Canadian Association of Occupational Therapists

CAOT Position Statement
Occupational Therapy in Primary Care (2013)

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The Canadian Association of Occupational Therapists (CAOT) believes that occupational therapy services within primary care should be accessible to all Canadians, especially for people with multiple chronic conditions, mental illnesses and disabilities. Occupational therapists can provide needs-based solutions to manage complex primary care needs of Canadians.


Recommendations for Occupational Therapists
 

  1. Occupational therapists advocate for their role in primary care services and for the development and implementation of best-practice models.  
  2. Occupational therapists collaborate with stakeholders in actions that promote and advance occupational therapy service delivery and access within primary care. 
  3. Occupation therapists collaborate with primary care researchers to generate evidence for the effectiveness of occupational therapy interventions.
  4. Occupational therapists engage in continuing professional development to enhance their skills, knowledge and expertise in the delivery of primary care services.
  5. Occupational therapists, working in  interprofessional collaboration, recognize, respect and understand the scope, roles and contributions of all professional groups.


Recommendations for Educators

  1. Education programs prepare occupational therapy students for roles in primary care settings. This may entail education on community needs assessments, community networks, health care system structures, interprofessional practice, population health promotion, role of family physicians, chronic disease management, leadership skills, program evaluation, business plan development, funding models, and service delivery models. 
  2. Education programs engage family physicians, nurses, social workers and any other health professionals practicing in primary care settings to participate in training that informs the future generation of occupational therapists about the benefits and processes of interprofessional collaborations.
  3. Educational programs develop and offer fieldwork placements in primary care settings as a way to prepare occupational therapy students and advance the practice in this area.


Recommendations for Researchers

  1. Research should be conducted on models of practice, training programs and best practices standards for occupational therapists and interprofessional collaborations in primary care. Specifically, it is essential to identify appropriate tools for evaluation in a primary care context, including measures of structure, process and outcome of occupational therapy services.
  2. Researchers in occupational therapy should collaborate with family medicine researchers as well as with researchers from all other health professions offering services in primary care settings and across the continuum of care (e.g. secondary and tertiary care).
  3. Researchers should disseminate knowledge regarding the practice of occupational therapy in primary care both within the profession and to the different stakeholders, partners, end users, and community members to ensure that evidences of effectiveness of occupational therapy interventions reach both clinical practitioners and primary care audiences. 

 

CAOT Initiatives


To promote occupational therapy practice within primary care, CAOT will

  1. Advocate for the integration and increased access of occupational therapy services within interprofessional primary care settings for Canadians.
  2. Develop and maintain partnerships with relevant coalitions, organizations and stakeholders to assist advocacy efforts and develop funding in promoting access to occupational therapy and interprofessional collaborations in primary care.
  3. Promote and disseminate the principles, frameworks and toolkits that facilitate knowledge transfer of important resources developed by such groups as the Canadian Collaborative Mental Health Initiative (CCMHI) and the Enhancing Interdisciplinary Collaboration in Primary Care Initiative (EICP).
  4. Support interprofessional education at the entry-level to the profession and in continuing professional development initiatives to promote collaborative interprofessional practice in primary care.
  5. Promote profession-specific and interprofessional research studies that expand the knowledge base on best practices in primary care services in Canada.

 

Background


Primary care is usually the first place people go when they need health advice or care. Essentially, primary care refers to an approach to health and a spectrum of services that includes all health services used in front lines by the population to address their health concerns (McColl & Dickenson, 2009). For instance, primary care services include visits to family physicians, nurse practitioners and mental health workers. These front line services also include telephone calls to health information lines and advice received from pharmacists. In Canada, primary care is responsible for coordinating access to other parts of the health care system. “It is also the best place within the health care system to prevent illness and injury and promote good health” (Health Canada, 2004).

