OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care

Article Reviews
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Read Full Text: OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: A randomized controlled trial
Journal: BMC Family Practice
Year Published: 2015
Ranked 59th on our 2015-2020 list of the 100 most influential OT-related articles

Here’s what I love about research:

If you’ve thought of a new or creative use of therapy, there is a good chance researchers have already explored it.

For example, I’m always dreaming about ways that OT could be more involved in the primary care model. And, while I’ve read hypothetical arguments about why OT should be more involved in primary care, I’ve never actually met any OTs who work in that setting.

That’s what makes this week’s article so exciting: the authors illustrate some pretty promising results for an OT-led self-management support program designed for patients with multimorbidity—and these are patients whose needs are not currently being fully met in primary care.

Let’s dive in.

A super brief refresher on multimorbidity

Multimorbidity refers to the coexistence of multiple health conditions in an individual—and it is now considered the norm, rather than the exception, in the primary care setting.

Multimorbidity is a predictor of multiple adverse outcomes, including:

  • Poor quality of life
  • Mortality and disability
  • Psychological distress
  • Financial difficulties
  • Restrictions in work, leisure, and social activities
  • Increased healthcare utilization

And, in addition to all of these challenges, we have another major challenge: Primary care—and healthcare, in general—simply was not designed to address the complexity and challenge of multimorbidities.

Just think about trying to address multiple serious conditions in your 15-minute doctor’s appointment. Or how many specialists you would have to see to treat multiple conditions…

What is the OPTIMAL program?

OPTIMAL is a 6-week, community-based program that is led by an OT. The program is occupation-based and focused on self-management. The intent behind the program is to build the self-efficacy of attendees. (I’ll give more details below.)

What was the research question being studied in this trial?

The researchers wanted to know if OPTIMAL would increase activity participation in individuals with multimorbidity. This study utilized a randomized control trial (RCT) design.

Who participated in this study?

50 patients were involved in this trial, all of whom were referred by a family practitioner in the Irish healthcare system. All of the patients had at least 2 chronic health conditions and were taking 4 or more medications on an ongoing basis.

Between the 50 patients, there were 43 different health conditions identified. The most common conditions were:

  • Arthritis
  • Congestive cardiac heart failure
  • Diabetes
  • Depression
  • Hypertension

What did the intervention look like?

You can find the full details of the sessions within this previous study. But, here are some of the highlights:

Session content

The six sessions covered this content:

  • Fatigue management
  • Healthy eating
  • Maintaining physical activity (these sessions were delivered by a PT)
  • Maintaining mental health
  • Managing medications (these sessions were delivered by a pharmacist)
  • Communicating effectively with health professionals

Individual goal-setting was a key element of the study, with goals discussed and revised at each session.

Duration/frequency

Each session lasted for 3 hours, and they were delivered once per week across a six-week period.

Professional support

While peer support was part of the group format, the designers of the program felt that professional leadership of the sessions (by an OT) was important for standardizing the program.

What did care look like for the standard-care group?

Patients who were randomized to the standard-care group simply received their standard care. They were then invited to join an OPTIMAL program after the study’s completion.

What outcome measures were utilized?

Primary outcome measure:

As mentioned above, activity participation was the primary outcome. Here’s the assessment they used to track this measure:

Secondary outcome measures included:

What were the results?

Attendance

Attendance is always an important consideration in any group program, because it’s unlikely that every subject is going to show up to every session. Based on a Cochrane review, you can expect that between 51%-87% of participants will attend half or more of the sessions in a self-management program.

In the OPTIMAL program, 76% of the participants attended at least half of the sessions.

Results from outcome measures

Significant differences were found between groups (in favor of improvement for the OPTIMAL group) in the following:

  • Activity participation (via the Frenchay Activities Index (FAI))
  • Self-efficacy (via the The Stanford Chronic Disease Self-Efficacy 6-Item Scale (SSE))
  • Canadian Occupational Performance Measure (COPM)
  • Nottingham Extended Activities of Daily Living (NEADL) Scale
  • EQ-VAS

Goal-setting

Goal-attainment scaling was only utilized with the OPTIMAL group, but significant progress was found in their goal progress. Their most commonly cited goals included:

  • Fitness levels
  • Losing weight
  • Increasing confidence
  • Improving diet
  • Developing a more structured daily routine

What did the authors conclude?

