to the provinces for health, but not to engage in the discussions of the renewal of health funding or services in Canada (Department of Finance, 2011). This decision by the federal government is in stark contrast to the previous federal, provincial, territorial partnership in 2003 to establish the Health Accord, and further federal leadership in 2004 to draft the 1

8 10-year Plan to Strengthen Health Care in Canada (Health Canada, 2004). At this time, the First Ministers worked together to create this federal, provincial, and territorial strategy aimed at making health care sustainable and able to respond to the needs of Canadians. The plan focused on the main principles of the Canada Health Act and identified 10 areas of leadership, targeted investment and strategy. These 10 areas included: Reducing Wait Times and Improving Access Strategic Health Human Resource (HHR) Action Plans Home Care Primary Care Reform Access to Care in the North National Pharmaceuticals Strategy Prevention, Promotion and Public Health Health Innovation Accountability and Reporting to Citizens Aboriginal Health As First Ministers prepare for the renewal of health funding in 2014, many of these issues are ongoing and require continued commitment. However, with the decision of the federal government to provide a guaranteed funding formula, but not to participate in the discussions or goal setting for a renewed health strategy, many stakeholders are left wondering what the future of public health care will look like. Regardless of federal involvement in the health care renewal discussions, the issues remain the same. The costs of health care are rising and governments must develop priorities based on the funding or resources within their respective budgets. Nonetheless, there are many variables that can impact decision-making regarding the allocation of funding. As identified in the 2006 report for CAOT, tough choices need to be made by governments and regional health authorities as to where scarce health care dollars are to be spent (Macdonald, 2006). However, there are many shades of grey when weighing the options of investment in health programs and services and evaluating the cost-effectiveness of health interventions. This is because there are many choices, involving numerous practitioner groups, using various models of delivery of care, for many health conditions, across a spectrum of health outcomes that relate to age, income, geographic location, access to care, education, housing security, complex and chronic disease management, culture, language, and other social determinants of health. In other words, the decision-making process for health services funding is complex and requires input and evidence from many different sources. Taking into account the complexity of the decision-making process, it is important to review and identify the evidence related to effective interventions across a spectrum of health services. In the field of health economics, a number of new studies have emerged since a 2006 environmental scan was completed for CAOT, which identified the costs and effects of health interventions specific to occupational therapy, or related to the occupational therapy scope of practice. Still, this research can help to inform the direction of CAOT when advocating for the provision of services in a variety of settings, but can also establish the 2

9 argument for a more robust primary health care system that incorporates a variety of health professionals and promotes interprofessional collaboration. The following section will examine the role of occupational therapy in Canada and how occupational therapy contributes to the achievement of overall public health system goals. Using evidence of cost effective interventions and research that identifies the benefits of occupational therapy, this paper will identify where occupational therapy can offer valuable interventions and service in health system transformation, but also look at the reality of changing services and the increasing reliance on unpaid caregiving and private sector delivery of care, particularly along the spectrum of aging, rehabilitation and therapy services. Health System Goals Regardless of whether one is looking at the direction of the 2003 Health Accord, or other opportunities to re-shape the health system, there are values entrenched in the design and delivery of health care in Canada. The Canada Health Act (CHA), which was passed in 1984, sets out the fundamental health system goals through a stated policy objective to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers (Canada Health Act, 1984: s.3). And, while the CHA is limited, and has been argued to be only a piece of legislation which outlines the criteria for transfer payments from the federal government, this policy objective has led to ongoing debates about whether the CHA is more than a guidebook for a fiscal relationship. As the country is preparing for the renewal of health funding, the goals or policy objectives stated in the CHA play an important role. Priorities for First Ministers, government decision makers, and other key stakeholders in the health system are on managing health budgets and maintaining infrastructure to respond to a) changing demographics, b) changing health needs, and c) changing fiscal or economic climate (particularly for the provinces or territories with limited resources and large deficits). To receive federal funding, the provinces and territories must meet the standards of public administration, comprehensiveness, universality, portability, and accessibility (Canada Health Act, 1984). However, as the federal government announced they will not participate in the renewal of a Health Accord, they have effectively removed themselves from a leadership role in setting priorities for a national health care framework and returned the federal role to that of a fiscal relationship. Although the federal government is not taking an active role in the coming discussions of health care renewal, this does not mean that provincial and territorial governments and other key stakeholders will not continue to work together to shape the public health system in a way that continues to meet the objectives of the CHA and the needs of Canadians. Nevertheless, stakeholders should be cognizant of the fact that the transformation of Canada s health systems changes depending on the financial commitment and vision of systems of care. The future of health care is a matter of political will and investment and must be a partnership between the federal, provincial, and territorial governments. This said, once a commitment is made, whether it be a fiscal arrangement or partnership based on principles of change, there are practical solutions to support the end goal. 3

10 In July 2011, the Canadian Medical Association (CMA) and the Canadian Nurses Association (CNA) worked in collaboration to publish a document outlining agreed upon principles for health care transformation. This document, Principles to Guide Health Care Transformation in Canada, was endorsed by nearly 40 health care organizations and professional associations and has provided a common starting point for the discussion of how Canada s health care system can better meet the health needs of Canadians (CMA & CNA, 2011). The preamble outlines the guiding principles which have been defined to transform the health care system in Canada toward one that is sustainable and adequately resourced, and provides universal access to quality, patient-centred care delivered along the full continuum of care in a timely and cost-effective manner (CMA & CNA, 2011: 1). The common goals in the discussion of health care renewal continue to be enhancing the quality of health care and the patient experience, improving population health, and improving the economic effectiveness of the system to ensure accountability and sustainability. The next section will explore the evidence of occupational therapy interventions, and identify how occupational therapy can help achieve these goals. Aligning Occupational Therapy with Health System Goals In Canada, occupational therapists are regulated health professionals with specialized training in physical, cognitive and affective components of human performance (CIHI, 2011). Occupational therapists maintain a holistic approach and incorporate spirituality, social and cultural experiences, and address occupational engagement components to help people overcome activity limitations or participation restrictions in activities of daily living, such as self-care, play, work, study, and leisure. In other words, the therapies and interventions focus on the idea that humans need occupation 1 and occupation has therapeutic potential. Interventions are therefore designed to improve health and wellbeing, organize time and develop structure to living, bring meaning to life by enabling individuals to engage in activities that contribute to one s social and self-identity, and be idiosyncratic or personalized to the needs of the individual (Townsend and Polatajko, 2007; CAOT, 1997a; Unruh, 2004; Yerxa et al., 1990). In 2006, CAOT commissioned an environmental scan of economic literature pertaining to occupational therapy and interventions that fall under the scope of practice of occupational therapy. The purpose of this report was to identify evidence that examined both costs and effects of occupational therapy practice. Overall, this report provided a basic understanding of the economic impact of occupational therapy services and provided some insight into interventions that measure health outcomes against health care costs. However, the conclusion summarized that little research had been done on economic effectiveness and the author encouraged more occupational therapy-specific research that incorporated economic evaluation of services compared to health outcomes (MacDonald, 2006). 1 Occupation is defined as everything people do to occupy themselves, including looking after themselves (selfcare), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity) (CAOT, 1997a, p. 34). 4

11 There is strong evidence to indicate that occupational therapy interventions can play an important role in health system transformation because they provide practical solutions to a range of problems, from simple to complex. For example, in 2007 the British Medical Journal (BMJ) published a cost-effectiveness study on community occupational therapy for older adults with dementia and their caregivers (Graff et al., 2007). The objective of the study was to assess the cost effectiveness of community-based occupational therapy compared with ordinary care of older patients with dementia. The study examined direct and indirect costs of health services, and costs outside of the health system, such as the role of unpaid caregivers and opportunity costs or productivity lost or gained with unpaid caregivers. The study found that community occupational therapy intervention was successful and cost effective. The study found that patients who received occupational therapy yielded significantly and clinically relevant improvements in daily functioning, care-givers developed a sense