Research priority 8: What is the role or impact of occupational therapy in reducing hospital admissions?

In 2019, The Royal College of Occupational Therapists (RCOT) embarked on a major collaborative project with the James Lind Alliance (JLA) to define the top 10 occupational therapy research priorities. The aim was to identify the questions and areas of uncertainty that could be answered by research. The JLA principles stipulated that the determination of the final priorities should be the exclusive preserve of practitioners, people who access occupational therapy services and their carers (RCOT, 2019).

Views from these groups alongside others working in the health and social care environment were gained and prioritised to identify the key research areas that need to be funded. In 2020, the RCOT and JLA Priority Setting Partnership (PSP) published a report on the top 10 occupational therapy research priorities. The 8th research priority identified was ‘What is the role or impact of occupational therapy in reducing hospital admissions?’ (RCOT, 2021) and as we head into inevitably another challenging winter for our health services, it is an ever important and timely question.

This research priority is intrinsically linked to all other nine research priorities but also has significant importance across national clinical and workforce strategies which aim to redirect healthcare away from emergency and secondary care (National Health Service [NHS] England, 2019).

So why is reducing hospital admissions so important? NHS agendas have an unrelenting focus on the importance of service users being seen by the right person, in the right place and at the right time. It is now acknowledged that this is often not in the acute hospital setting, or by following traditional care pathways (British Geriatrics Society [BGS], 2017).

As an emergency medicine therapist, I have always understood and advocated for the avoidance of or reduction in hospital admissions. There is extensive evidence available regarding the inherent risks of patients’ cognitive and physical function when admitted to hospital (Gordon et al., 2019) and also the benefits of avoiding hospital admission and receiving care at home (BGS, 2017). International campaigns such as ‘End PJ paralysis’ (EPJP) or the recent ‘Re-conditioning Games’ highlight the detrimental impact that an inpatient hospital stay may have on the most vulnerable patients (EPJP, 2022). Risk of hospital-acquired deconditioning, hospital-acquired infection, and increased falls, and the impact on psychological well-being for those who are admitted to hospital are well known (BGS, 2017; Gordon et al., 2019). In addition to associated poorer patient outcomes are delays in discharge and further pressures within the health and social care system all contributing to increased bed costs, poor patient flow and reduced hospital bed capacity (BGS, 2017; EPJP, 2022). Reducing hospital admissions and allowing service users to access care and support in the community have wide-reaching impacts on patients, their carers, families and health services alike.

The Royal College of Occupational Therapists 2017 publication ‘Reducing the pressure on hospitals’ highlighted the key role occupational therapists have in reducing hospital admissions and the variety of services they lead or support. As part of the RCOT campaign ‘Saving Lives, Saving money’, the report demonstrated the positive impact that occupational therapists have within various admission prevention services across emergency departments, community rapid response services, alongside paramedics and in falls response teams. However, the evidence provided around patient outcomes and cost-effective care were service examples rather than published research (College of Occupational Therapists, 2017).

The RCOT and JLA PSP identified the 8th research priority as an ‘area of uncertainty’ due to the lack of published work exploring the role and impact that occupational therapists have in reducing hospital admissions (RCOT, 2019). In the current uncertain economic times, it is essential that therapy services can demonstrate their effectiveness in reducing hospital admissions; however, there is little evidence specific to occupational therapy and the impact on preventing hospital admission.

Occupational therapists provide a unique skill set in understanding the direct impact that a disruption to health can have on participating in everyday activities, and how this contributes to our overall well-being and quality of life. An acute injury or illness can be detrimental to physical and cognitive function and occupational therapists are able to acknowledge the implication to daily life and provide measures to aid recovery, maintain meaning and support quality in everyday life, while also understanding how this translates for patients from acute to community or home settings. Occupational therapists in admission avoidance services often work in a transdisciplinary capacity providing a holistic assessment and intervention that not only reduces the need for hospital admission but can also impact the acute and long-term physical and psychological outcomes of both the service user and their support network. A presentation to an emergency department for those living with a long-term condition or frailty may be more about their ability to manage safely at home with their current health needs, than the medical issue itself. The input that occupational therapists provide to address these physical and cognitive functional needs is paramount to keeping people out of hospital and receiving appropriate care and support at home.

