Occupational Decline Prevention for Individuals with Progressive Neurological Diagnoses

An Occupation-Based L. S. Skaggs Wellness Center Program in Salt Lake County

McKenzie Silberman, OTS
University of Utah
Introduction

The goal in performing a needs analysis was to determine how occupational therapy

services could benefit underserved community populations in the Salt Lake area. A needs

assessment was administered at the L.S Skaggs Patient Wellness Center, located on the third

level of the parking garage in the dentistry building on University of Utah campus. At this time,

there are not any occupational therapists on staff within the clinic or associated with the clinic

and its current programs. The needs assessment consisted of semi-structured interviews and

observations of both clients and staff members over the course of four weeks. This evaluation

influenced the development and proposal of an occupation-based program that could be utilized

to assess and determine the unique needs of each client and employee within the facility. In order

to facilitate effective and efficient development of the program, a literature review will guide the

plan to address needs for these populations. There is also record of the current programs that are

being utilized currently within the Wellness center.

Description of the Setting

The L.S. Skaggs Wellness center was created with the mission of providing a medically-

supervised gym that promotes a physically active and healthy lifestyle for individuals within the

community (L.S. Skaggs Patient Wellness Center, 2018). The clinic that exists today was opened

in July of 2016 following the transfer of leadership, which transferred many members and the

functions provided through the facility to a new location. The director of the clinic is Ellen Reed-

Maxfield and she manages the Diabetes Prevention Program on site as well. The staffing at the

wellness center consists of interdisciplinary teams including: an administrative assistant, clinic

aides, volunteers, dieticians, exercise physiologists, pharmacists, psychiatric nurse practitioners,

health coaches, massage therapists, physical therapists, and physical therapy assistants. Full-time
staff includes the director, administrative assistant, massage therapists, and health coaches. Most

of the clinic aides, volunteers, and other professions work at the clinic part time. The average

cost of membership within the clinic is around $65.00/month but can vary depending on the

program in which they are attending. Scholarship options are available for those participants who

need assistance with making monthly payments to attend. Funding for the wellness center also

comes from the Skaggs family foundation, Jack Lundt Family foundation, and there is endowed

funding to cover scholarships. Lastly, there is a Parkinson’s grant available for those who

qualify. The facility has space for patients and/or their caregivers to sit in the waiting area, gym

space that is organized and clean, as well as private consultation rooms.

Currently, there are ~145 active participants within the clinic that belong to disease-

specific exercise programs and attend the workout area of the gym on a weekly basis. There are

additional members that attend classes, meet with wellness coaches, or work one-on-one with

professionals. The clinic offers supervised wellness gym memberships to those who meet

eligibility requirements and have diagnoses of Parkinson’s, Multiple Sclerosis, post-stroke,

bariatric care, obesity, or overweight/obese clients. Other programs offered include: Intensive

Lifestyle Program (ILP), Build a Bone, Orthopedic Care, and lastly wellness coaching. With

regards to the population within the clinic, geriatric patients make up a large majority of those

who attend, but there are individuals of varying ages and abilities that attend. The only age

requirement present is that you must be 18 years of age or older to qualify. There is a

combination of both male and female patients, and many participants have spouses or caregivers

that attend the facility with them.

A physician’s referral is a common starting point for those to begin attending the

wellness center. Those who see specialists like cardiologists, neurologists, or even the primary
care physician can receive referral to these services. Otherwise, acceptance to the program is

based on eligibility requirements upon application. Upon initiation of services, the patient meets

with a physical therapist (PT) and an individualized workout program is developed. The PT

demonstrates and educates the patient on exercises being prescribed. In the following workouts,

patients have the ability to request assistance from a clinic employee or student volunteer if they

wish. Every patient that attends the clinic is re-evaluated by the PT on an annual basis, or more

frequently depending on their needs or changes in medical status.

When a client arrives at the facility, there is a “check-in” routine that must be completed

prior to beginning their exercises. The check in consists of three questions, “How would you rate

your overall health today on a scale of 1-10?”, “Have you had any changes in medications?”, and

“Have you experienced any recent falls or trips to the emergency room?”. If a low overall health

score is reported, or either of those questions are answered with a yes, the employee is instructed

to inform Ellen or the supervisor present. Patients also have their vitals checked prior to activity

and as long as all are within appropriate ranges for that person, then it is clear for them to begin

working out. With or without assistance from employees, the patient then will perform their

exercises as determined on their workout plan established with the PT that is printed and carried

around with them. Once the patient has finished and an employee checks that they have

completed their plan for the day, a follow up on their vitals is taken at this time. This is another

opportunity to report any concerns about vitals or status of the patient with Ellen, as well as

making notations within their chart.

Varying contextual factors have the ability to influence the way in which services are

delivered for each patient. Current policy issues that influence patients at the wellness center can

include the limited days and/or times in which clients of maximum assistance are able to attend
for safe exercise, while clients with greater independence are able to come to the center freely on

their own time and availability during clinic open hours (see appendix A). This policy has been

established to ensure the safety of the patients so that the staffing needs are not overwhelmed by

the number of patients attending the gym at once. The aides need to be able to provide assistance

to those who have greater needs and/or safety concerns with transfers or performing weighted

exercises. There is no policy that exists for referrals to the clinic, meaning that patients are able

to be referred to services, but it is not required for attendance. Referrals can be placed through

the EPIC system, and System Smart Phrases are available to be placed in the patient’s After Visit

Summary (L.S. Skaggs Patient Wellness Center, 2018). The benefit of not having a strict referral

policy allows these services to be accessible to a greater population within the community.

Outside of the policies within the clinic, there are political policies that influence the

members of the clinic and their attendance as well. A vast majority of the patients are on either

Medicare or Medicaid services, and political shifts within national and state leadership and

healthcare policies can have large influences on a client’s ability to receive health care outside of

the clinic. Currently, we are amidst potential policy changes to Medicare and Medicaid funding

that could further limit our client’s abilities to access and utilize health care services that they

need. Within the clinic, the social and demographic factors that influence this population the

greatest involve the fact that the clients and their caregivers tend to be older adults (60 years or

older). Socially, this could be a driving or hindering factor based on those who attend the clinic

and their desire to reach out for friendships and support. The current culture within the Wellness

Center is one that is welcoming, supportive, and light-hearted. The staff members have

developed genuine relationships with the participants, and you can see the friendships that have

been able to develop between participants as they have attended the gym. Some people may find
it hard to “fit in” with those who have been attending the clinic for a long time, or if they have a

more severe disability, limiting interactions with others. Other clients may not desire to

participate in social activities or feel overwhelmed in those situations. Regarding age, the range

could act as a barrier between clients who are younger or older if they are not able to find

common interests. In the current culture, it does not seem apparent that these barriers are widely

experienced, as everyone in the clinic, including staff and participants, treats each other with

respect and kindness.

Socioeconomic statuses range within the clinic, but it is not a factor that divides those

who attend. Those who are not geographically located within a short distance of the clinic may

experience challenges with transportation if they are unable to drive themselves, do not have a

caregiver to transport them, or if they do not have the ability to access public transportation or

pay for a private ride. Religious backgrounds and beliefs vary greatly within the clinic but it is

not a factor that influences the delivery of services and those of all faiths are welcome in

attendance. While the clinic is a tremendous support for these patients and their physical needs,

there is a hope for the future of the clinic to provide more of a support during the development of

health changes for these individuals and act as a bridge to close the gap between home and

community. This new philosophy was described by Ellen as one that she envisions to create a

stepping stone for patients at the wellness center, so that they can integrate more fully within the

community and feel more confident to participate outside of the wellness center. This varies

from the current philosophy of the wellness center, since it provides access for clients to attend

on their assigned diagnosis days and continue to attend for as many years post-

referral/diagnosis/first appointment as they desire.