The authors ultimately concluded that OPTIMAL is effective in improving activity participation and performance. It also leads to improvements in self-efficacy, health-related quality of life, and goal attainment.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1.) Another win for OTs as coaches/facilitators!

Unfortunately, many of our reimbursement models force us to focus on what WE are doing as therapists, what is happening during our treatment sessions, and very specific goal areas.

But, we have to step back and appreciate that the research seems to keep showing us that when we take on more of a coach role—where we help our patients lean into the idea of self-management—we are seeing more successful outcomes in our patients’ health.

We are hopefully headed into a reality where we are reimbursed for the long-term impact that we have on our patients’ health status, rather than languishing in a world where we use these short-sighted reimbursement models. I look forward to occupational therapy professionals serving in more of these coaching roles…we seem so well suited for them!

2.) Let’s keep talking about OT and primary care!

I am such a big fan of primary care, in part because it has helped me so tremendously. When I hit my own complex health challenges a few years ago, I don’t know how I would have found the answers I needed without the brainstorming, elimination process, tweaking, and support I found in primary care.

My all-time favorite article about primary care is The Heroism of Incremental Care. Just get a load of this tagline:

We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.

It seems like the primary care model is struggling to find its footing during the COVID era— just like we are in traditional rehab. I hope that one silver lining of this pandemic is that it will accelerate changes to both primary care and rehab, and that the future will bring more strategic alliances like the ones we saw working in the OPTIMAL program.

I’m excited to keep having this conversation about OT and primary care with you!

(Possibly) Earn CEUs/PDUs for reading this article.

Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.

And, here’s the full APA citation you many need:

Garvey, Jess, et al. “OPTIMAL, an Occupational Therapy Led Self-Management Support Programme for People with Multimorbidity in Primary Care: a Randomized Controlled Trial.” BMC Family Practice, vol. 16, no. 1, 2015, doi:10.1186/s12875-015-0267-0.

What questions/thoughts does this article raise for you?

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I’m excited to see this article as an adjunct OT professor. We discuss Primary Care in class as a potential service area but our entry into that area of practice as OTs has been slow. I hope that studies like this allows us some additional traction in this area. Reimbursement models would need to change in order for OT in Primary Care to make more sense. The addition of Accountable Care Organizations that have been developed as a part of the ACA (aka Obamacare) provide incentives for bundled payments for chronic health conditions. This has helped but we have a long way to go. My prediction is that we’ll see OT in Primary Care first in internally insured groups like the VA and with HMOs that have a resource incentive to keep people healthy to save cost. Most of our country’s payment system is based on “sick” care, not the business of keeping people healthy, unfortunately. I’d love to see us keep pushing on this service area as a profession. AOTA has some resources to share with providers, like this video: https://youtu.be/JfmPaZ0h8a8. Thanks for sharing this article, Sarah!

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I love seeing this research article! We spent some time in OT school building a primary care program with similarities to OPTIMAL. While doing that assignment, I saw so much worth for OT in primary care. Programs could serve as ways to encourage individuals to take increased responsibility as well as have a COMMUNITY and SUPPORT system to educate, encourage, and hold them accountable. It is also a time to grow and learn to ask questions that can prevent and increase health!

I also had the privilege of working in a LTACH (long term acute care hospital) for two years where I would say a major of our patients had multiple chronic health conditions as listed in the article. I thought about our primary program we had built in school often with this patient demographic.

Community, socialization, education, and accountability, I believe, would truly increase quality of life for these individuals-not only physically but social, emotionally, and spiritually. And even for those that are unable to gather in person due to limited mobility or additional issues, the potential of virtual support groups that OTs could head up!

Excited for further research in this area!! Thanks for sharing!

