return to work (RTW) services for clients following stroke with regards to best practice and recommendations for future development. Facilitators and barriers to ...
Best Practices in Return to Work Services for Stroke Survivors: Perspectives from Experienced Clinicians Shannon L. Scott OTD, OTR/L
Salvador Bondoc, OTD, OTR/L, FAOTA
SUNY Stony Brook, Southampton, NY BACKGROUND
BARRIERS TO RTW SERVICE PROVISION
• Incidence of stroke in working aged adults is increasing (American Heart Association [AHA], 2013) but the rates of return to work following stroke are low (O’Brien & Wolf, 2010) • This paper explores the perspectives of OT practitioners (OTP) with experience in providing return to work (RTW) services for clients following stroke with regards to best practice and recommendations for future development. Facilitators and barriers to best practice are also explored.
Lack of knowledge of work related regulations, services, and reimbursement mechanisms Limited visits and reimbursement Multiplicity of client needs “…all of our time needs to be Lack of time productive… that’s probably Productivity demands the reason we don’t have time Medical healthcare model and extra energy into helping
METHODS Design: From a purposive sample of OTP’s (n=9) who participated in a national survey on RTW after stroke (Scott & Bondoc, 2015), semi-structured 1:1 phenomenological interviews were conducted to describe OTPs’ experiences and perceptions of best practice to facilitate RTW. All interviews were completed by the first author. Data Analysis: Interviews were transcribed verbatim and analyzed using “a-priori” coding. Subcategories were generated to maximize mutual exclusivity and exhaustiveness (Weber, 1990). Trustworthiness was addressed via member checking and peer review. Sample: All participants were employed in outpatient practice settings and the majority (78%) had greater than 5 years experience. Two participants worked in settings with funding sources other than 3rd party.
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people get back to work other than in the gym.”
“We focused a lot on neuroreeducation …on the upper extremity…As far as compensations and working on executive function deficits, we weren’t skilled in doing that.”
Lack of expertise Dissatisfaction with state VR leading to decreased referrals
FACILITATORS TO RTW SERVICE PROVISION Prior training and experience in work related services
“Most helpful were the other OT’s that I was working with because they were directly showing me”.
“I developed most of my skills when I was in the work hardening and work conditioning program… I developed relationships…and then just started applying it to stroke”.
Mentoring by experienced practitioners Organizational and administrative support “We have a nice amount of support from the Longer treatment time management …all the phone calls I make to Funding beyond employers or to the nurse case manager… I can’t bill for any of that. They are pretty 3rd party payers understanding …they allow me to do that but I pay for that in my productivity.”
Quinnipiac University, Hamden, CT
PERCEPTIONS OF BEST PRACTICE
DISCUSSION & IMPLICATIONS
Address RTW in the early stages following stroke Provide occupation-based, “It’s just a question I ask when I employer focused interventions do the evaluation, ‘were you Address emotional regulation, working? Are you planning on coping skills, executive functions going back to work?’ If they
OTP’s posses the foundations to implement services that facilitate RTW following stroke. However perceived barriers in specific RTW knowledge, clinical practice, and systems negatively impact service provision. Key to the provision of best practice for RTW is: 1. Evaluate all individuals after stroke. Many stroke survivors do not receive rehabilitation services (Wolf , Baum, & Connor, 2009) and for those who do return to work, persistent stroke related impairments negatively impact performance (O’Brien & Wolf, 2010) and 15% leave within the first 6 months (Wolf et al., 2009). 2. Collaborate with the work-site and employer. Research supports that RTW services that are coordinated with the work-site improve RTW outcomes (Ntsiea, Van Aswegaen, Lord, & Olorunju,
are, that should be addressed… if we don’t do it, no one else will.”
“I really wish the therapist would make that referral right off the bat; if you’ve had a stroke no matter what …let’s just refer you to an outpatient therapist and see…”
Refer ALL stroke survivors for comprehensive OT services Develop enhanced competencies Complete comprehensive & ecologically valid evaluations
NEED FOR RTW COMPETENCIES Understanding of work related laws, regulations, and resources Knowledge of variety of jobs, job demands, and ways to research job demands; conduct/complete “job analysis” “…communication (is) a huge part, with the employer, with the doctor, and the (payer source)”
Ability to engage in multidisciplinary and multi-service collaboration Collaboration with client’s employer
Advocating for needed services and reimbursement of services Critical reasoning abilities regarding RTW readiness and employability
“I have to defend that every day… it’s an area where there is so much push for productivity…it’s easy to lose sight of providing quality to get these folks back to being productive members of society”.
2014).
3. Develop specific RTW competencies through ongoing training and mentoring. Our study reinforces the concept of “occupation as an end” to guide practitioners in facilitating return to a worker role and successful participation and engagement in work occupations. Our study also highlights the importance of OTP’s in developing specific RTW competencies starting at entry-level preparation and through continuing professional development. Lastly, we recommend research to study the effectiveness of RTW service provision within relevant environmental contexts, and the efficacy of occupation-based approaches.