 Programming Strengths and Areas of Growth

Staff Perspective

Information collected from the perspective of the staff members was conducted through

semi-structured interviews in short periods of time when the director, administrative assistance

and/or clinic aides were available to talk (see appendix B). Through the process of these

interviews, multiple staff members voiced the need of occupational therapy services within the

clinic. In reference to any OT related tasks or exercises available within the current facility, there

is an arm bike and a small amount of fine motor activities stored in a cupboard. The fine motor

activities were described as seldom used due to constraints of space and staffing availability. As

previously mentioned, Ellen communicated that the wellness center was initially created with the

goal of acting as a transitional resource to assist those undergoing intense life changes of a new

diagnosis or health status change. The vision was that the wellness center would assist with

making adjustments and adaptations to new abilities and ways of life prior to integrating back

into the community so that they feel confident and secure in their ability to participate in similar

activities within their environment. While strong emotional bonds and connections are created

among the wellness center, its staff, attendees and their caregivers, this development can act as a

barrier to those who do not wish to go out and participate within the community as is it

unfamiliar to them. Ellen agrees that there are gaps within the services being provided and

wishes to identify and address these areas of growth and improvement within the wellness

center.

The clients and their caregivers are just beginning or continuing their journey with a

progressive neurological disease or deficit, and it is common for many to have well-established

routines for self-care, transportation, and caregiver assistance. While these routines are typically
expected to be established, over time there will also be development in approaches or skills that

can benefit those who need and/or provide assistance to others. Staff members voiced concerns

of caregivers, and even some of the clients themselves, possibly needing retraining or support

during the progression of health changes in order to remain safe and enable greater independence

and quality of life. This rings true as many of the client’s abilities range from independence in all

areas of life, to requiring total assistance or constant supervision.

Client Perspective

Through 10 semi-structured interviews, information collected from patients and/or their

caregivers voicing their opinions of strengths and weaknesses within the clinic (See appendix C).

Three individuals with MS, two individuals with PD, and one participant with fibromyalgia were

interviewed with a focus on ADL performance. For those with MS, it was reported among all

three that a good routine had been established for daily living, with minor concerns about

changes in status or abilities. Caregiver burnout or stress was a concern noted for one of the

patients with MS. For those with PD, reports showed challenges in daily activities involving

mobility, as well as noticing changes in mental status and displaying signs of depression. The

patient with fibromyalgia reported loss of roles, decreased abilities to perform functional

movements without pain or impact of fatigue. He seemed to have the largest impact on his daily

living and ability to participate in meaningful activities, as well as the influence his condition has

had on his mental state. A common theme that developed through these interviews was that of

gratitude for the wellness clinic and the people who work there. They voiced praise and

confidence when working with the aides, as the assistance provided allows them to participate in

exercise and a healthy lifestyle.

 A second theme came through by means of social interaction, most of the participants

greatly enjoy the participation in social groups and the ability to make new friends with patients

within the clinic. While most voiced the social support, a few reported changes in their social

group as their friends either have not been attending the clinic or have been attending at different

times/days. Majority of the patients expressed being satisfied with the services provided and their

needs being met, but there were a variety of reports consisting of challenges outside the clinic.

Upon discussion of occupational therapy and the potential services that could be offered, each

patient agreed that there was some degree of need that OT could address for them. Each

interview was unique to the natural flow of conversation with each patient, which the semi-

structured interview allowed for in-depth collection and establishment of rapport with patients

and their families.

One of the patient’s caregivers that I interviewed is a practicing PT, and she reflected

many of the topics previously brought up during data collection. She brought an interesting point

of view as she is a professional as well as a caregiver to her father. The need for OT services is

vast within these different populations and it could be challenging to find a need that addresses a

variety of diagnoses. She and I both agreed that a screening program could be beneficial to find

the gaps in services and/or needs for those who attend the clinic. Other caregivers did not specify

individual needs, but agreed that a resource for the patients, as well as themselves, to address all

aspects of life outside the clinic could create greater outcomes and quality of life for all those

involved.

Student Perspective

Through the time spent at the wellness center interacting with staff, clients, and their

caregivers I developed a sense of existing strengths and areas of growth within the clinic, as well
as potential gaps in the current services. The wellness center has many strengths, the greatest one

being the amount of support through staffing and programs that currently exist. There are many

free classes and resources available to all members of the clinic. Currently, there are PT students

that are able to assist with participation and running these extra programs with the patients,

providing hands on experience and development of professional knowledge and skills. Another

striking strength of the wellness center is its ability to bring those together who have similar

needs and allow for them to feel safe and supported while pursuing an active and healthy life.

The social interactions and supports present are remarkable and you can tell these people care for

and enjoy each other’s company.

An area of growth that I identify within the wellness center involves the lack of

occupation-based activities in their workout programs. While working on their strength, ROM,

and endurance are all important factors for these patients, it is important to remember the context

of the remainder of their lives and the influence that will have on their performance outside the

clinic. Another opportunity for growth involves the current lack of screening for quality of life,

which is a large factor for those who are living with chronic or progressive deficits. While there

is a mental health counselor on site, there seems to be a gap between the patients knowing about

this resource and utilizing it based on their needs. Overall, the gap seems to exist between what

patients do while attending the wellness center, and the rest of their lives outside the clinic. With

the amount of variety in types of need, as well as degrees of need, developing a program that is

broad can allow for addressing the needs of a diverse population. Filling in the gap with

assessing and identifying occupational needs, as well as consultation services to facilitate

changes that will increase occupational performance and levels of satisfaction on a daily basis.
This program will compliment their already existing exercise programs and will be incorporated

into their time at the Wellness Center to make the most of their time spent in the clinic.

Evidence-Based Practice

A literature review was completed in order to gain a clear understanding of the

occupational needs of the individuals attending the L.S. Skaggs Patient Wellness Center. This

review also assisted in gathering existing evidence for occupational therapy services in an

underserved community setting. The University of Utah online library databases (PubMed,

CINAHL, EBSCOHost) and the American Journal of Occupational Therapy were searched for

relevant articles pertaining to evidence for this population and their needs. Search terms included

a variety of combinations including terms: occupational therapy, neurological disorders, quality

of life, caregiver, ADL, chronic condition, Parkinson’s disease, Multiple Sclerosis, stroke,

outpatient, geriatric, screening. With the availability of scholarly articles to students through the

university library catalogs, most articles were located through that search engine. The decision to

include articles found was based on the relevance to this population and their needs, as well as

how comprehensive and overarching the information was within the evidence found in order to

address a variety of populations. Ten articles were kept assisting in development of this literature

review and are referenced below.

Patient Characteristics and Deficits

In order to identify and understand the needs of the population, an evidence-based review

was completed to discover the characteristics and the possible deficits of this community

population. Many of the patients attending the Skaggs Wellness center have been living with

their neurological diagnosis for multiple years, while some are experiencing a new medical

diagnosis and only beginning to develop new habits and routines due to such life changes.
According to Bienias, Ścibek, Cegielska, & Kochanowski, (2018), most neuromuscular

diagnoses are progressive in character, developing in varying degrees and leading to different

levels of impairment of physical performance in daily living. Diseases of neurological deficits

typically exhibit similar symptoms throughout the course of their progression, including

decreased muscle strength, increased fatigue, functional mobility challenges with walking and

performing activities of daily living. It is reported that most patients wish to remain as

independent as possible with their ability to perform basic level of self-care and their ability to

move around safely (p. 223).

