Natalie E. Leland

Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009

IMPORTANCE A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. OBJECTIVE To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. MAIN OUTCOME MEASURES Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). RESULTS Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%). CONCLUSION AND RELEVANCE Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

Volume Matters: Returning Home After Hip Fracture

To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participants fracture) and other facility characteristics on outcomes.

Occupational therapy in fall prevention: Current evidence and future directions

Falls are a serious public health concern among older adults in the United States. Although many fall prevention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear. This article presents a scoping review of current published research documenting the role of occupational therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in environmental modifications, exercise, and multifactorial and multicomponent interventions. Although research documenting the efficacy of occupational therapy interventions is identified as part of the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008), we identified little or no such research examining interventions to modify behaviors (e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage medications. Although occupational therapy is represented in the fall prevention research, the evidence for the professions role in many areas is still lacking.

Client Centeredness and Health Reform: Key Issues for Occupational Therapy.

Health reform promotes the delivery of patient-centered care. Occupational therapys rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapys perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapys research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

What is occupational therapy's role in addressing sleep problems among older adults?

Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Associations Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, multicomponent interventions, and other interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.

Advancing the Value and Quality of Occupational Therapy in Health Service Delivery

The authors set forth a foundation on which to build further dialogue and evidence to highlight occupational therapy’s distinctive contribution, significance, and viability as health care policies shift to focus on quality and value.

Decision Making and Outcomes of a Hospice Patient Hospitalized With a Hip Fracture

CONTEXT Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making. OBJECTIVES To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services. METHODS This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival. RESULTS Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001). CONCLUSION Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.

Special issue on productive aging: evidence and opportunities for occupational therapy practitioners.

Sharon J. Elliott, DHS, GCG, OTR/L, BCG, FAOTA, is Adult Therapy Services Coordinator, Therapeutic Life Center, Greenville, NC. In 1983, Robert Butler introduced the idea of productive aging in an effort to highlight the contributions of older adults in the United States (Butler & Gleason, 1985). This sociological concept broadly refers to activities that mark the multiple ways in which people contribute to their own health, to their families, to their communities, and to society as they age (Butler, 2002; Butler & Gleason, 1985). The principles of participation, highlighted in Butler’s definition of productive aging, are closely associated with the foundations of occupational therapy (Meyer, 1922; Peloquin, 1991a, 1991b). Yet not until the introduction of the Centennial Vision did the occupational therapy profession embrace the term productive aging (American Occupational Therapy Association [AOTA], 2006a, 2006b). The authors in this special issue of the American Journal of Occupational Therapy (AJOT), with the authors of the Occupational Therapy Practice Guidelines for Productive Aging (Leland, Elliott, & Johnson, in press), have striven to examine the literature through systematic reviews that focus on productive aging within the occupational therapy domain of practice (Arbesman & Lieberman, 2012). This examination, in turn, helps elucidate the effectiveness and benefits of occupational therapy interventions, as well as the implications for education and research, to support older adults’ participation and engagement in occupations as an avenue to achieve productive aging (Arbesman & Lieberman, 2012). By 2030, approximately 20% of the U.S. population will be 3 age 65 (U.S. Census Bureau, 2009), and chronic conditions will likely be the leading cause of disability (World Health Organization, 2011). Irrespective of existing chronic conditions, adults face challenges as they age as a result of normative aging processes (e.g., physical changes), contexts and environments that constrain optimal functioning (Gill, Williams, Robison, & Tinetti, 1999; Gitlin, 2003), community mobility changes (Dickerson et al., 2007), and alterations in social and caregiving resources (Neal, Wagner, Bonn, & Niles-Yokum, 2008). The cumulative impact of these vicissitudes affects older adults’ performance and places them at risk for institutionalization, disability, loss of independence in meaningful occupations, and greater health care use (Breyer, Costa-Font, & Felder, 2010; Christensen, Doblhammer, Rau, & Vaupel, 2009; Stel, Smit, Plumjim,& Lips, 2004; Stevens, Corso, Finkelstein, &Miller, 2006; Tinetti & Williams, 1997). The aspiration of most older adults to age in place (Gitlin, 2003) and maintain their ability to participate in desired occupations challenges the occupational therapy profession to expand service delivery beyond traditional medical settings (e.g., hospitals, institutions) to fulfill the need for community-based services in which prevention, health, and wellness are the priorities. Abundant opportunities exist for occupational therapy researchers, educators, and clinicians in current and emerging settings to help older adults age productively by (1) retaining or enabling participation in meaningful occupations (e.g., instrumental activities of daily living [IADLs]) and (2) providing strategies to manage the sequelae of chronic disease, prevent injury, age in place, and maximize quality of life. Natalie E. Leland, PhD, OTR/L, BCG

