Occupational therapy discharge planning and recommendations in acute care

344 Pages·2017·2.5 MB·English

Nova Southeastern University
NSUWorks
Occupational Therapy Program Student Theses,
Department of Occupational Therapy
Dissertations and Capstones
4-19-2016
Occupational therapy discharge planning and
recommendations in acute care: An action research
study
Helene Smith-Gabai
Nova Southeastern University
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NSUWorks Citation
Helene Smith-Gabai. 2016.Occupational therapy discharge planning and recommendations in acute care: An action research study.Doctoral
dissertation. Nova Southeastern University. Retrieved from NSUWorks, College of Health Care Sciences – Occupational Therapy
Department. (54)
https://nsuworks.nova.edu/hpd_ot_student_dissertations/54.
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OCCUPATIONAL THERAPY DISCHARGE PLANNING AND
RECOMMENDATIONS IN ACUTE CARE: AN ACTION RESEARCH STUDY

by

Helene Smith-Gabai

Submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy in Occupational Therapy
Occupational Therapy Department
College of Allied Health and Nursing
Nova Southeastern University
Fort Lauderdale, Florida 33328
ProQuest Number: 10188959
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Abstract
In today’s health care environment of quick discharges and shortened hospital stays
discharge planning has become increasingly important in acute care occupational therapy
practice. Discharge planning is a complex process and an important aspect of patient care
as poor discharge planning has been associated with poor patient outcomes and increased
risk of adverse events and readmission. This study addressed the following research
questions: (a) How do acute care occupational therapists describe their role in the
discharge planning process? (b) What guides acute care occupational therapists discharge
decisions and recommendations? (c) How do acute care occupational therapists define
optimal discharge planning? and (d) What actions can acute care occupational therapists
take to optimize the effectiveness of their discharge planning skills within the current
health care system? Using an action research methodology, two groups of five
occupational therapists met online to discuss acute care occupational therapy discharge
planning practices, and actions that could be taken to strengthen their practice. Action
plans generated, implemented, and evaluated focused on improving communication with
discharge planners, language used in documentation, and incorporating the use of
standardized assessments to assist with discharge planning. Schell’s ecological model of
professional reasoning as the theoretical model underlying this study was used to
examine factors that influence occupational therapy discharge decision making. Data
were collected from audio chat transcripts, survey responses, and researcher notes, and
analyzed using Stringer’s action research sequential data analysis and interpretation
methodology. Five themes emerged including (a) the role of occupational therapy, (b) the
complexity of discharge planning, (c) pragmatics of practice, (d) why don’t they pay
attention, and (e) the importance of stakeholder communication. Participants felt that
discharge planners were not reading occupational therapy documentation, occupational
therapy consults were late so that occupational therapy discharge recommendations were
just a formality, and physical therapy discharge recommendations had more weight than
occupational therapy recommendations. Participants felt that if patients were discharged
without benefit of occupational therapy recommendations they could be at increased risk
for an adverse event and compromised safety. Good communication among stakeholders
was seen as essential for optimal discharge planning.
vii

Table of Contents
Chapter 1: Introduction ....................................................................................................... 1
Background to the Problem ............................................................................................ 1
Statement of the Problem ................................................................................................ 5
Time Issues ................................................................................................................. 6
Reimbursement ........................................................................................................... 7
Standardized Assessments .......................................................................................... 8
Ethical Conflicts.......................................................................................................... 9
Constrained Practice ................................................................................................. 10
Utility of Pre-Discharge Home Assessment ............................................................. 11
Challenges to Client-Centeredness ........................................................................... 12
Delivering Holistic Care in a Medical Model Setting .............................................. 12
Purpose of the Study ..................................................................................................... 16
Research Questions ....................................................................................................... 16
Definition of Terms....................................................................................................... 17
Rationale and Need for Study ....................................................................................... 18
Theoretical Framework for the Study ........................................................................... 23
Assumptions and Limitations ....................................................................................... 24
Summary ....................................................................................................................... 25
Chapter 2: Selected Review of the Literature ................................................................... 26
The Nature of Acute Care Discharge Planning ............................................................. 27
Role of Acute Care Therapists .................................................................................. 28
Knowledge, Skills, and Abilities of the Therapist .................................................... 29
Clinical Reasoning .................................................................................................... 32
Factors Considered by Therapists in Making Discharge Recommendations ........... 35
Optimal Discharge Planning ......................................................................................... 37
Perceived Barriers to Successful Discharge Planning .................................................. 39
Time Constraints ....................................................................................................... 40
Challenges of Client-Centered Practice .................................................................... 45
Influences and Constraints of the Institutional Setting ............................................. 50
Communication as a Barrier ..................................................................................... 53
Elderly Patients ......................................................................................................... 54
Ethical Dilemmas ...................................................................................................... 58
Discharge with Unmet Needs ................................................................................... 60
viii