Typically, healthcare professionals currently see patients with neurological conditions in

an inpatient rehabilitation or outpatient setting and aim to increase overall health and

participation in their patients’ ability to perform: activities of daily living (ADLs), rest, work,

play, education, instrumental activities of daily living (IADLs), leisure, and social participation

(Rao, 2012). These intervention areas target common deficits experienced in neurological

disorders involving physical abilities, health and well-being, social participation, as well as

changes in participation across all activities of daily living. In regard to the patients currently

attending the Skaggs Wellness center, they are receiving services overseen by a physical

therapist (PT) to address their strength, range of motion (ROM), endurance, and functional

mobility training.

When an individual experiences functional limitation, especially with a chronic and

progressive disorder, several risk factors can arise in one’s ability to remain independent. Lien,

Guo, Chang, Lin, and Kuan (2014), listed these risk factors as: lower extremity limitations,

decreased self-perception of health status, less physical activity, depression, cognitive changes

and impairment, co-morbidities, extreme changes in weight and/or body mass index, lessened
social interaction, increased risky health behaviors (i.e. smoking), as well as impairments

affecting vision. One’s ability to adjust to both their diagnosis and new environmental challenges

can be a determining factor reflecting their potential for success in the context of their daily

lives. This conclusion determines the importance of the perception the patient has of their own

abilities. In regard to community-dwelling older adults this is applicable as their perception of

abilities, or lack thereof, will have an impact on their actual performance. This emphasizes the

importance of understanding and addressing the patient’s perception of environmental barriers

limiting participation in desired activities with the aging population, with a rise in disabilities in

the future.

Contextual and Environmental Barriers

Diseases with progressive characteristics can lead to a variety of impairments in physical

performance (Bienias, et al, 2018). These limitations in physical performance, which are

personal contextual factors of the client, can create newfound challenges when attempting to

safely move about the physical environment. In the same scenario, the physical environment has

the potential to act as a barrier if it is not accessible to those of all abilities. Other contextual

factors that influence the ability to perform daily activities within this population include social

and emotional aspects. Individuals with chronic diseases can experience a spectrum of

unforeseen challenges and limitations in social roles, also based upon their perception of their

disease. Cardol, Jong, Bos, Beelen, Groot, and Haan, (2002) reported that one’s perception of a

restriction is in fact different than experiencing actual restrictions, and a perception of

restrictions can have a negative impact on their ability to participate in life roles. Individuals with

a variety of diagnoses all reported substantial perceived restrictions in social roles, but these

restrictions were not labeled as the most severe impact across populations. This indicates those
who experience chronic illness will have unique perceptions and individualized needs depending

on the patient’s roles and the value they place on their ability to participate in such roles.

Assessing their perception of their abilities will also influence their participation in roles and

meaningful activities.

Emotional factors come into play with chronic progressive diseases such as Parkinson’s

disease, multiple sclerosis, and patients post stroke. Depression is a commonly experienced

syndrome for individuals with chronic neurological illness and is a disabling factor influencing

one’s ability to function in their desired occupations, potentially decreasing their quality of life

(Rickards, 2005). The stressors experienced throughout the course of a progressive disease can

also likely have an influence not only the patient with the diagnosis, but also their caregiver(s)

and family members. According to Canam and Acorn (1999), years of healthcare reform has led

to many chronically ill people being cared for at home by family members. When evaluating the

quality of life (QOL) among caregivers for chronically ill individuals, it was determined that

developing treatment focused on one’s quality of life versus the stress and burden they are

experiencing is supportive in developing care assessing a range of health determinants, (i.e.

societal factors) on both the caregiver and client level (p. 196).

Addressing not only the patient’s quality of life through the progression of their disease,

but also the caregiver’s quality of life is essential as they are the role that provides support for

their loved ones. This is important due to the impact of burden placed on the caregiver.

Additional stress placed on the relationship between patient and caregiver has the potential to

have a negative impact on the state of well-being for both parties, aside from the stress of health

status (Balhara, Mathur, Sharma, Verma, 2012).

 Due to the nature of chronic progressive disorders over the lifespan, there are vast needs

for each individual as they uniquely navigate their diagnosis. While this is not an exhaustive list

containing each contextual aspect, a largely influential factor involves the cost of needed

services. In a study conducted by Wynford-Thomas and Robertson (2017), the economic impact

of having a neurological disease was explored due to the recurrent nature of MS, similar to other

chronic progressive diseases such as Parkinson’s disease. The results demonstrated the need for

more effective and comprehensive care within the community for patients that have higher levels

of limitations in daily living (p. 2346). This highlights the need for affordable health-care

services accessible to those within the community that have physical and/or psychosocial deficits

to prolong independence and quality of life.

Role of Occupational Therapy in Chronic Progressive Diseases

The American Occupational Therapy Association (AOTA) has defined OT’s role in

chronic disease management as one that focuses on assisting individuals in their ability to remain

engaged in meaningful and rewarding activities of daily living (AOTA, 2015). OTs play a vital

role in enabling the collaboration between the clients, families, and caregivers through evaluation

and development of the intervention process. The fact that these patients will be managing a

chronic and progressive disease for the remainder of their lives dictates a need for services that

address maintaining independence and satisfaction of participation in desired occupations. The

AOTA has established this as an OT’s role when working with patients with Parkinson’s Disease

(PD), survivors of stroke, and patients with multiple sclerosis (MS), those with diabetes and/or

obesity, therefore, identifying a place for OT in a community setting like the Skaggs Wellness

center.
 Occupational therapists have a responsibility in assessing daily performance deficits that

influence one’s ability to perform every day tasks. These tasks include: self-care, managing

household care, techniques of energy conservation and modifications to daily activities meeting

new physical demands as well as managing impact of fatigue. OTs specialize in providing

individualized, client-specific adaptations in order to effectively promote management of health,

education of health management tasks, and assistance with incorporating them into current

patterns of habit. Lastly, the development of coping strategies, habits, routines, behaviors, and

adaptations to daily living in order to support not only physical, but psychosocial health and

wellness. The AOTA supports the benefit of educating and enabling a patient’s self-efficacy and

problem-solving skills to develop a sense of self-control, allowing them to play a role in

managing their health versus being managed by their diagnosis (AOTA, 2015).

Existing literature on comprehensive assessments utilized by healthcare teams for the

older adult population is limited in evidence-based effectiveness in all settings. The

comprehensive geriatric assessment (CGA) is a tool that has been proven effective to be used in

screening patients in inpatient, rehabilitation units, or home health settings (Reuben, Frank,

Hirsch, Mcguigan, & Maly, 1999). A randomized control trial was carried out in order to study

the possible effectiveness of the CGA in an outpatient or office setting. At the time, conclusions

on the effectiveness of utilizing the CGA in outpatient settings was inconclusive (p. 269). The

CGA is a diagnostic and process of intervention that addresses medical, psychosocial, and

functional limitations and is typically utilized in evaluation of older adults. The assessment

allows for evaluation of a variety of occupations and context including physical, cognitive,

social, affective, economic, environmental, and religious/spiritual aspects. The CGA was
designed to be a systematic evaluation of older adults in regard to their healthcare team, allowing

for greater detection of health deficits and improve desired outcomes.