of competence, who also developed confidence that the patient was able to function, thus providing respite from their regular duties. The study also showed the interventions saved on average 1748 ($2641 USD) over three months, compared to other health services (Graff et al., 2007). This example of cost effectiveness and community-based occupational therapy is one study in an emerging field of research. In 2006, David MacDonald identified 20 primary economic evaluation articles related to occupational therapists performing an intervention in a home or community care setting, in primary health teams, or related to wait times. An additional 26 economic evaluation articles of health interventions were identified where occupational therapists were not the primary practitioner involved in the project, but the intervention fell under the areas of competency or scope of practice of occupational therapists (e.g., acquired brain injury, stroke rehabilitation, orthopedics, geriatric assessment including dementia, developmental disabilities, mental health, pain management and return to work, driving assessment and rehabilitation, fall prevention, and sensory motor integration) (MacDonald, 2006). Of the articles reviewed, MacDonald was able to identify a range of cost-effective interventions with fall prevention and early discharge for stroke patients being the most studied topics, presenting the firmest conclusions with regard to economic effectiveness (MacDonald, 2006). Since this environmental scan was completed in 2006, additional research reports and publications have added to the scope and body of evidence regarding economic evaluation of interventions falling within the scope of occupational therapy. For example, in 2007 the Institute for Work & Health released a systematic review indicating strong evidence supporting economic benefits of disability management programs and ergonomic programs and other interventions to prevent musculoskeletal disorders. Other contributions include the Alzheimer s Society of Canada s 2010 report Rising Tide: The impact of dementia on Canadian society, which has a strong emphasis on health care and the economic burden of dementia today, as well as increasing costs as the population ages. And in April 2012, the Health Council of Canada released Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada? This report responds to the growing number of people receiving home care in Canada and the desire for many to remain at home as they age. However, while a growing body of research suggests that when home care is properly managed and integrated into the health care system it can improve patient outcomes and reduce the costs of care in hospitals and long term care facilities, Canada s current system is not well managed and does not provide the necessary care or support to prevent 5

12 injury (e.g., fall prevention), manage chronic health problems, or improve health or well-being. All three of these studies identify the importance of occupational therapy interventions specifically, and a clear role for interventions most appropriately performed by occupational therapists. Fifteen other articles were reviewed for this paper relating to cost effectiveness and occupational therapy in the areas of therapeutic interventions in mental health and depression, preventative occupational therapy for aging adults, occupational therapy in end of life care or palliative care, and the cost effectiveness of occupational and other related therapies in the insurance industry. In general, the conclusions suggest a strong foundation of evidence indicating positive health outcomes in occupational therapy intervention with good value from an economic perspective (Gladman, Whynes & Lincoln, 1994; Brandis, 1998; Mcnamee et al., 1998; Beech et al., 1990; Anderson et al., 2000; HCC, 2012; Ramos et al., 2004; Goldstein et al., 1997; Griffith et al., 2001; Park Lala & Kinsella, 2011; Salkeld et al., 2000; Hay et al., 2002; Smith & Widiatmoko, 1998; Campbell et al., 2005; Robertson et al., 2001a, 2001b, 2001c; Rizzo et al., 1996; Mickan, 2005; Constant et al., 2011; Schene et al., 2007; Dooley & Hinojosa, 2004; Combe et al., 2006; IWH, 2007). There is also opportunity for occupational therapy to reduce health care spending through its contributions to health care transformation, these opportunities are discussed below. Health Care in Canada In 2004, the First Ministers agreed to uphold the basic principles of the Canada Health Act through the 10-Year Plan to Strengthen Health Care. The document began by saying: In recent years, through an ongoing dialogue between governments, patients, health care providers and Canadians more generally, a deep and broad consensus has emerged on a shared agenda for renewal of health care in Canada. This agenda is focused on ensuring that Canadians have access to the care they need, when they need it (Health Canada, 2004). At this time, the national priority for health care was to guarantee access to timely care across Canada. However, the significance of this document was in the fact that it was the first time First Ministers came together to agree on a national action plan for health services in Canada marks the year for renewal of Canada s Health Accord; and while the federal government will not renew the process of discussion, it has committed to a renewal of the financing of health services in Canada. The commitment is a continued six per cent annual increase to the Canada Health Transfer until fiscal year, and an ongoing commitment starting in of at least three per cent per year, with additional funding based on economic performance of the provinces (Office of the Parliamentary Budget Officer, 2012) While the federal government has chosen to not engage in the discussion, it does not mean that collaboration between the First Ministers and the provincial Ministers of Health, nor the principles of the Canada Health Act (universality, accessibility, portability, comprehensiveness, and public administration), will not be honoured in the next phase of health system renewal. In fact, key stakeholders in Canada s health services have acknowledged the need for comprehensive discussion and collaboration in the future transformation of health care in Canada. 6