Occupational Therapy and Management of Multiple Chronic Conditions in the Context of Health Care Reform

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

The need for uniform quality reporting across post-acute care rehabilitation settings: an examination of accidental falls

To the Editor: A fall event can limit a patient’s ability to make functional gains and safely return home, two of the primary goals of rehabilitation services.[1] Public reporting of falls, which are a Medicare “Never Event,”[2] is not mandated in all post-acute care (PAC) rehabilitation settings. Consequently, little is known about the similarities or differences in the occurrence of this adverse event and its risk factors in these settings. Thus, stakeholders do not have important information necessary to make informed decisions about PAC service utilization. This study utilized a unique dataset to examine variations in accidental falls and risk factors among PAC patents receiving rehabilitation services in skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and home health agencies (HHA). Methods: This prospective cohort study evaluated data from 576 Medicare beneficiaries admitted to PAC rehabilitation after an acute hospitalization with a primary diagnosis of a stroke, hip fracture, or joint replacement. Data were collected using a standardized assessment protocol utilized within 48 hours of admission and discharge; details have been described elsewhere.[3] The primary outcome for this study was the occurrence of a fall reported during the PAC stay. Data on fall status was available for 520 patients. Additional study variables included patient demographics, fall risk factors, and mobility device use. Results: Twenty-seven patients (5.2%) had a fall during their PAC stay. Falls occurred most often among patients with stroke (10%; 12/119), followed by those who experienced hip fracture (6%; 10/173), and joint replacement (2%; 5/228). While falls occurred most commonly among SNF patients, falls occurred differentially by setting and diagnosis. For example, among IRF patients, more stroke patients fell, whereas among HHA patients, more joint replacement patients fell (see Figure 1). Risk factors for falls were similar to those reported in the literature. Falls occurred more often among patients with urinary incontinence (p<0.001) and depression (p<0.001), and poorer mobility (p<0.05), impaired balance (p<0.01), and cognitive limitations (p<0.001). Assistive mobility device use was more common among non-fallers. Walker/cane use was reported for 85% of non-fallers and 63% of fallers. Bedrail use was reported for 64% of non-fallers and 20% of fallers. Figure 1 Frequency of Accidental Falls by Post-Acute Care Setting Discussion: In PAC rehabilitation, an accidental fall is a sentinel event that diminishes the rehabilitation patient’s ability to achieve desired goals.[4, 5] This study demonstrated that falls do occur across PAC settings and there may be differential rates of falls by diagnosis and setting. Disparate quality reporting of falls prevents transparency and leaves stakeholders ill equipped to make decisions about the best setting to receive PAC. Currently Medicare requires falls be reported by nursing homes (but not SNFs); HHAs report falls and fall prevention quality measures; IRFs are not required to report any fall quality measures.[6] In the context of escalating PAC costs, concerns about health care quality, and a growing emphasis on patient engagement, there is a need for consistent and accurate public reporting of rehabilitation-relevant quality indicators across all PAC settings. Interventions targeting the modifiable risk factors for Never Events in acute care hospitals have resulted in