Reuben et al. (1999), determined a major goal in the care of older adults was developing

an effective model that provides comprehensive evaluation and provide a simple transition

between inpatient and outpatient settings. The results from the RCT indicate that one outpatient

CGA consultation, in addition to moderate intervention addressing follow through of

recommendations provided during the session, had positive effects in prolonging function in both

physical and social participation in the population of community-dwelling older adults at risk for

decline in function. It was recommended that use of the CGA in a clinical setting and future

developments of the program in order to provide an interdisciplinary care for older adults while

being easily incorporated into existing healthcare delivery systems. Even though the clinic does

not have an on staff MD, collaboration with the participant’s physician could provide overview

and follow the CGA structure. This evidence is beneficial in the development of an outpatient

preventative screening program within the wellness center that can streamline into the current

programs and systems utilized.

Summary

The L.S. Skaggs Patient Wellness center is a part of the University of Utah’s healthcare

system (“About Us,” n.d.). The university’s mission is stated to provide services to the people of

Utah and surrounding areas who have needs in improving health on both individual and

community levels, as well as improving overall quality of life. Their mission is achieved by

striving to provide great patient care, education, and evidence-based practice for those in the

community. Each aspect of care contributes equally to the stability and delivery of services

within the university. Currently, the wellness center provides a variety of resources and programs
that are widely utilized and benefits participants within the community. Programs offered

through the clinic include: functional mobility and strength, maintaining social connections,

community group-based classes, mental health counseling services, as well as the ability to

participate in research studies on campus. To facilitate increased outcomes in these programs, the

Wellness Center would benefit from occupation-based individualized screening program to

address a variety of occupational needs among the populations seen at the clinic. OT services can

assist in bridging the gap by advocating for use of current programs and resources available,

educating on self-advocacy skills, as well as expertise in activity analysis during occupational

performance.

Data collected during semi-structured interviews including narrative from patients and

caregivers demonstrated a variety of interests, needs, values, beliefs, and goals held by each

individual. Providing individualized, client-centered services through a prevention screening

program has the potential to assist in collaborating with the clients and their families to address

their unique set of needs and/or goals beyond functional mobility. The influence to improve

overall delivery and outcomes within healthcare treatment exists with the involvement of the

patient’s team, by informing the MD and all team members with updated progress as treatment is

carried out. This program would facilitate an increased ability to maintain independence through

progressive deficits, development of self-efficacy, increased satisfaction with performance of

occupations across multiple contexts, and overall health and well-being while aging (Ward,

Reuben, 2018).

Combining the evidence collected through a needs assessment and the current literature

review, an area of need was highlighted, and appropriateness of a screening program to prevent

occupational decline became apparent. This program would create a role that allows for smooth
integration of services with ones that are currently provided and fill a gap in the needs identified

by administrative and staff members, through student observation, patient interests, caregiver

report of needs, abilities, and goals. The program will assist in addressing limitations

experienced from physical impairments that can put this population at risk for decreased quality

of life, development of co-morbidities, decreased social interactions, as well as increased stress

and impact on the caregiver(s). Lastly, this program will reinforce the desired outcomes and

mission established for the university in which the L.S. Skaggs Patient Wellness center by

providing a community occupation-based program providing client-centered, individualized, and

evidence-based care.

Program Proposal: L.S. Skaggs Patient Wellness Center – Occupational Decline Prevention

“Comprehensive Community Occupational Decline Prevention Program for Clients and

Caregivers at the L.S. Skaggs Patient Wellness Center

Program Overview

The needs analysis and literature review performed highlighted current gaps within the

services offered within the L.S. Skaggs Wellness Center, and it seemed beneficial to create a

program that could address a wide range of needs. The results of the literature review displayed a

variety of occupation-based areas of need for individuals with chronic conditions when

considering occupational decline and satisfaction of overall performance in daily living.

Designing a program that offers comprehensive OT evaluation and intervention for both the

clinic participants and their caregivers will assist in enabling occupational performance and

ensuring the quality of life for those who deal with chronic progressive diagnoses. The positive

effects of the program will extend to building confidence among participants and their caregivers
within their homes and the community. The aims of the Patient Wellness Center are to provide

programs that encourage health and wellness for individuals within the community.

Upon review of the social, economic, political, geographic, and demographic factors the

service of delivery was designed in order to accommodate for the populations needs. Clients will

not be limited to services due to their level of assistance and the program will be available to all

clients within the clinic. There is potential for individuals with Medicare to have coverage when

attending the L.S. Skaggs Patient Wellness Center, which would allow access to OT services for

these individuals. A referral is not required to participate in the program since there is no referral

needed to attend the clinic. Political influences have the chance of leaving the future of

healthcare services uncertain, as they have in the past and will continue to do so. Cuts to the

funding for healthcare services limits the access for individuals covered by Medicare and

Medicaid outside of the clinic when they may need services due to progression of conditions and

decline in occupational participation.

This limitation in the healthcare system highlights the need for a program offered within

the Wellness Center in order to address the progression of chronic conditions and the influence

those changes have on the ability for clients and their caregivers to maintain balance in their

occupations and continue to improve quality of life and satisfaction of occupational performance.

This also has the potential to reduce hospital readmissions related to decline in functional and

mental status in clients with chronic conditions. The age limit for the program will follow the

regulations established for the clinic, which will be a minimum of 18 years of age. All caregivers

will be welcome, as well as encouraged, to attend sessions as often as possible. For those who

may have challenges with transportation to the clinic, specific ride options can be explored and

arranged to meet their needs. During group and/or individual sessions, the client’s cultural and
religious backgrounds will be taken into consideration when establishing goals, developing

intervention, and providing treatment.

Program Value
Occupational Justice. This program will address occupational justice of all those who

attend the Wellness Center and will focus on occupational alienation, occupational apartheid,

occupational deprivation, and occupational imbalance. Occupational justice is an important

aspect as a healthcare system, as referenced in Duroucher, Gibson, and Rappolt (2014), Stadnyk

et al. (2010) states that occupational justice is to focus on meaningful and purposeful tasks and

activities that individuals want to do, need to do, and can do in regard to their personal and

environmental contexts. This program will allow for the evaluation of occupational performance

and satisfaction through use of COPM, determining meaningful areas within individuals lives

that may need to be focused on in order to increase overall occupational justice. This will

facilitate what they want to do, need to do, and can do, by receiving OT intervention that allows

for greater participation and satisfaction with outcomes.

Occupational alienation will be addressed, as those with chronic conditions can often

experience alienation or loss of roles, leading to isolation and changes in identity. This program

will allow for maintaining roles among caregivers and clients, reducing likelihood of

disconnectedness. Occupational apartheid is addressed since the program will provide services to

underserved or under-covered populations that are not able to receive services due to SES,

disability, and/or poverty. Occupational deprivation will be intervened for individuals who are

experiencing health status changes out of their control, this program will provide services to

those who are unable to influence their social, environmental, economic, geographic, historical,

cultural, political, and/or interpersonal factors. These conditions can have long-term and

invasively progressing courses, having significant implications on their health, as well as the
health of their caregivers. For clients and caregivers experiencing chronic progressive disorders,

there is chance for occupational imbalance. Some individuals begin losing abilities to perform

occupations independently leading to a decline in participation, while caregivers are becoming

over-occupied, causing a misalignment. Intervention will assess and address these imbalances,

allowing for ability to maintain satisfaction with participation within one’s life.