13 Health System Transformation Over the past couple of years, many health service and health professional organizations have been preparing briefs on the future of health care in Canada, health care funding, and identifying key issues affecting the delivery of comprehensive and quality care. The issue most often examined is arguably the concern with rising costs and the sustainability of publicly-funded health care. A decade ago these issues were discussed in the context of market competition, efficiency, effectiveness, and increasing the private delivery of health services and health care. While these issues have not gone away, the discussion has shifted to managing rising costs in light of a monumental demographic shift in the age of Canadians. Currently, all eyes are on the aging baby boomer. According to Statistics Canada (2011), the proportion of seniors in Canada is projected to rise from approximately 14 per cent of the population to 23 to 25 percent of the population by Not only will this generation be leaving the workforce in record numbers in the coming years (and no longer contributing to taxes at the same rate), as the population ages, individuals can expect to have an increase in health problems and use of health services. To put this in the context of health care, in 2009, 25 per cent of seniors reported at least four chronic health conditions and accompanying poor health, compared with six per cent of adults aged 45 to 64 (Statistics Canada, 2011). In the next few years, there will be significantly more seniors, and these seniors will likely be affected by similar health problems as what we see today. The result of this shift will be a much greater number of individuals and illnesses that need to be cared for and managed. What this means for Canada s health care systems is the need to prepare and have the most appropriate services in place to respond to the changing needs of the population. In a 2011 article in Gravitas, Brian Postl discussed the effects of an aging population. He identified that the use of home care services begins to increase from ages 65 to 74, and after age 75, the demand for home care, other community-based services, and long-term care services increases dramatically (Postl, 2011). In response to this he prescribed enhanced programming in community-based services such as home care, day programming and day hospital care, but also specialized programming in areas such as post-stroke care (Postl, 2011). These recommendations are consistent with other findings for health services for aging Canadians and those with chronic health problems. The Health Council of Canada s 2012 report, Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada?, identified that home care is a valuable service for Canadians, but it is currently under-funded based on the needs of the clients (Health Council of Canada, 2012). More specifically, the study identified many home care recipients have chronic conditions, but nearly one-third are high needs with complex health problems, such as a physical disability, cognitive impairment and/or challenging behaviors (Health Council of Canada, 2012). In addition to this, the report identified 95 to 98 per cent of home care clients had difficulty with activities of daily living, such as cleaning, cooking, grocery shopping, and home maintenance, and 23 to 41 per cent need help with personal functions or self-care (bathing, eating and toileting). The report specifically identifies the services to support activities of daily living are most appropriately provided by occupational therapists or physiotherapists, but there are substantial regional differences and gaps in home care teams leaving clients without the professionals to respond to their health needs (HCC, 2012). These challenges do not affect the client or patient alone; 7

14 there is and will continue to be an increasing burden on unpaid caregivers if the necessary supports and services are not given the appropriate level of funding, or expanded to meet the needs of the population. The examples of home care or community-based services are opportunities or areas in need of transformation where solutions exist and can be readily implemented if the funding is made available. As identified by the Health Council of Canada, one of the challenges in the home care sector is increasing levels of need are not necessarily matched by increasing levels of home care services (Health Council of Canada, 2012: p. 14). The data analyzed for the study also show that pain, depression and falls are common problems faced by clients using home care services, all of which can be addressed through interventions with the appropriate health professionals. Unfortunately, the study found low involvement of occupational therapists and physiotherapists across all five regions where the analysis was conducted, despite the fact that the majority of challenges faced by seniors