The effectiveness of occupational therapy local authority social services interventions for older people in Great Britain: A critical literature reviewFunding: UKOTRFFunding: UKOTRF

Rationale for the review Rationale for the review A rapid growth in numbers of older people at

a time of scarce resourcesGovernment policy emphasis on maintaining

older people in the communityOccupational 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: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: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: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critically appraise and synthesising the qualitative and quantitative, published and unpublished available evidence from January 2000 to February 2012.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 flexibleLiterature 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 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:Stages in the process:Literature search and retrieval: Electronic

databases, library holdings, websites, local social services' occupational therapy networks

Piloting and refining and appraisal templatesData evaluation : Screening and assessing for

relevance , data managementCritical appraisal : using a customised template

Data extraction: findings were identified

independently by two reviewers and a consensus reached

Overview of appraised literature

Data synthesis Data synthesis

Thematic synthesis: Findings from included studies were entered

into an overview documentIndependently coded by two reviewers for

meaning and content.Codes from each study were added to a

coding frameworkThemes generated and refined

Quality summary: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.

Main weaknesses: Main weaknesses: Impacting on the review:

A lack of detail on the context or study locationLimited description of participants or explanation

of the service, team or interventionA medical rather than social model perspectiveA lack of reflexivity where the researcher

appeared to be part of the setting being researched.

Review findingsReview 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 issuesAccess to services Occupational therapy interventionEffectivenessService user issues Issues for carersReshaping occupational therapy servicesCollaboration/relationshipsTime related to OT service provisionCommunication issues

The nature of OT social care service The nature of OT social care service provision 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 issuesProfessional 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 Access to OT services for older people: 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 interventionOccupational 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 Effectiveness of OT services for older people & carersolder people & carersSummary 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.  

Service user issuesService user issuesSummary 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 carersIssues 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 Reshaping occupational therapy servicesservicesSummary 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: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: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:Executive Summary is available from:

College of Occupational Therapists:College of Occupational Therapists:www.cot.co.uk

UKOTRF – funded project outputsUKOTRF – funded project outputs