Prevention. The program being proposed will also provide levels of prevention for the

individuals within the Wellness Center and the community. Primary prevention will be carried

out through the program by providing informational handouts on common areas of

intervention/focus. This prevention would be mainly education of commonly experienced

challenges, with or without a diagnosis, for individuals who could benefit from suggestions for

remaining safe during daily living or begin the process of looking into receiving OT services as

needed. Provide general safety information to prevent occupational decline across this

population. Secondary prevention will be provided through education classes on risk factors of

occupational decline when experiencing changes in physical state, especially in regards to

chronic progressive disorders. Education will be provided not only through informational

community sessions (IPE type meeting for students to gain hands on experience). These sessions

would be provided during the evening hours of the clinic, or once a semester for multiple

disciplines. Risk factors of possible challenges experienced with at risk populations of diagnoses

regarding neurological disorders, or other diagnoses that put individuals at risk for occupational

decline. Tertiary prevention will be provided through direct services for those who have a

disability or impairment, carried out by MOT students, possibly as level 2 Fieldwork in the

community/underserved setting during the Fall semester. Following the assessment of the OTR/L

on staff, students will provide OT services 2-3 days out of the week for varying populations and
needs. The tertiary level of prevention will involve rehabilitation following significant health

status changes. The aim will be to help client’s retrain, re-educate, and rehabilitate in the

presence of a condition limiting participation.

The prevention program will follow the course of the participant’s attendance at the

Wellness Center. Upon evaluation or re-evaluation for PT services (current program offered), an

occupational therapist will perform an assessment, including formal evaluations, semi-structured

interviews, observations of performance, and self-report surveys for clients and caregivers. As

areas of intervention are identified, a collaborative effort for goal-setting and intervention

planning will be established between the therapist, client, and/or caregiver. At this point, the

program will reflect what is currently established within the clinic with the individualized

program is printed out on the client’s intake paperwork. For 2-3 days of the week, depending on

the availability for students to be available at the clinic, direct services will be provided through

the MOT students as determined on the initial plan. Students can have the opportunity to practice

hands on intervention and perform evaluations or other need analysis for the participants and/or

facility.

Rationale for Occupational Therapy’s Role

An occupational therapist is well-equipped in designing and implementing a preventative

occupational decline program that is focused in aiding participants to continue to improve their

occupational participation in meaningful daily living. An OT can utilize task analysis, evaluation

of client factors and performance skills in order to address the client’s in their natural and

unfamiliar environments and determine intervention that is individualized and tailored to their

needs. Interventions will be designed by the OT to be client-focused and specifically developed

to meet the needs of each unique client. The areas of intervention will be established through the
understanding of client’s goals, occupational roles, performance in occupations, environmental

factors, and client factors and/or performance skills.

Occupational therapy focuses on working with individuals who are experiencing

challenges in performance of ADLs and/or IADLs, limiting independence and decreasing

satisfaction in performance of meaningful activities due to chronic health conditions influencing

level of ability. Occupational therapy keeps the client at the center, with an individualized and

holistic view of each circumstance surrounding the client. OT’s are able to design unique

exercise and activity plans that address specific areas of need for each client receiving services,

and in this program following the evaluation performed by the OT, MOT students will then carry

out weekly interventions. Caregivers will hold a vital role in treatment planning as they are

another resource for the client, as well as the ability to contribute knowledge of the context and

daily living at home with the client. They also have the opportunity to participate in furthering

education and learn new ways to support the client, and themselves within the home and

community.

Regarding the aging population, sometimes referred to as the geriatric population,

occupational therapy specifically works to promote healthy aging, and the ability to remain in

place while aging. The profession of occupational therapy places great emphasis on creating

evidence-based research in order to facilitate the best practice possible for each individual. As

the body of evidence for occupational therapy continues to grow, the use of evidence for

intervention planning will expand, allowing those to benefit from researched, individualized,

occupation-based intervention. This program will provide affordable, evidence-based

intervention through utilization of MOT students and volunteer OT applicants/students,

supervised at least once a week by an OT. The students and clients will always be supervised by

the staff at the Wellness center.

Theoretical Foundation

The theoretical support for this program ensures that the delivery of services is client- and

family-centered intervention and treatment planning. The person, environment, and occupation

(PEO) model provides the framework that reaches all spectrums of the population, regardless of

contextual factors. The foundational theory of this model focuses on occupational performance

and the perspective that a dynamic interaction exists between a person, the environment, and

their desired occupations, which is also referred to as transactionalism, (Law, et. al, 1996). The

guiding principles for practitioners to understand this phenomenon in order to remain as holistic

and client-centered as possible. The transaction between the person, environment, and

occupation contributes to the choice of assessment and intervention planning which enables

improved occupational performance by addressing the impact each factor has on daily living.

According to the PEO model, this model is supportive of those who are not satisfied with the

level of occupational performance due to an imbalance, or lack of congruence between the

person, occupation, and environment.

Postulates for change in the PEO model indicate the person’s perceptions and beliefs

about their immediate environment and occupations has a direct impact on one’s occupational

performance. This is an important aspect and supports one of the aims with the program being

proposed, which involves gaining an understanding of the client’s perspective and personal

priorities. The clients at the Wellness Center will receive intervention that is designed

collaboratively following assessment of each participant’s unique priorities and beliefs,

perceptions of the environment, current and/or former occupations, to gain understanding of the
factors contributing to one’s daily performance. Also applicable to this population, another

change postulate determined in the PEO model states that environmental barriers commonly

arise for those with limited abilities, and that the environment is easier to change than the person.

Interventions targeted towards the environment have the potential to enable one’s ability to

participation in daily occupations and improve personal satisfaction with performance. This

change postulate supports modifications within the home, including the need for home

evaluations, or occupational observation within the natural environment of the individual to

understand the contextual influence being experienced. Simple modifications and strategies can

be suggested and carried out within one’s immediate environment, therefore increasing safety in

daily occupations, regardless of one’s ability level.

Lastly, the PEO model states that when a change occurs within a person, their

environment, or their occupation, the level of occupational performance has the chance for

improving. As stated previously, the environment, and even the occupation, is generally simpler

to make changes and/or modifications in those areas of the transaction than within the person.

This factor applies across multiple contexts and environments within an individual’s life,

enabling occupation through assessment of broad characteristics in the person, their

environment, and occupations transacts. In summary, the PEO model develops intervention and

collaborative interactions at all levels of one’s life and in each combination of transaction: the

person, environment, and occupation.

In contribution to the PEO frame of reference, the Model of Human Occupation (MOHO)

has been selected in providing support of the program being proposed. The MOHO is a broad

model with a unique focus on a contextual factor influencing occupational performance located

within the person: motivation, which is also referred to as volition in this framework. This model
supports the development of a positive relationship with life’s roles and routines, as well as the

necessary performance skills required for daily tasks. The influence of physical and social

environments is taken into account with this frame of reference, considering other contextual

factors that influence occupational performance. Change postulates for MOHO reflect an aspect

of the previously discussed model, as the interaction of external environments and an

individual’s unique characteristics are viewed as linked and part of a dynamic system. The

occupational performance and satisfaction reflect the level of influence both the personal and

environmental contexts have in daily activities. This model is important for the development of

the program due to the emphasis on one’s inner characteristics and the fact that engaging in

occupations can maintain or change inner personal factors – taking into account both the mind

and body when intervening.

The complementary model chosen to support both organizing frames of reference has

been the Life Balance model. This model is focused largely on populations that experience

imbalances within their life, due to lack of environmental supports for a healthy lifestyle balance.

Individuals that can benefit from this frame of reference includes those experiencing burnout,

retirement, sleep disorders, obesity, MS, arthritis, and other chronic conditions influencing the

balance of daily living. Postulates of change in the Life Balance model emphasize the influence

occupation and events that can become synchronized with the body’s circadian rhythms and the

external world. Another change postulate involves the congruence between self-perception,

valued occupations, as well as one’s meaning and purpose in life, and that optimal congruence in

these areas can improve satisfaction. For this program, an important change postulate also

involves addressing psychological needs, and by meeting those needs the amount of stress can be

buffered. Meeting psychological needs is also required for one to be able to flourish. Lastly, the
Life Balance model states that the ideal balance in one’s life is represented through equal

involvement in physical, mental, social, and rest occupations.

