The effectiveness of occupational therapy local authority social services interventions for older people in Great Britain: A critical literature review Funding: UKOTRF Jill Riley & Gail Boniface School of Healthcare Studies, Cardiff University RileyJM@Cardiff.ac.uk

Rationale for the review A rapid growth in numbers of older people at a time of scarce resources Government policy emphasis on maintaining older people in the community Occupational therapists’ skills have been identified as key to the delivery of Government policies in England, Scotland and Wales No systematic reviews of the evidence since Mountain (2000).

Study Aim: To critically review and synthesise the post 2000 evidence on the effectiveness of occupational therapy interventions for older people in social care services in Great Britain in preventing the need for complex packages of care.

Objectives: To establish: The nature of social services' occupational therapy interventions for older people in Great Britain. The policy contexts and organisational factors that influence the delivery of such interventions. The effectiveness of these interventions in maintaining older people's independence and preventing dependency and how these are evaluated. The benefits of occupational therapy interventions for older people themselves. The cost-effectiveness of such interventions.  

Methodology: A systematic approach to identifying, selecting, critically appraise and synthesising the qualitative and quantitative, published and unpublished available evidence from January 2000 to February 2012. Related to: Older people living in the community. Local authority based occupational therapy services. Local authority occupational therapists' interventions.

Theoretical approach: Pragmatic and flexible Literature was not excluded on grounds of quality alone The historical, social, political and organisational contexts of included studies were taken into account during the process of appraisal, synthesis and reporting (Pope et al 2007). The resulting thematic synthesis is both aggregative and interpretive in nature

The research team: The collaborative team consisted of: 2 researchers (both occupational therapists/academics with a social services background). 3 practice collaborators (1 from each country working in social care settings). A representative from Involving People (a carer of an older adult, with experience of social services). A research assistant.

Stages in the process: Literature search and retrieval: Electronic databases, library holdings, websites, local social services' occupational therapy networks Piloting and refining and appraisal templates Data evaluation : Screening and assessing for relevance , data management Critical appraisal : using a customised template Data extraction: findings were identified independently by two reviewers and a consensus reached

Overview of appraised literature (articles, reports, documents) n=75 Published peer reviewed discussion/opinion-based articles n=10 Published peer reviewed research based articles n=38 Published research based reports Published briefing papers n=3 Unpublished reports, audits and service evaluations, dissertations n=14 *These number 61: Out of the original 75, 10 papers were discussion not research based, 3 were briefing papers and 1 report was discussion based. n=3 RCT Quantitative n=8 Survey n=12 Mixed-method n=24 Qualitative n=14

Data synthesis Thematic synthesis: Findings from included studies were entered into an overview document Independently coded by two reviewers for meaning and content. Codes from each study were added to a coding framework Themes generated and refined

Quality summary: Small-scale studies tended to use one data collection method and were restricted to one location Larger scale studies utilised mix-methods or conducted RCTs within and across organisations Unpublished reports were variable in quality. Ranging from rigorously conducted dissertations and service evaluations, to audits and service user satisfaction questionnaires. small-scale studies were most likely to specifically address occupational therapy and collectively could provide worthwhile evidence. The larger-scale studies, with the exception of the CAMELOT trial, which individually were more generalisable, tended to address broader issues which occupational therapists were involved in, but their part was often difficult to disaggregate. Satisfaction questionnaires: were generally conducted in-house and present raw numeric or qualitative data with limited analysis.

Main weaknesses: Impacting on the review: A lack of detail on the context or study location Limited description of participants or explanation of the service, team or intervention A medical rather than social model perspective A lack of reflexivity where the researcher appeared to be part of the setting being researched.

Review findings Key themes related to occupational therapy social care service provision for older people: The nature of OT social care service provision Influences on provision Professional issues Access to services Occupational therapy intervention Effectiveness Service user issues Issues for carers Reshaping occupational therapy services Collaboration/relationships Time related to OT service provision Communication issues

The nature of OT social care service provision Summary of key points: The majority of adult social care OT service users are 60 + and female. Equipment and adaptations provision is central to adult social care OT services in England, Scotland and Wales. Self care is the main occupational dysfunctional area. OT services appears to be organisational and resource driven despite attempts by OTs to be more needs led.