Therapist Perceptions of Discharge Planning ........................................................... 63
Strategies and Recommendations for Comprehensive Discharge Planning ................. 65
Assessment and Screening Tools .............................................................................. 66
Discharge Interventions ............................................................................................ 71
Schell’s Ecological Model of Professional Reasoning ................................................. 79
Occupational Therapy Action Research ....................................................................... 85
Summary ....................................................................................................................... 99
Chapter 3: Methodology Research Design and Methodology ........................................ 140
Rationale ..................................................................................................................... 140
Specific Procedures ..................................................................................................... 141
Strengths and Weaknesses of Design ......................................................................... 142
Participants .................................................................................................................. 144
Inclusion Criteria .................................................................................................... 145
Exclusion Criteria ................................................................................................... 145
Characteristics ......................................................................................................... 145
Recruitment Procedure............................................................................................ 151
Ethical Considerations and Review ........................................................................ 152
Study Setting ............................................................................................................... 155
Instruments and Measures........................................................................................... 155
Reliability and Validity of Measures ...................................................................... 155
Data Collection Procedures Used ............................................................................... 160
Online Audio Chat .................................................................................................. 161
Researcher Journaling ............................................................................................. 162
Data Analysis .............................................................................................................. 162
Assumptions and Limitations of Methods .................................................................. 163
Summary ..................................................................................................................... 164
Chapter 4: Results ........................................................................................................... 166
Data Analysis Results ................................................................................................. 167
Categories ............................................................................................................... 169
Research Question 1: How do Acute Care Occupational Therapists Describe Their
Role in the Discharge Planning Process?................................................................ 170
Research Question 2: What Guides Acute Care Occupational Therapists’ Discharge
Decisions and Recommendations? ......................................................................... 193
Assessments ............................................................................................................ 205
ix

Research Question 3: How do Acute Care Occupational Therapists Define Optimal
Discharge Planning? ............................................................................................... 210
Consensus, Collaboration, and Communication ..................................................... 212
Research Question 4: What Actions can Acute Care Occupational Therapists Take
to Optimize the Effectiveness of Their Discharge Planning Skills Within the Current
Health Care System? ............................................................................................... 216
Findings....................................................................................................................... 228
Summary of Results .................................................................................................... 233
Member Check and Peer Review ................................................................................ 235
Summary ..................................................................................................................... 238
Chapter 5: Discussion ..................................................................................................... 239
Summary of Earlier Chapters ...................................................................................... 240
Discussion and Interpretation of Results in Context of Problem Statement, Literature
Review, and other Theoretical Background ................................................................ 241
The Role of Occupational Therapy in Discharge Planning .................................... 243
Factors Considered in Discharge Planning ............................................................. 244
Standardized Assessments ...................................................................................... 246
Discharged with Unmet Needs ............................................................................... 248
Understanding and Respect by Team Members ..................................................... 249
Professional Reasoning ........................................................................................... 252
Theoretical Perspective ........................................................................................... 253
Optimal Discharge Planning ................................................................................... 265
Conclusions, Interpretation, and Speculation About Results...................................... 267
Implications for Practice ......................................................................................... 274
Implications for Further Research .......................................................................... 277
Limitations and Delimitations Based on Results and Interpretation ...................... 283
Recommendations ....................................................................................................... 289
Summary ..................................................................................................................... 291
References ....................................................................................................................... 293
Appendix A ..................................................................................................................... 307
Appendix B ..................................................................................................................... 311
Appendix C ..................................................................................................................... 313
Appendix D ..................................................................................................................... 315
Appendix F...................................................................................................................... 319
Appendix G ..................................................................................................................... 320
x

Appendix H ..................................................................................................................... 321
Appendix I ...................................................................................................................... 324
Appendix J ...................................................................................................................... 325
Appendix K ..................................................................................................................... 332
xi

List of Tables
Table 2.1 Literature Findings .............................................................................................99
Table 3.1 Participant Information ......................................................................................45
Table 4.1 Research Questions and Related Categories and Themes ...............................166
Table 4.2 Factors Considered When Making Discharge Recommendations ..................193
Table 4.3 Percentage of Participants’ Discharge Recommendations to Selected Settings
and Programs ...................................................................................................199
Table 4.4 Participant responses to the Question About Optimal Discharge Planning ....209
Table 4.5 Areas of Concern Identified by Study Participants and Action Plans
Adopted ............................................................................................................231