This model is important when framing intervention with the populations at the Wellness

Center because those with chronic progressive disorders, as well as their caregivers, likely

experience an imbalance in occupational performance over time. The psychological factors that

have an influence on one’s ability to be motivated and satisfied in participation need to be

addressed in order for the individual to feel as though their activity patterns, roles, satisfaction

need, and time-use are all congruent, promoting overall holistic health. The desired outcome of

using this model is to obtain a balanced lifestyle through valued patterns of daily occupations

that promote health, have meaning, and are sustainable within current life circumstances.

Goals and Objectives

Goal 1. Improve overall balance of occupations and perceived health status of both patients and

caregivers experiencing chronic progressive disorders by providing education and information

sessions to address a variety of daily occupational needs.

Objective 1. By discharge, 75% of participants will report improvement in self-

perception of abilities in performing daily occupations by demonstrating a change score of at

least two points on the Self-Perception and Relationships Tool (S-PRT).

Objective 2. By discharge, 75% of participants and caregivers will report improved

balance of occupations during daily living through implementing strategies of stress and time

management at home
Goal 2. Improve overall satisfaction in performance of daily occupations as measured by COPM

that were previously interrupted by progression of health status by implementing strategies

learned during OT sessions

Objective 1. By discharge, 75% of participants will report improvement of occupational

performance by improving score on COPM by at least two points for at least one previously

identified daily occupation.

Objective 2. By discharge, 75% of participants and caregivers will report at least one

implementation for suggested strategies in preventing occupational decline within the home

Program Considerations

The proposed program aims to address the delivery of affordable health care services

within an underserved community, providing education to clients and caregivers, provide

community resources and support of well-being for all individuals regardless of SES or access to

insurance coverage plans. The services will provide direct occupational therapy services at little

to no cost addressing occupational performance across all aspects of one’s life. This program

will not consist of a standardized timeline, as each participant’s experience will be individually

tailored to suit their specific needs. Evaluation will occur with an occupational therapist

employed through the University, either upon first-time evaluation, or re-evaluation, for all

supervised gym services with the OT assessment to be performed on the same day the PT

evaluation takes place. At this point, the participant, caregiver, and the occupational therapist

will determine priorities for intervention that are perceived by the client and caregiver. This

information will be obtained by performing the COPM (see Appendix C), as well as other

subjective assessments to be completed to gain information vital to creation of treatment

planning. The Medical outcomes study (MOS) 36-item short form health survey (2014) will be
used as a pre- and post- assessment (See Appendix E) to track progress among participants and

their caregivers. The timeframe for intervention and/or re-evaluation will be decided upon during

time of assessment (typically 6-10 weeks).

The intervention plan will be carried out by 2nd and 3rd year MOT students, and

hours/days of the week services are available will be dependent on availability for coverage from

students. The students will be able to utilize the OT on staff for consult and/or assistance with

direct services. The opportunity for level II fieldwork students could be created once the program

has been established, allowing for greater potential of providing OT intervention to the

population through affordable and accessible services. Re-evaluation will take place upon

determined date and suggestions for further services will be given at this time, whether it be to

continue services, discharge services, or provide recommendations and/or referrals to meet one’s

needs.

Clients already attending the Wellness Center come to the clinic for about 30-60+

minutes/day in order to complete exercise programs, and some will attend multiple days out of

the week. The OT interventions will be focused to target performance areas without taking up

too much time and would aim to be completed with supervision within 30-45 minutes. This

could increase the client’s time spent at the clinic over the week by 1-2 hours. The scheduling

could be flexible for participants and students as much as possible to support ease of access to

services. Community classes providing general information regarding caregiver and client health

and well-being, will be held once a week after hours in the evenings for 60 minutes and will be

carried out by the OTR/L and MOT student volunteers. The staff existing at the Wellness Center

will continue to provide general safety supervision and assistance with treatment plans, but will
not have to directly carry out OT specific interventions as the MOT students will play that role in

the plan.

MOT students will be required to check the client in, supervise their exercise program, as

well as supervise/intervene with client during OT activities. For clients that are potential

candidates to receive services will be referred to the OT on staff to perform evaluation. Students

will not only carry out day-to-day intervention with clients, but they will have the opportunity to

perform portions of assessments, provide general education handouts, collaborate with client and

caregiver to maintain focus on areas of priorities. Face-to-face services will be the main focus of

delivery, but telehealth sessions can be arranged upon barriers to attendance or by request. Each

session will recap goals, outcomes, individual intervention, and answer any questions the client

or caregiver has.

Participant Criteria

Clients attending the L.S. Skaggs Wellness Center and their caregivers will be recruited

for participation in this program. Members at the clinic have at least one chronic condition

limiting abilities and have the influence of creating occupational imbalance or decline.

Exclusionary criteria include clients that are unable to attend the Wellness Center at least 75% of

the time, those who are resistant or unable to incorporate suggestions within the home,

environment, or lifestyle changes. Clients are not required to have caregiver present during each

session or attendance, but it is recommended that they attend at least one session a month, so

they can contribute to intervention, as well as receive education to support the client, as well as

themselves.

Staff Involvement
 The program will take place within the clinic, at a client’s home (home evaluations), and

within the community (community evaluation). Aside from the occupational therapist and MOT

students, other staff members will involve clinic staff, volunteers, and/or research administrators.

The clinic director, Ellen Maxfield, will assist with additional services such as securing funding,

approving/adapting marketing, and encouraging client participation could have a positive

influence in delivery of services. The administrative assistant in the clinic will also serve a role

in directing clients to the accurate spaces for meetings, providing information during phone calls,

and walk-in questions about the program services.

The role of the occupational therapist will include providing direct services during

evaluation and re-assessment, as well as occasional presence during daily intervention sessions.

Consult services will be provided as needed case by case when challenges or concerns arise

during one’s treatment plan. The administration of the COPM, goal setting and intervention

planning, and supervision of service delivery will be the general interactions the occupational

therapist will be involved in. For all group meetings after hours, the occupational therapist will

lead the group and interact with MOT students. When other staff members possibly lead group

sessions for specialized topics, the OT will be present for supervision and direct service

suggestions as well as facilitating group discussion, answering questions and concerns about

suggestions, interventions, goals, and occupational participation.

Community Resources

Clients will be located within the community occasionally when intervening with

occupations occurring within the community environment. For each client, depending on the

circumstances, a home evaluation can be carried out, as determined by the OT on staff.

Community resources will be suggested as needed for clients, whether it concerns mental health
resources, transportation resources around the community, caregiver resources and/or support

groups. Clients will also be given educational handouts for local resources supporting social and

leisure activities, as well as maintaining occupational performance in desired activities.

Space Requirements

This program will be utilizing the space within the learning annex classroom located in

the clinic, the individual consult rooms, patient homes and community sites. A table and space

for storage of supplies for intervention could be placed within current storage spaces or

additional storage units could be purchased. Space requirements do not greatly exceed the

current available space within the clinic.

Program Marketing

This program will be marketed within the clinic, as well as through the clinic website,

monthly newsletter, the informational bulletin board in the clinic, and handout flyers for clients

to take home. Clients and caregivers currently attending the facility will be the population in

which is initially targeted. After the first 12 weeks of the program being carried out, a review of

the process done by the clinic director and OT on staff in order to determine if greater marketing

needs to be done to reach a greater population located outside of the clinic. The Wellness Center

is affiliated with the University of Utah with access to additional marketing through the U health

system. When clients learn about the program, specific areas of need can be discussed in order to

understand how the program would be applicable for the individual inquiring about services.