Influences on provision Summary of key points: The localised nature of local authority social services provision. Workforce issues e.g. career progression, staff turnover, recruitment and retention and different patterns of pay and grading. The social model of disability predominates in social care settings. Client centredness can be compromised by service eligibility criteria. Older service users tend to regard the occupational therapist as their guide through complex and lengthy service provision processes. In home care reablement services, OTs appear to be central even where the occupational therapist is not part of the team.

Professional issues Summary of key points: OT’s core values can be compromised by concentrating on service users’ functional limitations. OTs in social care services have professional support needs in using their core values. Increasing the focus of personalisation of services for older people could enable OTs to work in an even more client centred manner. The creation of reablement services for older people complements the enabling and client centred nature of occupational therapy.

Access to OT services for older people: Summary of key points: Access is controlled by eligibility criteria in England, Scotland and Wales. Service users with higher levels of need receive occupational therapy services. OTs in social care tend to use their professional judgement when applying eligibility criteria. The complexities of criteria and their implementation can lead to problems for older service users and carers. Referral rates for OT services are high, and most authorities operate a priority system. OTs in local authority social services have begun to develop structures for dealing with referral rates e.g. telephone duty systems. Referrals for social care OT mainstream services come mostly from individuals and their carers; for reablement they mostly come from other professionals.

Occupational therapy intervention Summary of key points: Single shared assessment processes have led to OTs’ involvement in generic assessments, which can detract from specialist professional action. Some OT services have introduced self or assisted self-assessments, which tend to be completed by more able service users. The most commonly reported actions following assessment included equipment and adaptations provision. Post OT intervention follow-up has been inconsistent in local authorities in England, Scotland and Wales.

Effectiveness of OT services for older people & carers Summary of key points: OT is considered effective in improving independence and quality of life for older people living in their own homes. Timely spending on equipment and adaptations is usually recouped in a service user’s lifetime. Maintaining older people independently at home creates savings in other services. The effectiveness of OT interventions and services is influenced by the individual, professionals involved and organisational structures. Outcome measures in social care should reflect a social rather than a medical model approach. Outcomes of OT interventions should be measured in the medium to long rather than the short term. The most frequently used standardised measures are the Community Dependency Index, Morriston Occupational Therapy Outcome Measure, the Canadian Occupational Performance Measure and the Barthel Index. There is a generally high level of service user satisfaction with OT services once accessed and received. Dissatisfaction focused on a perceived lack of funding, equipment charges, waiting lists, difficulties making contact, lack of follow up and links with other services. OT in social care for older people should be audited and evaluated regularly.   Effectiveness should be considered in terms of increased independence and quality of life.

Service user issues Summary of key points: Outcomes for older service users should take needs into account whilst also considering the home and personal preferences. Older service users value regular contact and assistance from professionals (e.g. During DFG process). Individual provision needs to reflect service users’ preferences and culture. Personal care is important to older people, and lack of independence in this area impacts on perceptions of safety, quality of life, self esteem and mental well-being. Older service users and their carers need to be included at all stages of the decision making process regarding OT interventions. Service users of reablement services should be fully informed of the service’s purpose and expectations of them for it to be effective.

Issues for carers Summary of key points: Good adaptations and equipment have positive outcomes for carers by providing assistance, easing their burden and preventing service-users’ admission to care. Carers need to be involved in OT interventions, rather than the service concentrating only on the service user. Carers need choice as to whether they become carers.

Reshaping occupational therapy services Summary of key points: There are calls for occupational therapy in social care to widen its role. Occupational therapists in social care are developing roles in rehabilitation and home care reablement. Occupational therapists need to become more proactive in shaping social care agendas such as assessment roles, equipment and adaptation provision, addressing occupational issues, prevention and early intervention.

Conclusions: Local and geographical variability makes benchmarking and comparisons of services problematic. Transferability of findings was complicated by a lack of description of the context and location. The discussion-based and opinion pieces reviewed, together with policies and reports added further detail on specific topics. Disaggregating the effectiveness and cost-effectiveness of occupational therapy interventions from others is problematic

Conclusions: No specific differences were found in the mainstream range of interventions used by occupational therapists across Great Britain. In all three countries, the area of rehabilitation and reablement is developing, with OT involvement to a greater or lesser extent. There is a high level of service user satisfaction once OT services have been accessed and delivered Timely services are deemed to be effective and preventative for older people.

Executive Summary is available from: College of Occupational Therapists: www.cot.co.uk UKOTRF – funded project outputs