Figure 1 provides an overview of the distribution of clients’ presentation and needs when consulting a primary care resource (Wallace & Seidman, 2007). People with multiple chronic conditions (which could include a combination of physical and/or mental illnesses and disabilities) represent a relatively small proportion of a typical caseload (i.e. 6%) but yet, require up to 33% of the practice’s resources. Furthermore, these clients may encounter several barriers in their attempts to access primary care services and are likely to experience inequities. They might have difficulty getting an appointment, using and navigating through the different health facilities and being understood (Anderson & Kitchin, 2000; Kroll & Neri, 2003; Sanchez et al., 2000; Saulnier, Shortt, & Gruenwoldt, 2004). In a recent pan-Canadian survey conducted on 1,200 people with chronic conditions, poor coordination and information flow among health care providers and difficulties being understood were reported (Health Council Canada, 2011). Other evidence suggest that they are less likely to be thoroughly examined, receive appropriate accommodations and  obtain a reasonable standard of care for both routine and specialized health problems (Anderson & Kitchin, 2000; Iezzoni, Davis, Soukup, & O'Day, 2003). In sum, individuals with chronic conditions might be disadvantaged in receiving specialist health care, administrative and social benefits and entitlements associated with their disabilities or conditions (DeJong, 1997). People with one chronic condition (middle layer of Figure 1 – 21% of a typical caseload) are also at risk of experiencing functional difficulties and could benefit from interprofessional collaborative team interventions aiming to prevent deterioration and maintain or restore functional capacity (Beatty et al., 2003; Bingham & Beatty, 2003; DeJong, 1997).

Overall, there is approximately one-quarter of a typical caseload in a primary care setting that could benefit from occupational therapy. There is an opportunity for occupational therapists to contribute to interprofessional collaborative teams and offer services within primary care settings, particularly to clients who present with either multiple chronic conditions or one chronic condition that, if not managed properly, could lead to further health complications and/or disabilities. Occupational therapists can provide holistic and client-centered support and services to address occupational performance issues, activity limitations and participation restrictions. They can also offer services which might effectively prevent exacerbation of existing conditions or the development of new chronic conditions.

There is a growing consensus that interprofessional collaborative practice in primary care will result in better health outcomes, improved access to services, more efficient use of resources and greater satisfaction for both clients and providers. Research evidences and experts suggest that such teams are well positioned to offer comprehensive and efficient management of chronic diseases and promote healthy lifestyle choices among vulnerable populations (EICP - ACIS Steering Committee, 2005).

The evidence to support occupational therapy interventions in primary care are numerous (see Appendix A). Possible services that occupational therapists would be ideally positioned to offer in primary care settings are provided in Table 1.

Table 1. Sample of services occupational therapists can provide in a primary care setting:

Glossary


Occupational Therapists
are university-educated health professionals who are regulated in all 10 Canadian provinces. Their education is devoted to the study of occupation and occupational performance. Occupational therapists work with clients to achieve outcomes related to their participation in valued activities. As specialists in the area of occupation and occupational performance, they facilitate an interprofessional collaborative approach that puts clients and their occupational performance at the center of all decision-making (Manitoba Society of Occupational Therapists, 2005).

Occupational therapy is the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life (Townsend & Polatajko, 2007).

Patients / clients / users/ end-service recipients in primary care are the individuals who receive health services.

Primary Health Care refers to an approach to health and a spectrum of services beyond the traditional health care system. It includes all services that play a part in health, such as income, housing, education, and environment (Health Canada, 2012).

Primary Care is the element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury (Health Canada, 2012).

 

References


Anderson, P., & Kitchin, R. (2000). Disability, space and sexuality: access to family planning services. Social Science & Medicine, 51(8), 1163-1173.

Beatty, P. W., Hagglund, K. J., Neri, M. T., Dhont, K. R., Clark, M. J., & Hilton, S. A. (2003). Access to health care services among people with chronic or disabling conditions: patterns and predictors. Archives of physical medicine and rehabilitation, 84(10), 1417-1425.

Bingham, S. C., & Beatty, P. W. (2003). Rates of access to assistive equipment and medical rehabilitation services among people with disabilities. Disability and Rehabilitation, 25(9), 487-490. doi: 10.1080/0963828031000071723

DeJong, G. (1997). Primary care for persons with disabilities. An overview of the problem. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 76(3 Suppl), S2-8.

EICP - ACIS Steering Committee. (2005). Enhancing Interdisciplinary Collaboration in Primary Health Care: The Principles and Framework for Interdisciplinary Collaboration in Primary Health Care (pp. 8). Ottawa: EICP - ACIS.

Health Canada. (2004). Primary Health Care. Health Care System  Retrieved December 3, 2012, from http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/fs-if_08-eng.php

Health Canada. (2012). Health Care System: About Primary Health Care.  Retrieved from http://www.hc-sc.gc.ca/hcs-sss/prim/about-apropos-eng.php.

Health Council Canada. (2011). How do sicker Canadians with chronic disease rate the health care system? Results from the 2011 Commonwealth fund international health policy survey of sicker adults Canadian health care matters: Bulletin 6 (pp. 28). Toronto: Health Council Canada - Conseil canadien de la santé.