Budget

The estimated budget considers many factors influencing funding and is depicted in

Appendix D. The weekly occupational therapist workload of 10-12 hours will require one OT to

be contracted part-time. The clinic is open and provides services for many hours during the
week, but this budget is specifically detailed for the parameters of the program being proposed.

The hourly wage was determined by calculating the average salary for an occupational therapist

in the Salt Lake area, without addition of benefits. The cost of purchasing main initial

evaluations (COPM) and printing for participant education handouts and other printed materials

are direct costs and included in the proposed budget. All other furniture, supplies, resources, and

rooms already exist within the clinic and are determined to be in-kind contributions from the L.S.

Skaggs Patient Wellness Center.

Funding Options

Funding option 1: There are many local grant opportunities available for funding a

program similar to the one being proposed. The George S. and Delores Dore Eccles Foundation

provides grants to the university and areas involving art and culture, community education,

healthcare and preservation, and availability of healthcare services in the state of Utah. Funds are

provided for both rural and urban areas supporting healthcare services. Grant amounts vary and

are often utilized for equipment, facilities, and program support for individuals involved in

medical diagnosis, education and treatment, prevention of disease, healthy lifestyle promotion,

and working towards developing innovative approaches to address healthcare challenges (George

S. and Delores, 2017). The occupational decline prevention program being proposed would be a

valuable candidate for funding through this organization.

Funding option 2: Another grant funding option that was located is the Marriner S. Eccles

Foundation. This foundation focuses on community development and access to services for those

with needs, underserved populations, and issues with human resources. This foundation gives

varying amounts to support higher education, health, hospitals, medical research, family and

social services, including programs for rehabilitation. Other areas this foundation supports
includes senior services, mental health care, and outpatient medical care. Since the program

being proposed is provided for an underserved, older adult, community population would make

this a great candidate for funding from this source. The focus of diseases and conditions in the

program is also supportive of this foundation’s aim to give to services promoting health of those

dwelling within the community.

Audit Trail

The above funding information was located through the Funding Opportunities website

within the Spencer S. Eccles Health Library, additional grants were located that could be used to

fund this program. Search terms that were used to narrow down the search criteria included:

healthcare, university of Utah, community, underserved, community development, human

resources, diseases and conditions, health, rehabilitation, senior services, mental health care,

outpatient medical care.

Expected Outcomes

The desired outcomes for this program will involve both participants and their caregivers.

the intended outcome for participants is to improve and/or enhance one’s occupational

performance. This outcome will be addressed through providing education and risk factors of

occupational decline through individual intervention planning. The comprehensive occupational

decline prevention program will address the client’s ability to prevent further decline in

performance through education or health promotion efforts. Desired outcomes involving the

clients and their caregivers, health and wellness will be addressed through addressing the state of

physical, mental, and social well-being within an individual. Also, by addressing one’s social

and personal resources can create a positive influence in the level of health and wellness. Lastly,
the outcome of participation and role competence through engagement in desired occupations in

ways that are satisfying and congruent with personal and cultural expectations.

Program Evaluation

The program will provide both qualitative and quantitative data in order to determine the

level of efficacy, participant success, participants feelings, and to provide outcome information

that could drive adjustments needed to be made within the program, beginning on a 12-week

basis. Qualitative and quantitative data will be collected from the COPM, (Appendix C) which is

being performed upon initial evaluation and prior to discharge of services. At the end of the

program, clients will be given a questionnaire to complete that gathers both qualitative and

quantitative data. The MOS described above will provide data of pre- and post- measurements,

indicating effectiveness of the occupation-based program. Clients will lastly be asked to perform

follow up surveys 3- and 6-months post participation in the program (Appendix F). The

qualitative questions will focus on self-perceived barriers and strengths, relationships and quality

of life in the presence of illness. Questions regarding the client’s occupations that they may or

may not have experienced improvement in, how they perceived those changes themselves, and if

the clients have any feedback for the program. Caregivers will also be provided with caregiver

quality of life questionnaires to monitor changes within the caregiver’s status, as well as the

ability to collaborate with clients in the answers on other surveys.

Qualitative data will be collected from the COPM conducted at the discharge of services,

utilizing the patient’s narrative by asking a series of questions regarding occupational

performance. Quantitative data will also be measured through the numerical scoring of the

COPM addressing a client’s performance of an occupation and satisfaction of that performance,

using a rating scale of 1-10. (1 = not able to perform, or 1 = not satisfied at all; 10 = can perform
independently, or 10 = extremely satisfied with performance). The client questionnaire being

sent 3- and 6-months post-program will ask clients to report answers by circling numbers on a

scale of 1-5 based on answers to several questions. Clients will also be asked to circle how many

intervention areas that they made changes in. Data will be collected through follow up phone

calls and/or email reminders.

Site Feedback
A meeting has been scheduled with the director of the clinic to introduce and explain the

occupational decline prevention program that has been designed for the Wellness Center. The

director will be given detailed information about the program and what it offers for the clients,

caregivers, and staff members in the clinic, as well as the benefits of implementing the program.

The director will be inquired to provide feedback and address any specific questions about the

outline, framework, or details provided about the program.

 References

About Us. (n.d.). Retrieved from https://healthcare.utah.edu/about/

American Occupational Therapy Association, (2015). The Role of occupational therapy in

chronic disease management. Retrieved from www.aota.org

Atkinson, M., Wishart, P., Wasil, B., & Robinson, J. (2004). The self-perception and

relationships tool (S-PRT): A novel approach to the measurement of subjective health-

related quality of life. Health and Quality of Life Outcomes, 2(36), doi:10.1186/1477-

7525-2-36

Balhara, Y. S., Mathur, S., Sharma, S., & Verma, R. (2012). A study of predictors of anxiety and

depression among stroke patient-caregivers. Journal of Mid-life Health,3(1), 31.

doi:10.4103/0976-7800.98815

Bienias, K., Ścibek, J., Cegielska, J., & Kochanowski, J. (2018). Evaluation of activities of daily

living in patients with slowly progressive neuromuscular diseases. Neurologia I

Neurochirurgia Polska,52(2), 222-227. doi:10.1016/j.pjnns.2017.10.007

Brittle, N., Brown, M., Mant, J., Mcmanus, R., Riddoch, J., & Sackley, C. (2008). Short-term

effects on mobility, activities of daily living and health-related quality of life of a

conductive education programme for adults with multiple sclerosis, parkinsons disease

and stroke. Clinical Rehabilitation,22(4), 329-337. doi:10.1177/0269215507082334

Canam, C., & Acorn, S. (1999). Quality of life for family caregivers of people with chronic

health problems. Rehabilitation Nursing,24(5), 192-200. doi:10.1002/j.2048-

7940.1999.tb02176.x
Cardol, M., Jong, B. A., Bos, G. A., Beelen, A., Groot, I. J., & Haan, R. J. (2002). Beyond

disability: Perceived participation in people with a chronic disabling condition. Clinical

Rehabilitation,16(1), 27-35. doi:10.1191/0269215502cr464oa

Kielhofner, G. (2009). Conceptual foundations of occupational therapy practice (4th Ed., pp.

147-174). Philadelphia: F. A. Davis Company.

L.S. Skaggs Patient Wellness Center. (2018). Retrieved from

https://healthcare.utah.edu/locations/skaggs/programs.php#supervised

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-

environment-occupation model: a transactive approach to occupational performance.

Canadian Journal of Occupational Therapy, 63, 9-23.