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Hi Sarah, First off, thank you for all you do, Kudos to you for keeping us all educated and informed!!
I know that PT’s are working in a few emergency rooms in some hospitals throughout the country, and I believe OT’s could and should be there too as well as in Primary Care Settings and doing evaluations to find out what is going on with the patients before they go home if they are not admitted in the hospital and before they walk out of the door in the doctors office. Educating our primary care doctors and specialist to inform them of the value of OT in all populations in these times of isolation and especially for our geriatric community can really help get us recognized. Communicating to our primary care doctors the important components of OT and how we can help their patients self-manage in these unsure and isolating times. Myself and the OT’s I work with at a home health company in “The Villages” in central Florida are providing primary care providers, patients and caregivers education on how we can help like:
• Set-up daily schedule for meaningful activities/meals/medications/ social contact
• Assist with creating menus/light meal prep/cooking ahead
• Assist with grocery lists & shopping
• Assist with setting up and teaching online shopping options or curb side pick-up
• Assist with and teach automatic medication refills
• Assist with set-up and teach virtual visits with family/friends/physicians/church groups
• Assist with and set-up of phone and computer for online games/video calls
(YouTube/Zoom/WhatsApp/FaceTime etc.)
• Identify, assist and provide basic supplies for meaningful engagement: music/beach balls/ pool noodles/balloon tennis/cane exercises/ playing cards/puzzles/board games.
We believe this is the beginning to get us in the doors and have our “OT” name in the community and to the primary care doctors, ARNP’s and PA’s as well as educating them on how OT’s can really help their patients not only with ADL’s but important IADL’s which I believe is a crucial component on their primary care, as we should be one of the important and top face-to-face contacts with folks that really need our important “OT” service!
:slight_smile: Kelly Barlow OTR/L, CLT

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Welcome @kelly3! I’m really passionate about improving communication with primary care providers! That was the single biggest thing that helped me grow the first OT department I worked in. And, I think our care is SUCH a compliment and natural fit for people in the primary care system

I’m curious what you’ve been doing to communicate these things with your primary care providers? I’m always curious if this is an area where the OT Potential Club could provide more support to OTs. (@lauren2, let’s brainstorm this sometime!)

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As a brand-new pediatric OT, I immediately started thinking about the impact OT could have in pediatric primary care, and what that could look like for a pediatrician’s office.
It’s true - doctor’s visits are so short, and those 15-minute increments may not be enough to answer parent questions on development, play/toy recommendations, sensory-based strategies, and many other topics OTs are uniquely qualified to address. I picture an OT available in the office, coming in to see the family after the doctor and going through any new diagnoses or changes to find way to support the family. This could also be a perfect opportunity to screen for potential therapy needs.

At AOTA last year I was able to connect with an OT who volunteers in a free community clinic, providing education and exercises as needed (I wish I remembered her name!). She suggested that volunteering in these reimbursement-free settings would be an excellent way to demonstrate our value in this new practice area while providing much-needed services. I would be eager to hear from others who have done so or are looking into the idea.

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@kelly3 This is great to hear and sounds like a very strategic way to build support and gather traction to show the value of OT. As an educator (and proponent of the Capstone experience to accomplish some much needed program development) have you ever considered bringing on a Capstone student to help with some of these outreach/programmatic pieces?

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@SarahLyon that sounds super exciting! It’s an area I’m very much in support of and @kelly3 I wonder if there are resources that you would find helpful as you’re making your case for OT working with chronic health conditions and making the way into (at least more interfacing) with Primary Care. Welcome to the Club!!

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@abigail1 I haven’t thought about how OT could interface in the pediatrician’s office (because my practice focus has always been adults - that’s where my mind goes). What an AWESOME opportunity for collaboration for OT, from sensory diagnosis to behavioral support, development, recommendations - it seems like a no-brainer! I think the idea of studying this as a model within a different reimbursement model could really help. I also wonder if HMO’s like Kaiser would be more incentivized to support a wellness model like that. Curious!