Iezzoni, L. I., Davis, R. B., Soukup, J., & O'Day, B. (2003). Quality dimensions that most concern people with physical and sensory disabilities. Archives of Internal Medicine, 163(17), 2085-2092. doi: 10.1001/archinte.163.17.2085

Kroll, T., & Neri, M. (2003). Experiences with care co-ordination among people with cerebral palsy, multiple sclerosis, or spinal cord injury. Disability and Rehabilitation, 25(19), 1106-1114. doi: doi:10.1080/0963828031000152002

McColl, M. A., & Dickenson, J. (2009). Inter-Professional Primary Health Care: Assembling the Pieces. A Framework to Build your in Primary Health Care. Ottawa: CAOT Publications ACE.

Sanchez, J., Byfield, G., Brown, T. T., LaFavor, K., Murphy, D., & Laud, P. (2000). Perceived accessibility versus actual physical accessibility of healthcare facilities. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 25(1), 6-9.

Saulnier, M., Shortt, S. E., & Gruenwoldt, E. (2004). The taming of the queue: toward a cure for health care wait times.

Townsend, E. A., & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being and justice through occupation (First ed.). Ottawa: CAOT Publications ACE.

Wallace, P., & Seidman, J. (2007). Improving population health and chronic disease management. In J. Dorland & M. A. McColl (Eds.), Emerging approaches to chronic disease management in primary health care (First ed., pp. 15-20). Montréal: Queen's Policy Studies.

Appendix A: Evidence on the effectiveness of occupational therapy, rehabilitation or interprofessional interventions in primary care

Chronic pain, musculoskeletal disorders and arthritis in primary care

Albaladejo, C., Kovacs, F. M., Royuela, A., del Pino, R., & Zamora, J. (2010). The efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial. Spine (Phila Pa 1976), 35(5), 483-496. doi: 10.1097/BRS.0b013e3181b9c9a7

Buszewicz, M., Rait, G., Griffin, M., Nazareth, I., Patel, A., Atkinson, A., . . . Haines, A. (2006). Self management of arthritis in primary care: randomised controlled trial. Bmj, 333(7574), 879. doi: 10.1136/bmj.38965.375718.80

Cup, E. H., Pieterse, A. J., Hendricks, H. T., van Engelen, B. G., Oostendorp, R. A., & van der Wilt, G. J. (2011). Implementation of multidisciplinary advice to allied health care professionals regarding the management of their patients with neuromuscular diseases. Disabil Rehabil, 33(9), 787-795. doi: 10.3109/09638288.2010.511414

Dziedzic, K., Stevenson, K., Thomas, E., Sim, J., & Hay, E. (2009). Development and implementation of a physiotherapy intervention for use in a pragmatic randomized controlled trial in primary care for shoulder pain. Musculoskeletal Care, 7(2), 67-77. doi: 10.1002/msc.151

Hay, E. M., Foster, N. E., Thomas, E., Peat, G., Phelan, M., Yates, H. E., . . . Sim, J. (2006). Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. Bmj, 333(7576), 995. doi: 10.1136/bmj.38977.590752.0B

Kroenke, K., Bair, M. J., Damush, T. M., Wu, J., Hoke, S., Sutherland, J., & Tu, W. (2009). Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. Jama, 301(20), 2099-2110. doi: 10.1001/jama.2009.723

Lambeek, L. C., Bosmans, J. E., Van Royen, B. J., Van Tulder, M. W., Van Mechelen, W., & Anema, J. R. (2010). Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. Bmj, 341, c6414. doi: 10.1136/bmj.c6414

Lambeek, L. C., van Mechelen, W., Knol, D. L., Loisel, P., & Anema, J. R. (2010). Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. Bmj, 340, c1035. doi: 10.1136/bmj.c1035

Martensson, L., & Dahlin-Ivanoff, S. (2006). Experiences of a primary health care rehabilitation programme. A focus group study of persons with chronic pain. Disabil Rehabil, 28(16), 985-995. doi: 10.1080/09638280500476246

Patel, A., Buszewicz, M., Beecham, J., Griffin, M., Rait, G., Nazareth, I., . . . Haines, A. (2009). Economic evaluation of arthritis self management in primary care. Bmj, 339, b3532. doi: 10.1136/bmj.b3532

Smith, B. H., & Torrance, N. (2011). Management of chronic pain in primary care. Curr Opin Support Palliat Care, 5(2), 137-142. doi: 10.1097/SPC.0b013e328345a3ec

Williams, N. H., Amoakwa, E., Belcher, J., Edwards, R. T., Hassani, H., Hendry, M., . . . Wilkinson, C. (2011). Activity Increase Despite Arthritis (AIDA): phase II randomised controlled trial of an active management booklet for hip and knee osteoarthritis in primary care. Br J Gen Pract, 61(589), e452-458. doi: 10.3399/bjgp11X588411

Interprofessional services delivery in primary care

Barley, E. A., Robinson, S., & Sikorski, J. (2012). Primary-care based participatory rehabilitation: users' views of a horticultural and arts project. Br J Gen Pract, 62(595), e127-134. doi: 10.3399/bjgp12X625193

Coin, I., Di Pollina, L., Drezet-Munch, N., & Maringue, A. (2011). [Collaboration between the primary care physician and the occupational therapist]. Rev Med Suisse, 7(310), 1858-1861.