Lien, W., Guo, N., Chang, J., Lin, Y., & Kuan, T. (2014). Relationship of perceived

environmental barriers and disability in community-dwelling elderly in Taiwan – a

population-based study. BMC Geriatrics,14(1). doi:10.1186/1471-2318-14-59

Medical outcomes study (MOS) 36-item short form health survey. (2014). Encyclopedia of

Quality of Life and Well-Being Research,3972-3972. doi:10.1007/978-94-007-0753-

5_102466

Matuska, K. (2011). Validity evidence of a model and measure of life balance. OTJR:

Occupation, Participation and Health, 32, 229-237.

Rao, A. K. (2014). From the desk of the associate editor—Occupational therapy in chronic

progressive disorders; Enhancing function and modifying disease. American Journal of

Occupational Therapy, 68, 251-253. http://dx.doi.org/10.5014/ajoit.2014.012120

Rao, A. K. (2012). Occupational therapy in neurological disorders: Looking ahead to the

American occupational therapy association’s centennial vision. American Journal of

Occupational Therapy, 66, 119-130. doi:10.5014/ajot.2012.005280

Reuben, D. B., Frank, J. C., Hirsch, S. H., Mcguigan, K. A., & Maly, R. C. (1999). A

randomized clinical trial of outpatient comprehensive geriatric assessment coupled with

an intervention to increase adherence to recommendations. Journal of the American

Geriatrics Society,47(3), 269-276. doi:10.1111/j.1532-5415.1999.tb02988.x

Ward, K. T., & Reuben, D. B. (2018, September). Comprehensive geriatric assessment.

Retrieved from https://www.uptodate.com/contents/comprehensive-geriatric-assessment

Wynford-Thomas, R., & Robertson, N. P. (2017). The economic burden of chronic neurological

disease. Journal of Neurology,264(11), 2345-2347. doi:10.1007/s00415-017-8632-7

 Appendix A
Supervised Medical Exercise Gym
The Medically Supervised Exercise Gym is a supervised exercise program designed to promote a
physically active lifestyle in a supportive group atmosphere. Most participants will be referred by
their physicians.
Features of the Program
• Baseline exercise fitness test and functional mobility assessment by an exercise
specialist
• Supervised individual and group-based exercise program (aerobic, strength, yoga,
boxing...)
• Regular evaluation of exercise tolerance and progress
• Group educational classes on varying health topics- nutrition, stress management,
sleep hygiene
Eligible Participants: Check-In & Specific Days & Time
Check- Out? Info:
Multiple Sclerosis Yes M,W,F M,W,F M,W,F Maximum
Independent 7am-7pm Moderate 8am-4pm 10am-3pm
Parkinson's Disease Yes T, Th T, Th T, Th
Independent 7am-7pm Moderate 8am-4pm Maximum 10am-
Saturdays 8- 12pm 3pm
Balance/ Medical Yes T, Th T, Th T, Th
Gym Independent 7am-7pm Moderate 8am-4pm Maximum 10am-
Saturdays 8- 12pm 3pm
Stroke/CVA Yes M, W, F M,W,F Moderate M,W,F Maximum
Independent 7am-7pm 8am-4pm 10am-3pm
Bariatric Patients Yes M-F Saturdays 8-12pm
7-l0am or 4-7pm
Diabetic Patients Yes Tuesday and
Thursdays 7am-7pm
Intensive Lifestyle No M-F 7-l0am or 4-7pm
Program Participants
Build a Bone No 3x/week total M-F
Participants 7-l0am or 4-7pm
Ortho Yes Tuesdays and
Thursdays 12-3pm
Saturdays 8-12pm
Cost
• $65 a month (some individuals may have different pricing per scholarship)
• Parkinson's Group $35 (grant)
*Clinic hours: Monday-Thursday: 7am-7pm, Fridays: 7am-5pm, Saturdays: 8am-12pm
(Independent Exercisers Only)
Appendix B
Staff members including administrators, the director, and aides were interviewed with a semi-
structured interview with guidelines from the Canadian Occupational Performance Measure
(COPM), as well as general questions about the site and services.
-How long have you worked here?
-What is your role within the clinic?
-Are you familiar with occupational therapy profession and/or services that can be provided?
-What is your opinion of the current services provided? Do you notice any current gaps in needs
for services?
-Is there a common theme that patients may report having challenges with?
-What is the process for referral/review of eligibility within the clinic?
-If you could add any services to the clinic, what would they be?
-How is the clinic funded?
Appendix C
Patients and/or caregivers were interviewed using a semi-structured interview using the
Canadian Occupational Performance Measure (COPM) and other general questions to gather
data.
-Have you received OT services previously? If yes, what did they address? Were you satisfied
with the services you received?
-What is a typical day like for you? Are there any areas of your life involving your own self-care
or care of others that you are experiencing challenges or frustrations?
-In regards to the clinic, are there services you wish were provided here or any tasks you would
like to address during your time here?
-Do you feel you have the support and access to resources that you need?
COPM is pictured below
Appendix D
Source of Specific costs or sources of Cost
income
Start-up Costs
In kind Laptop to utilize electronic COPM, ($1000)
assessments, treatment plans, etc. (use
clinic computer)
COPM – initial fee and cost for 300 $34.61
electronic measures
In Kind Tables and chairs for intervention and ($2,000)
group/individual meetings
Total= $3034.61
Direct Costs
OTR Salary to consult and provide $28,800
evaluation services to cover 50-60
hours/month, $40 x 60 hrs/month x 12
months
Print budget for patient handout materials $100
Patient binders (to keep program and $200
patient information, notes, updated info) (1
binder/patient, ~150 patients binder @2.50
Total= $31,000
Indirect Costs
In Kind Charge for classroom, weekly group ($1,200)
meeting ($100/hr x 12 months)
In Kind Charge for small meeting rooms – ($4,800)
individual meetings ($100/hr x 4x/month x
12 months)
In Kind Utilities ($2,400)
In Kind Maintenance ($3,000)
Total = $11,400
Income In Kind total = $14,400.00
Self pay TBD
Grants TBD
Total= TBD
Budget Summary
Total costs $45,434.61

Total income or In-Kind; $14,400

in-kind
contributions
Net cost of $31,034.61 – to be covered by self-pay and
program grants
Appendix E – S-PRT Survey given Pre- and Post- program
Appendix F
Post Program Example Questionnare Items
Qualitative:
1. What occupations have you experienced improvement in?
2. How can you tell if you have/have not improved?
3. What topic was most helpful to you?
4. What advice or resource have you been given to facilitate participation?
5. How do you plan to utilize information given during OT sessions to improve
occupational performance and satisfaction of daily living?
6. What is a topic that you wished had been covered during intervention?
Quantitative
1. Please circle how many modifications/adaptations you made within your physical
environment:
a. (1) (2) (3) (4) (5 or more)
2. Please circle how many times you participated in a meaningful occupation that you had
not been able to participate in prior to receiving OT services:
a. (1) (2) (3) (4) (5 or more)
3. Please circle which categories from the program you have made changes to:
a. ADL
b. IADL
c. Social/leisure participation
d. Home environment modification
e. Community environment modification
f. Quality of life/Self-perception of ability
g. Fatigue management
h. Time management
i. Occupational balance

4. Consider the occupations identified by you and the OT in the Canadian Occupational
Performance Measure that you expressed decreased performance with. How many have
you been able to experience improvement with?
a. (1) (2) (3) (4) (5 or more)

5. Consider the occupations identified by you and the OT in the Canadian Occupational
Performance Measure that you expressed decreased satisfaction with. How many have
you been able to experience increased satisfaction with?
a. (1) (2) (3) (4) (5 or more)