are related to both basic and broader activities of daily living (Health Council of Canada, 2012). The aging population, however, is not the only reason for health system transformation. It is agreed by many that Canada s health care system is not appropriate for the needs of the 21 st century. Public health care, or the public health insurance system, was designed in the 1960s to provide access to acute care, primarily in the form of doctors and hospitals. However, as knowledge and understanding of health and health care has evolved, the acute care system of the 60s has expanded to incorporate many other forms of care including access to specialized services, disease or ailment-specific professionals, improved technology and diagnostic imaging, enhanced pharmaceutical intervention and treatment options, as well as increased awareness of the importance of the social determinants of health in health prevention and promotion. As the health system continues to change, the public s expectations of coverage and care must also undergo a renewal. In 2012, despite the discussion of sustainability and financing, there remains an expectation that health care in Canada can be better, faster, and cheaper. There are differing theories and projections about what is possible for governments and health providers to achieve, but ultimately financing is not the only challenge facing Canada s health services system. In 2011, the Canadian Health Services Research Foundation (CHSRF) launched a series of reports on health system transformation. The first paper in this series, Assessing Initiatives to Transform Healthcare Systems: Lessons for the Canadian healthcare system, identifies that a clear vision and coherent set of strategies are required to transform the system and achieve better alignment between the care offered and the care the population needs today (Denis et al., 2011: 1). In a review of achievements and efforts to improve health services over the past decade, the paper identifies strategies to support transformation in the future. Overall, the conclusion is that money alone is not the solution to fix the system. Rather, the authors identify a number of priority areas they believe will make a difference in health care including; strategic realignment towards patient needs, organizations working as the engine for delivery and change, changing professional culture and roles, create an enabling environment, patient engagement, and evidence-informed policy and decision-making (Denis et al., 2011). 8

15 Public Health Care The desired goal of many practitioners, patients and health care decision-makers is to create a system that promotes health, effectively manages illness, and achieves desirable health and well-being outcomes for the country as a whole. Even though the guiding principles of health system reform can be endorsed by most stakeholders, issues of cost and economic effectiveness are perhaps the most important factors driving the public policy decision-making process. Thus, the discussion of public health care in Canada continues to rely on commitment to financing. To frame the discussion of the sustainability of the public health system, this section will examine one basic fact: health spending in Canada is rising faster than the rate of economic growth. In 2011, CHSRF commissioned a report on cost drivers in the health sector and health system efficiency. The report argues that understanding the factors that underlie the rise in healthcare expenditures in Canada (known technically as cost drivers) is essential to a productive debate on healthcare sustainability (Constant et al., 2011: i). In this research synthesis, the authors identify that decisions in expenditure growth are driven by population growth, population aging, income growth, inflation, and other enrichment factors (i.e., advances in technology and medical science). However, the conclusion suggests that if the public health system is to improve on value for money, or cost effectiveness, the discussion must extend to the areas where most funds are allocated (hospitals and physicians) or where growth significantly exceeds revenue growth (capital, drug and public health) (Constant et al., 2011: 21). This research synthesis is rich in economic data and indicators related to health care expenditure trends in the provinces and territories, comparing them to international outcomes. Based on this report and the examination of other evidence related to cost effectiveness of occupational therapy interventions, there is a clear opportunity to put forth recommendations for alternatives which maximize the skills and professional resources in Canada. In fact, based on the primary indicators of cost drivers in the system presented by Constant and colleagues, the diversity of specialization and expertise of occupational therapists offers a ready-made solution to the complex challenges affecting the health system today. Occupational therapists are highly educated and regulated health professionals who promote health and well-being by enabling individuals, groups and communities to participate in occupations that give meaning and purpose to their lives (CAOT, 2009). With an increased interest in the economics of health care, many studies are finding that occupational therapy offers solutions that are both cost-effective and respond to other pressures on the health system (HCC, 2012; IWH, 2007; Graff et al., 2008; Denis et al., 2011; MacDonald, 2006; Alzheimer Society, 2010). Based on evidence from a range of sources, some key opportunities for occupational therapists in health system reform include: Shortening the length of hospital stays Evidence shows that occupational therapy can respond to the demand for beds or space in hospitals and long term care facilities by providing services to move out of hospital and back home after a stroke, fall, injury, onset of mental health challenges, or at the end of life (Gladman, Whynes & Lincoln, 1994; Brandis, 1998; Mcnamee et al., 1998; Beech et al., 1990; Anderson et al., 2000; HCC, 2012; Ramos et al., 2004; Goldstein et al., 1997; Griffith et al., 2001; Park Lala & Kinsella, 2011; Salkeld et al., 2000; Hay et 9