Letts, L. J. (2011). Optimal positioning of occupational therapy. Can J Occup Ther, 78(4), 209-219.

McColl, M. A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O'Brien, P., & Donnelly, C. (2009). Models for integrating rehabilitation and primary care: a scoping study. Arch Phys Med Rehabil, 90(9), 1523-1531. doi: 10.1016/j.apmr.2009.03.017

Richardson, J., Letts, L., Chan, D., Officer, A., Wojkowski, S., Oliver, D., . . . Kinzie, S. (2012). Monitoring physical functioning as the sixth vital sign: evaluating patient and practice engagement in chronic illness care in a primary care setting--a quasi-experimental design. BMC Fam Pract, 13, 29. doi: 10.1186/1471-2296-13-29

Lifestyle interventions in primary care: Obesity, physical activity, and eating disorders

Allen, S., & Dalton, W. T. (2011). Treatment of eating disorders in primary care: a systematic review. J Health Psychol, 16(8), 1165-1176.

Bennett, G. G., Warner, E. T., Glasgow, R. E., Askew, S., Goldman, J., Ritzwoller, D. P., . . . Colditz, G. A. (2012). Obesity treatment for socioeconomically disadvantaged patients in primary care practice. Arch Intern Med, 172(7), 565-574. doi: 10.1001/archinternmed.2012.1

Fleming, P., & Godwin, M. (2008). Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician, 54(12), 1706-1713.

Gusi, N., Reyes, M. C., Gonzalez-Guerrero, J. L., Herrera, E., & Garcia, J. M. (2008). Cost-utility of a walking programme for moderately depressed, obese, or overweight elderly women in primary care: a randomised controlled trial. BMC Public Health, 8, 231. doi: 10.1186/1471-2458-8-231

Orrow, G., Kinmonth, A. L., Sanderson, S., & Sutton, S. (2012). Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. Bmj, 344, e1389. doi: 10.1136/bmj.e1389

Mental health services in primary care

Hunkeler, E. M., Katon, W., Tang, L., Williams, J. W., Jr., Kroenke, K., Lin, E. H., . . . Unutzer, J. (2006). Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. Bmj, 332(7536), 259-263. doi: 10.1136/bmj.38683.710255.BE

Kroenke, K., Bair, M. J., Damush, T. M., Wu, J., Hoke, S., Sutherland, J., & Tu, W. (2009). Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. Jama, 301(20), 2099-2110. doi: 10.1001/jama.2009.723

Lambert, R. A., Harvey, I., & Poland, F. (2007). A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care. J Affect Disord, 99(1-3), 63-71. doi: 10.1016/j.jad.2006.08.026

McNaughton, J. L. (2009). Brief interventions for depression in primary care: a systematic review. Can Fam Physician, 55(8), 789-796.

Quartero, A. O., Burger, H., Donker, M., & de Wit, N. J. (2011). Exercise therapy for stress-related mental disorder, a randomised controlled trial in primary care. BMC Fam Pract, 12, 76. doi: 10.1186/1471-2296-12-76

Seekles, W., van Straten, A., Beekman, A., van Marwijk, H., & Cuijpers, P. (2011). Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res, 187(1-2), 113-120. doi: 10.1016/j.psychres.2010.11.015

Stant, A. D., TenVergert, E. M., Kluiter, H., Conradi, H. J., Smit, A., & Ormel, J. (2009). Cost-effectiveness of a psychoeducational relapse prevention program for depression in primary care. J Ment Health Policy Econ, 12(4), 195-204.