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What I appreciate about this article is that they are referencing a specific, structured program and yet is still individualized. There definitely seems to be an abundance of research methods that are so vague and based on therapists designing their own interventions around topics rather than having specific guidelines. This complicates things when it comes to carry over or entering into a new area of practice. What a wonderful collaboration this could lead to between OT’s and primary care providers while really shining the light on the heart of OT!

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@abigail1 I love your idea. Though I am not a pediatric OT, I have always envisioned a similar thought with the adult population-an OT being part of the primary doctor’s office. If the MD, NP or PA identified co-morbidities, the client would have to visit the OT next door who would do a comprehensive assessment of their living conditions and skills, address deficits, and provide strategies for successful living at home.This could provide a great opportunity to screen clients for falls and prevent hospital admissions. The reimbursement for this would have to be included somehow in the MD wellness visit, I would guess.

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Sarah,
I am excited to see this article on “OT in primary care”. In my “Specialized practice in OT” class, we discuss primary care as an emerging area of practice for OT.
I am reminded of the AOTA article a few years ago which described how OT was the only spending category that was associated with decreasing hospital readmission rates. I believe that if OT was offered as a service in primary care (as part of the Wellness model), I am sure many hospital admissions would be reduced.
A few years ago, a group of us (OTs, PTs, SLPs) conducted educational sessions on chronic disease management at a local church as part of our career ladder requirements. We discussed arthritis, CHF, diabetes, and COPD. I noticed that there was a huge need for education and discussion on specific things that can be done to manage these chronic conditions.
Our reimbursement models need to change to include programs such as OPTIMAL. It gives me hope to read what you write-" one silver lining of this pandemic is that it will accelerate changes to both primary care and rehab and that the future will bring more strategic alliances like the ones we saw working in the OPTIMAL program"
The article I mentioned is cited below if anyone is interested. Thank you for another great article.
Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016, September 2). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19. https://doi.org/10.1177/1077558716666981

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This is so exciting!!! Thank you for sharing.

OT is extremely broad and our knowledge base is constantly growing. As innovators, facilitators, and LISTENERS, I find our role in routine development, self-care, leisure participation… extremely important. I am constantly trying to expand on my list of trusted referrals including chiropractors, audiologists, SLP and feeding specialty, PT, developmental optometrists, neuropsychologists, holistic MDs that test for food allergies and sensitivities (as well as poor nutrient absorption)!psychologists… and more. So many times people are looking for answers, or some kind of linking information, that they just DO NOT get until they see an OT. As a pediatric therapist, I find myself explaining the importance of tummy time, positive reinforcement, teaching critical thinking and self-efficacy skills. And then expanding to explain things in different approachable, adaptable, and meaningful ways. We also have more TIME than MDs often do to EXPLAIN and TEACH and identify things that are inhibitory to growth!

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I would love to volunteer and do this! What a great opportunity.

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Hi Sarah, We have been marketing door to door in our area to the primary care providers about our strong OT program which first includes a cognitive program which is well needed in the area of “The Villages” a huge retirement community with multiple morbidlies as well as cognitive decline from many reasons. Addressing cognition & psychological is crucial and it is really getting primary care providers interested in OT can help their patients besides retraining with ADL’ and IADL’s. We have been doing cognitive staging with patients to find out how much support they need. Primary Care providers know this is a huge problem and this is where we maintain value. Yes would love to brain storm and talk to you about what is happening down here. Thank you again for OTPOTENTIAL!

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@sanchala, I’m so glad you brought up this article!! I actually had it scheduled for later in the year, but I’m going to cover it next week. Because it seems so relevant to our current conversation of OT as a prevention/wellness service. It also seems like a super important read as therapy departments are starting to see more COVID patients.

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@kelly3, YES! Let’s brainstorm!! I’ve had some ideas in the past, but I would love to run them by someone like you! I will put it on my list to send you an email tomorrow!

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Yes, it is a good one for our club discussion. I was disappointed that it did not create more waves when it was published.
Sanchala

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