Every facility has their own twist for what an occupational therapist might do,” says Marla Quinney, OTR/L, assistant director of Adult Inpatient Therapy Services at the University of Chicago (UC) Medical Center. Occupational therapists look at “how patients spend their days and ask, ‘What do they engage in and what do they not engage in because of the current condition?’”
The occupational therapist then helps to rehabilitate patients to baseline. “In an acute care facility,” says Quinney, “a lot of what we do is evaluation and then getting patients to the correct discharge disposition and follow-up care.”
Depending on the institution, occupational therapy offerings may involve management for range of motion, strength, coordination, and sensation; they also include therapy for activities of daily living (ADLs), such as self-care, home management, and community involvement, including vision retraining and cognitive and/or perceptual retraining as they relate to ADLs. Occupational therapists might also include management using assistive devices, and the provision of adaptive equipment. In some institutions, occupational therapy involves aspects of home evaluations, and feeding and swallowing therapy.
Working with Hospitalists: Challenges and Highlights for Occupational Therapists
Occupational therapists cite a few areas where hospitalists could provide more help to their fellow professionals in occupational therapy.
Distinction between occupational and physical therapists: To expedite care, hospitalists need to know whether to refer patients to occupational therapy or physical therapy.
“In general, a physical therapist would look at gross motor functions, which affect the patient’s ability to be mobilized from one place to another,” says Quinney. “This also includes whether or not they need assistance to do that safely, and then there’s a myriad of things they look at, including wound care, generalized weakness, and—with a general medicine patient—deconditioning, to make sure that they’re safe in their mobility. An occupational therapist looks more at ADLs, and what patients need to do in order to function in their daily lives and the safety associated with that.”
Timeliness of referrals: Quinney concedes that in the case of a patient who is deconditioned, it might be difficult to discern whether a patient requires occupational therapy or physical therapy. That is one reason why the timeliness of referral is important. If an occupational therapist receives a referral on the day the patient is scheduled for discharge, it may be too late to help them.
But referrals can also be made too soon, says Quinney, “because when the patient is in the ER being admitted, what’s needed may be something as simple as getting their fluids corrected, and once that’s done, then [occupational] therapy is no longer indicated.”
Another example of inappropriate referral timing, she says, might be in the case of a diabetic “whose blood sugars are too high or too low, and clearly, they’re not functioning at their premorbid level. But given the right intervention by the medical team, they’ll bounce back to their baseline.”
Other inappropriate referrals: A patient might also be assessed as having too high or too low a functional status to benefit from occupational therapy. For instance, “a patient might be at too low a level if they came from a nursing home for a UTI or some other complication,” says Quinney, “but their functional status is not something that a therapist would be able to impact in a short hospital stay once that medical problem is corrected.”
From what his occupational therapists tell him, Vijay Rajput, MD, FACP, senior hospitalist at Cooper University Hospital in Camden, N.J., concurs. “If the patient has been in a nursing home for 10 years and is completely custodial and bed-bound, when that patient comes to the hospital and a hospitalist has ordered an occupational therapy consult … , the occupational therapist then has to assess it, and there are no [achievable] goals of care in terms of occupational therapy, then the therapists think that is a [poor use of their] time.”
In that case, however, the family may benefit from a home visit that will provide maintenance or training.
When Quinney receives what she believes is an inappropriate referral from a hospitalist or other provider, she encourages her therapists to say that back to the hospitalist in a direct, to-the-point communication. Therapists are encouraged to say, “This is what I saw with patient X. I’m not seeing any skilled therapy needs. Is there something else I’m missing?”
“We always give [the provider] the benefit of the doubt of having done an assessment in their mind,” explains Quinney.
How consults are written: Quinney’s team has discussed whether to ask hospitalists to be specific about what they are referring for, so “we as therapists are able to affect the whole person. Because if they only give a referral for a specific task, then it makes it more limiting,” she explains. “If they write a referral for ‘functional ability’ or [one] that says ‘concerned with balance,’ that [allows us] to do some problem-solving.”
Tiffani Morales, LOTR, the occupational therapy team leader at Our Lady of Lourdes Regional Medical Center in Lafayette, La., agrees. “We’ve only had hospitalists for about a year, and the three that we have are really doing a good job, [including the way in which] they’re writing their consults,” says Morales. “They’re leaving it open and trusting us to make recommendations, and they’re going along with them.”
Because hospitalists write the chart note as “Consult,” occupational therapy “gives us leeway to make any equipment recommendations or, actually, any of the treatments that may be warranted versus having to call them back, which takes time to keep giving an order over the phone,” explains Morales.