16 al., 2002; Smith & Widiatmoko, 1998; Campbell et al., 2005; Robertson et al., 2001a, 2001b, 2001c; Rizzo et al., 1996; Mickan, 2005; Constant et al., 2011). This saves money per patient visit, frees up space for new patients, and can potentially save in capital investment and infrastructure if the system doesn t need to build as many new facilities to meet patient demand. Increased effectiveness of community-based services A collaborative and proactive approach to health prevention and health care management allows clients to get the care they need before it reaches the stage of acute care. Occupational therapists have expertise and areas of specialization that can play a greater role in the management of complex diseases, pain management and disability. There is also emerging evidence to show occupational therapists play an important role in primary care, particularly in the involvement with interprofessional primary health teams. Broadening the professional expertise of health teams and incorporating the best professionals to manage, diagnose and treat illness or injury along the continuum of care will allow for a more functional and effective health services system that acts to promote health and well-being at all stages of life, rather than treating illness at points of acute care or crisis. Figure 1 offers a visual diagram representing the continuum of care and the opportunities for effective intervention, which maximizes the scope of practice of occupational therapists. The evidence of cost effectiveness indicates clear opportunities for occupational therapists to use their expertise and full scope of practice to improve client care as a health promotion expert or primary care practitioner in case management, chronic disease management, injury prevention, care-giver education, intervening at the point of health crisis or hospitalization to prevent hospitalizations, shorten hospital stays, provide community or care-giver support to prevent re-admission, work in rehabilitation, and help clients redefine or better understand changing occupation at the end of life to improve productivity and quality of life. However, it should be noted that occupational therapists, like many other health professionals are currently facing a shortage in many areas across Canada. Therefore, health human resource planning, and promoting retention and recruitment must be part of any plan to expand the use of occupational therapists along the continuum of care. 10

17 Figure 1: Occupational Intervention along the Continuum of Care Primary health care Case management Chronic disease management Injury prevention Care-giver education Prevention Hospitalization Crisis Prevent hospitalization Shorten hospital stays Prevent re-admission Redefining occupation Quality of life Productivity Care-giver education End of Life Rehabilitation Reducing costs of pharmaceutical intervention Drug costs are the fastest growing area in Canada s health system. Studies have examined nonpharmaceutical therapeutic interventions such as occupational therapy and found evidence of improved ability to treat, particularly in areas such as depression and mental health, stroke rehabilitation and pain management (Schene et al., 2007; Dooley & Hinojosa, 2004; Combe et al., 2006). Based on some of the research indicating positive and improved outcomes with occupational therapy in areas where pharmaceutical treatment is the standard treatment, there is an opportunity to further explore if the health system can begin to reduce the overall spending in one of the highest cost areas of health care by reducing the reliance on pharmaceutical intervention. A number of studies or systematic reviews have been conducted to look at the efficacy of non-pharmaceutical interventions. While some research has identified promising results for clients using non-pharmaceutical or additional therapeutic interventions (Schene et al., 2007; Bausewein et al., 2011; Leonard et al., 2007), other conclusions indicate the need for more sufficient evidence, including randomized controlled trials, to determine appropriate recommendations (Hermans, Htay, & Cooley, 2007; Bowen et al., 2011). These initial examinations and the interest in this line of inquiry suggests potential opportunities to find alternative therapeutic interventions to treat conditions that have traditionally been prescribed pharmaceutical treatment alone. End of life care Research has shown that aging doesn t cost the system, dying does. The last two years of life are the most costly in the health system (Constant et al., 2011). Emerging evidence is identifying how occupational therapy can help to support patients and caregivers with end of life care. With both formal options in palliative care, as well as with informal and family care givers in the home, occupational 11