Wallace, M. L., Dombrovski, A. Y., Morse, J. Q., Houck, P. R., Frank, E., Alexopoulos, G. S., . . . Schulz, R. (2012). Coping with health stresses and remission from late-life depression in primary care: a two-year prospective study. Int J Geriatr Psychiatry, 27(2), 178-186. doi: 10.1002/gps.2706

Watkins, E. R., Taylor, R. S., Byng, R., Baeyens, C., Read, R., Pearson, K., & Watson, L. (2012). Guided self-help concreteness training as an intervention for major depression in primary care: a Phase II randomized controlled trial. Psychol Med, 42(7), 1359-1371. doi: 10.1017/s0033291711002480

Older adult services: Fall prevention, cognitive impairments and dementia in primary care

Boult, C., & Wieland, G. D. (2010). Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through". Jama, 304(17), 1936-1943. doi: 10.1001/jama.2010.1623

Callahan, C. M., Boustani, M. A., Unverzagt, F. W., Austrom, M. G., Damush, T. M., Perkins, A. J., . . . Hendrie, H. C. (2006). Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. Jama, 295(18), 2148-2157. doi: 10.1001/jama.295.18.2148

Graff, M. J. L., Adang, E. M. M., Vernooij-Dassen, M. J. M., Dekker, J., Jönsson, L., Thijssen, M., . . . Rikkert, M. G. M. (2008). Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study. Bmj, 336(7636), 134-138.

Gusi, N., Reyes, M. C., Gonzalez-Guerrero, J. L., Herrera, E., & Garcia, J. M. (2008). Cost-utility of a walking programme for moderately depressed, obese, or overweight elderly women in primary care: a randomised controlled trial. BMC Public Health, 8, 231. doi: 10.1186/1471-2458-8-231

Hunkeler, E. M., Katon, W., Tang, L., Williams, J. W., Jr., Kroenke, K., Lin, E. H., . . . Unutzer, J. (2006). Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. Bmj, 332(7536), 259-263. doi: 10.1136/bmj.38683.710255.BE

Michael, Y. L., Whitlock, E. P., Lin, J. S., Fu, R., O'Connor, E. A., & Gold, R. (2010). Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med, 153(12), 815-825. doi: 10.1059/0003-4819-153-12-201012210-00008

Ploeg, J., Brazil, K., Hutchison, B., Kaczorowski, J., Dalby, D. M., Goldsmith, C. H., & Furlong, W. (2010). Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: randomised controlled trial. Bmj, 340, c1480. doi: 10.1136/bmj.c1480

Pediatric interventions in primary care

Lavigne, J. V., Lebailly, S. A., Gouze, K. R., Cicchetti, C., Pochyly, J., Arend, R., . . . Binns, H. J. (2008). Treating oppositional defiant disorder in primary care: a comparison of three models. J Pediatr Psychol, 33(5), 449-461. doi: 10.1093/jpepsy/jsm074

Systemic disorders such as diabetes and chronic obstructive disorders (COPD) in primary care

Bastiaens, H., Sunaert, P., Wens, J., Sabbe, B., Jenkins, L., Nobels, F., . . . Van Royen, P. (2009). Supporting diabetes self-management in primary care: pilot-study of a group-based programme focusing on diet and exercise. Prim Care Diabetes, 3(2), 103-109.

Christison-Lagay, J. (2007). Facilitating diabetes self-management goal setting in a real-world primary care center. Diabetes Educ, 33 Suppl 6, 145S-150S. doi: 10.1177/0145721707305215

Khunti, K., Gray, L. J., Skinner, T., Carey, M. E., Realf, K., Dallosso, H., . . . Davies, M. J. (2012). Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. Bmj, 344, e2333. doi: 10.1136/bmj.e2333

Kruis, A. L., & Chavannes, N. H. (2010). Potential benefits of integrated COPD management in primary care. Monaldi Arch Chest Dis, 73(3), 130-134.

McGeoch, G. R., Willsman, K. J., Dowson, C. A., Town, G. I., Frampton, C. M., McCartin, F. J., . . . Epton, M. J. (2006). Self-management plans in the primary care of patients with chronic obstructive pulmonary disease. Respirology, 11(5), 611-618. doi: 10.1111/j.1440-1843.2006.00892.x

Ravaud, P., Flipo, R. M., Boutron, I., Roy, C., Mahmoudi, A., Giraudeau, B., & Pham, T. (2009). ARTIST (osteoarthritis intervention standardized) study of standardised consultation versus usual care for patients with osteoarthritis of the knee in primary care in France: pragmatic randomised controlled trial. Bmj, 338, b421. doi: 10.1136/bmj.b421

Sanchez, I. (2011). Implementation of a diabetes self-management education program in primary care for adults using shared medical appointments. Diabetes Educ, 37(3), 381-391. doi: 10.1177/0145721711401667



[1] Adapted from Wallace & Seidman, 2007 (Wallace & Seidman, 2007).

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