Geography of patient assignments: The system or structure by which patients are assigned will usually differ between occupational therapists and hospitalists. For instance, at Cooper University Hospital, a 520-bed academic, tertiary hospital in Camden, N.J., where Dr. Rajput began the hospitalist program, the six occupational therapists are assigned patients on a geographical basis, according to floor in a 10-story building. But the group of 25 hospitalists, which has grown from four since 1999, is not assigned that way.
“If I am on service,” says Dr. Rajput, “my patients are assigned [perhaps as] one on the 10th floor, one on the ninth floor, [and] one on the eighth floor.”
His occupational therapists told him that if the hospitalists could be assigned to patients the way they are, it would certainly improve the communication between the two groups.
“It is much better to have a verbal communication with the hospitalist than [simply] reviewing the chart,” says Dr. Rajput.
Some hospitalist groups are looking at returning to this geographically based system. “To restructure the whole system would be very complex,” says Dr. Rajput, who is also the program director for the Internal Medicine Residency Program at UMNDNJ—Robert Wood Johnson Medical School in Camden, “but… it still makes sense [from a communication perspective], for instance, the way it does in the ICU.”
Given the difficulties and drawbacks of making that system a widespread reality, however, Plan B would be to increase and encourage contact between occupational therapists and hospitalists. At the UC Hospital, which employs 12 occupational therapists who work with the patient population that hospitalists are responsible for, “the volume of [patients in] the general medicine unit is too high for OTs to meet with hospitalists daily” explains Quinney, who has been with the UC hospitals for six years.
To breach what might be a communication gap, however, she says, “all OTs have pagers, and whenever they write their note in the chart they will leave their pager number. There is always a way for someone to get in touch with them.”
That, of course, can also be said of hospitalists. And because hospitalists respond quickly when occupational therapists page or call them, says Morales, it can help with patient satisfaction.
“The hospitalists round more quickly or at certain times; they have a routine down,” she says. “And that’s a big thing because when patients are ready to be discharged, they want it now. They don’t want to wait.” And when they can be discharged expediently, “we all look better.”
Throughput and quality care: At the UC Medical Center, as at most institutions, hospitalists are encouraged to move patients from admitting through discharge in the most timely and efficient way possible.
“Hospitalists know that [occupational] therapy is part of that important closure of getting them from one site to another,” says Quinney. But sometimes she hears a [hospitalist or resident] say, “I was just told I need to refer them to you in order to get my patient out of the hospital.”
That’s important, Quinney emphasizes, because occupational therapists want to be part of discharge planning. “But we want to be referred to appropriately so that the people who need us most can utilize us, versus going after patients that aren’t appropriate and are using our resources,” she says. “It’s not that we aren’t happy to see those patients, we truly are; it’s a matter of getting people in a timely manner so that we can really make a difference.”
Great Working Relationships
Morales thinks hospitalists have a good understanding of the services that are available from occupational therapists “because whenever we see them about a patient, if they’re not sure about something, they ask questions such as, ‘Is there anything else you can offer?’” she says. “I think they’re right on target [with us].”
Morales’ team thinks hospitalists are involved, friendly, and open. “It’s just a great work relationship,” she says, “because they’re actually seeing the patients in therapy and asking for our input; it’s very refreshing.” Most of all, she appreciates how they show respect for what the occupational therapists do. “They are listening to what we are saying and that makes a difference.”
Because hospitalists look at the bigger picture of what is going on with patients, they generally consult occupational therapy early enough so that therapists can educate hospitalists, patients, and families at Morales’ institution. This also helps prevent patients’ further deconditioning, and helps them to arrive at a discharge disposition earlier.
Dr. Rajput, who is an associate professor of medicine at the University of Medicine and Dentistry, (Brunswick) New Jersey–Robert Wood Johnson Medical School, thinks it would benefit those involved in medical education and hospital medicine “to see that there is sufficient formal training for the residency level or hospitalist level to understand the component [of occupational therapy] and the indication for occupational therapy, and occupational therapy versus physical therapy, as practice.”
Hospitalists can help their occupational therapist colleagues by recognizing the distinction between occupational therapy and physical therapy, making timely and appropriate referrals, writing consults in an open-ended manner to allow occupational therapists to do “whole-person” assessments, and making sure to educate themselves and their hospitalist colleagues on the services and needs of occupational therapists. TH
Andrea Sattinger regularly writes the “Alliances” department.