The scope of occupational therapist’s roles and their impact in admission avoidances services is extensive. Occupational therapists have established themselves in a variety of services across emergency and community services and further roles continue to emerge to support reducing hospital admission, enabling service users and families to access care at home. There is much value in embedding occupational therapists in admission prevention services, for example, ambulance handover for enhanced triage; rapid comprehensive occupational therapist intervention in the emergency department; with paramedics as first attenders; in GP practices, or working in rapid community services to prevent a conveyance to hospital. Anecdotally, the impact of occupational therapist expertise within these teams is known to those who receive these services, and health professionals who work within these teams. However, there is little quantitative or qualitative evidence to demonstrate the impact. The ongoing support and development of emerging roles such as Occupational Therapist Advanced Clinical Practitioners in Emergency Departments or rapid response community teams, or GP-based first contact therapists are also in need of research to evidence the benefits they provide. The enhanced assessment and diagnostic skills of these experienced therapists allow for patient needs to be met by fewer health professionals, improving care delivery and efficiencies. However, the take-up by services for these roles may be delayed without current evidence supporting positive outcomes. Similarly, the argument for occupational therapists to be granted the legal right to become independent prescribers can only be strengthened by research.

It is interesting to note from the RCOT, JLA and PSP report that people in the ‘lived experience group’ ranked the role or impact of occupational therapy in reducing hospital admissions of great importance, and their rating was significantly higher than the professionals group (RCOT, 2019). Receiving care at home is important to patients and their families and carers, and it is vital not to underestimate the positive impact occupational therapy can have on patient experience and quality of life. Occupational therapist’s aim is to understand an individual’s unique needs, aspirations and environment, and to provide interventions to enable meaningful contributions within their home and communities. There is a focus on an individual’s experience and quality of life, not just a medical diagnosis. This holistic approach incorporates what matters to them and helps them to achieve this in practicable and creative ways.

Sarah Markham, editorial co-author and member of the RCOT JLA PS with lived experience, states

As a long-term patient occupational therapy is a practice close to my heart and has proved invaluable in my personal recovery. I know that I am not alone in this experience. No one wants to go into hospital, or worse have to be re-admitted for treatment for a previously treated condition. The reality is that too many are admitted and potentially re-admitted unnecessarily.

The role of occupational therapist in reducing hospital admissions acts to minimise disruption and stress and support recovery in the community.

We have just lived through the most significant health and care crisis in living memory where all healthcare practitioners have been challenged to work differently, or step into different roles. As our NHS and economy recovers, services continue to flex and adapt within an altered health and financial landscape. Learning to take from the COVID-19 pandemic is a new perspective on how we deliver healthcare and a knowledge that we are capable of delivering new, evidence-based ways of working in the face of adversity. We should use this learning and new understanding as an opportunity to continue to challenge our practice, and more importantly evidence the exceptional work that occupational therapists are doing across all healthcare sectors in reducing hospital admissions. This involves research on the impact of our more traditional, well-known occupational therapist roles in this field, but also championing exciting new possibilities such as independent prescribing.

Occupational therapists are integral to the successful reduction in hospital admissions. But we are also a humble profession, one that historically has not focused on highlighting, celebrating and demonstrating our worth. It is essential that this changes. We must actively promote our profession, champion our values and in particular evidence the difference we make to services, service users and their families. In the current health and financial climate, services are required to prove the need for every staff member and this cannot be achieved without robust research and evidence of the cost-effectiveness of these services.

W Edwards Deming, a pioneer of Quality Improvement theory famously quoted, ‘Without data, you’re just another person with an opinion’. It is up to us all to engage in research to ensure that the impact of occupational therapists in reducing hospital admissions is known and promoted across the healthcare community.