18 therapy helps patients plan for their care needs and provides options for dying with dignity without expensive health and pharmaceutical interventions (CAOT, 2011). This is all to say that for major public health system challenges there are concrete and cost-effective solutions that are provided in the context of interprofessional collaboration and care. With a wide range of skills and diversity of expertise, occupational therapists are ideal health professionals to intervene in many areas where costs are creating a barrier to the delivery of quality and comprehensive care. Moreover, evidence shows occupational therapy interventions are cost effective in treating or preventing injury and improving health outcomes in areas such as fall prevention, musculoskeletal injury, stroke rehabilitation, early intervention in developmental disabilities, respiratory rehabilitation, and home care (MacDonald, 2006). Additional research indicates opportunities for occupational therapy to play an increased role in the management of health outcomes in complex and chronic diseases, pain management, non-pharmaceutical mental health interventions, dementia, end of life or palliative care, and homecare (HCC, 2012; Hay et al., 2002; Schene et al., 2007; IWH, 2007; Graff et al., 2007; Park Lala & Kinsella, 2011). Private Sector Health Care While the majority of occupational therapists in Canada are funded through the public health system (79.8 per cent), occupational therapy is available in the private sector and sources of funding may come from a mix of public and private financing. As with the discussion of public health care in Canada, the private sector is also adapting to meet the needs of a changing population and changing economic circumstances. A driving consideration for private sector involvement relates to the predicted increase in demand for services which will come with an aging population. In fact it is likely, if not inevitable, that health system transformation will include more services being provided by private sources of revenue. Therefore, the private delivery of health care must be part of the overall discussion of the future of health services, particularly if patients will be required to pay out-of-pocket for treatments that affect their quality of life. In the examination of sustainability and publicly-funded health care in Canada, the discussion of privatization, or the private delivery of care, inevitably enters into the public policy debate. Even though there is publically funded health care in Canada, the system is actually a combination of both public and private delivery of care and a mixed method payment system. For example, a doctor s visit and diagnosis for a health condition is paid for, but the prescription to treat the illness is not and is paid for either by the patient or a third party, such as an insurance provider for someone with extended health benefits. The private sector also provides health services which are covered under public funding, but delivered in a private setting, such as a clinic, or by a private practitioner. A common example of this is a diagnostic imaging clinic. Taking the example of home care in Canada, there are both opportunities and challenges associated with a shift in the model and delivery of Canada. The 2003 Health Accord opened the door to community-based care as an ideal solution for modern, integrated and patient-centred health care. In the 2004 Ten-Year Plan to Strengthen Health Care, it was stated that improving access to home and community care services will improve the quality of life for many Canadians by allowing them to be 12

19 cared for or recover at home (Health Canada, 2004). Governments and advocates in the community agree that home care can provide a cost-effective means of delivering services; however, there is a risk of increasing reliance on un-paid caregivers to provide services that should be delivered by health professionals. For this reason, there must be appropriate investment and resources provided to integrate home care with hospitals and primary care (HCC, 2012). With the aging population and corresponding increases in chronic diseases such as diabetes, dementia, arthritis, heart disease and stroke, there will be increased opportunities for occupational therapy interventions in both the public and private sectors of health care. Occupational therapy as a profession must be responsive to all the changes in the health services system, whether it be through preparation for changing demographics, through case management of complex disease and diagnoses, or by preparing for the changes in management of health services and the funding of services in the public and private sectors. Regardless of whether services are delivered through a public institution or community-based setting, occupational therapy as a profession is flexible to respond to the needs of the population and provides excellent remedies to challenges for people throughout the life cycle. Nevertheless, one of the most significant gaps in private care relates to private insurance coverage. A preliminary review of coverage by private insurance conducted by CAOT in 2010 revealed a lack of access to the occupational therapy profession despite the fact that occupational therapists often provide the most appropriate services in rehabilitation and care (CAOT, 2010). Some research has been conducted comparing the coverage of occupational therapy in Canada to the United States. The obvious difference in coverage can be attributed to the different systems of health care that is, the public and private models of the delivery of care. However, the study by Jongbloed and Wendland (2002) explored the funding and cost-control mechanisms in Canada and the United States and found that the source of funding has a powerful influence on occupational therapy practice. The article identifies that health care policies in the United States are driven by financial priorities and services are measured based on cost control (Jongbloed & Wendland, 2002). Because occupational therapy in the United States is held accountable based on cost effectiveness, a great deal more data collected related to measureable health outcomes for each intervention. This means that because the funding is so tightly managed, therapists in the United States must be sure that each intervention is making a difference using quite narrow measures of success. The authors identify the pressure therapists in the United States experience forcing them to shift their focus from occupational performance to the performance components of occupation. In other words, the documentation focuses on recording patient improvement in feeding or dressing, rather than reporting on improvement in psychosocial skills or management of leisure time (Jongbloed & Wendland, 2002). In Canada, occupational therapy practice is much different and not dominated by the medical model to the same extent, creating room for other measures of occupational engagement, like the Canadian Occupational Performance Measure (COPM), and national guidelines for practice (Department of National Health & Welfare & CAOT, 1983). Conversely, the documentation in the United States is limited to measureable, objective descriptions of functional change. While having a limited measure of performance is not necessarily all positive, outcome measures from a cost effectiveness perspective can 13

20 be used to support recommendations for interventions to improve health outcomes and to determine the most appropriate practitioners to deliver care in both the public and the private systems. Summary and Recommended Actions It is inevitable that as the public health system comes under increasing financial pressure there will need to be a shift in priorities and changes to the delivery of care. These changes are currently being discussed by governments, patients, advocates, medical experts, and other key health system stakeholders under the subject of health system transformation. The goal of the discussions is to come up with a framework for the future of health care that meets the policy objectives of the Canada Health Act, (to protect, promote and restore the physical and mental well-being of residents of Canada) and balance care objectives with fiscal responsibility and accountability. The added challenge is bringing together 14 jurisdictions with different models health care delivery in Canada. To summarize the evidence put forth in this paper, there are opportunities to increase the use of occupational therapy interventions to meet not only the current gaps and challenges in health care in Canada, but to provide solutions for changing health service needs. For instance, using specific economic challenges put forth by Constant and colleagues (2011), there are four primary cost drivers in the health system today that could benefit from the evidence indicating cost effectiveness of occupational therapy interventions. These are: hospitals, physicians, pharmaceuticals, and public health. Table 1 identifies costs drivers and the corresponding evidence related to health outcomes and economic or cost effectiveness of occupational therapy, or other interventions that fall into the scope of practice of occupational therapy. 14

21 Table 1: Responding to Cost Drivers in the Health System Cost Driver Opportunities Evidence Hospitals Occupational therapy interventions in stroke rehabilitation, home care, respiratory rehabilitation, end of life care, and fall prevention can reduce the number of hospital visits and move patients out of valuable bed space in hospitals, freeing up room for other patients. Gladman, Whynes and Lincoln, 1994; Brandis, 1998; Mcnamee et al, 1998; Beech et al, 1990; Anderson et al, 2000; HCC, 2012; Ramos et al, 2004; Goldstein et al, 1997; Griffith et al, 2001; Park Lala & Kinsella, 2011; Salkeld et al, 2000; Hay et al, 2002; Smith & Widiatmoko, 1998; Campbell et al, 2005; Robertson et al, 2001a, 2001b, 2001c; Rizzo et al, 1996; Mickan, 2005 Physicians As some provinces are attempting to tackle rising health services budgets they are attempting to cap the cost of physicians. However, it is recognized that the multiple methods of remuneration creates difficulties in the ability to cap the cost of physicians. Integrating other health professionals (including occupational therapists) into interprofessional health teams and maximizing the scope of practice of alternative care providers will assist in a shift Constant et al, 2011; Mickan, 2005 Pharmaceuticals Public Health towards more cost-effective activity-based funding models. Studies have examined non-pharmaceutical therapeutic interventions such as occupational therapy and found evidence of improved ability to treat, particularly in areas such as depression and mental health, stroke rehabilitation and pain management. Studies relating to home care, care giver needs, independent living, fall prevention, mental health and depression all offer cost-effective arguments for increasing the role of health providers, such as occupational therapists to address the needs of the patient, while continuing to provide quality care. Schene et al, 2007; Dooley & Hinojosa, 2004; Combe et al, 2006; HCC, 2012; Ramos et al, 2004; Schene et al, 2007; Graff, 2007; Park Lala & Kinsella, 2011; Glascoe et al, 1997; Clarke et al,