Primary
Content
Occupation-based program development in primary health care
Melissa Howey, Tania Angelucci, Dawn Johnston and Elizabeth Townsend Inclusion of occupation-based programs in primary health care increases the availability of services that contribute to comprehensive, quality primary health care and to occupational community development (Lauckner, Pentland, & Patterson, 2008). In this article we illustrate how a theoretical understanding of occupation and enablement may be applied to develop primary health care occupational therapy. ronment with a focus on clientAbout the authors – centred occupations (Wittman & Melissa howey, MSc(OT), is an occupational theraVelde, 2001). pist at the Vancouver The difference between the General Hospital two approaches is the focus on Vancouver, British Codisability and illness prevention in lumbia. primary health care and the remeTania Angelucci, MSc(OT), diation or rehabilitation of existis an occupational ing disability or illness through therapist in the Living Sky community-based occupational School Division in North Battleford, Saskatchewan. therapy. In the past twenty years there has been a shift from institu- Dawn Johnston, MSc(OT), is an occupational theration-based, remedial occupational pist for Harbourstone therapy to community-based Enhanced Care Sydney in remedial occupational therapy. Cape Breton, Nova Scotia. Now the shift is extending Elizabeth Townsend, PhD., occupational therapy into primary OT (C), Reg. NS, is a Profeshealth care within the community, sor and the Director of redefining health as physical, the School of Occupationmental, and social well-being al Therapy at Dalhousie University in Halifax, Nova rather than simply the absence of Scotia. disease (Perrin & Wittman, 2001). Community-based occupational therapy aims to remediate the impact of everyday life changes in a client’s community, including changes within the multiple systems of clients: psychological, emotional, physical and social, by using occupations that clients define as meaningful (Ward et al., 2007). Primary health care occupational therapy aims to enable clients to live and interact within their community, preventing disability and illness (Ward et al., 2007). Primary health care’s focus on building healthy and supportive communities goes beyond individualized disability and illness prevention to improve the physical, social, and institutional environment (Baum, 1998). Improving the environment for occupational engagement assists in creating healthy surroundings that contribute to future health, well-being and justice (Townsend & Polatajko, 2007). The lack of a healthy environment has a negative impact on physical and mental health (Wilcock, 2005). With an increasing shift to primary health care and increasing attention on prevention and (inter)dependence, there is an increased need and opportunity for occupational therapy services to enrich the services available through primary health care (Baum, 1998).
read full colour version @ www.caot.ca 5
Occupation-based primary health care
Primary health care places attention on health promotion, disease prevention, and identifies needs to increase access to services for all individuals (Health Canada, 2006). The goal of primary heath care is to provide preventative services as opposed to reactive services that focus on the diagnosis and treatment of illness and injury. Primary health care encompasses services beyond traditional health care to include education, income, housing, and environment (Health Canada, 2006). Client-centred, occupation-based health care has been the implicit if not explicit theoretical foundation for remedial occupational therapy for many years (Townsend & Polatajko, 2007). Occupational therapists have a role in primary health care by focusing on the occupational needs of populations, and on enabling occupational performance and engagement as a means of preventing injury and promoting health (CAOT, 2003). This involves responding to the occupational needs of clients. Practitioners use a combination of enablement skills in adapting communities and programs, and advocating for health promotion programs that emphasize occupational engagement (Townsend & Polatajko, 2007). The aim is to provide more population health, illness prevention, chronic disease management, and health promotion by all professions (Heuchemer & Josephsson, 2006). It is within the primary health care context that occupational therapists have increasingly had the opportunity to develop and deliver community-based services at a primary level of care.
Community-based and primary health care occupational therapy
Both community-based and primary health care occupational therapists work with clients in their envi-
Occupation-based primary health care: An example
Situation #2
In collaboration with a community primary health care centre, occupational therapy students generated a business proposal aimed at enhancing primary health care services for community members. The program goal was to enable target populations within the community to increase their occupational engagement and community participation in the areas of: • Safety and independence • Re-engagement into the community and daily occupations • Capturing their potential • Social inclusion Based on a community needs assessment conducted by talking with the staff of the community health centre and members of target populations, options for specific occupation-based programs were discussed. Two client situations are presented in which the primary health care needs were for transportation, communication, community support and safety. These examples of occupationbased primary health care implemented by one of the authors are presented here; the aim in both situations was to increase participation through facilitating occupational re-engagement.
Linda- worked with the occupational therapy student on enhancing Linda’s exercise routine and setting daily goals. Linda was provided with routine planning agenda sheets to write down daily goals the night before; when waking up in the morning there was a concrete list of things to accomplish. The occupational therapy student accompanied Linda to YMCA on a day pass to try exercise equipment and see what Linda could do; Linda enjoyed the gym and is now thinking about joining a community network that offers a YMCA membership for individuals living in the community with mental stresses. Situation #2 is a second example of an occupationbased program implemented to assist in Linda’s sense of accomplishment and to facilitate change for the future. The approach began by capitalizing on Linda’s strengths to ensure successful completion of goals (Schultz-Krohn, Drnek, & Powell, 2006). Linda seemed to accomplish her objectives by setting goals that were important to her. The sense of accomplishment was taken forward to facilitate community engagement both within the mental health community and the community at large. By collaborating with Linda, coaching her to achieve her goals, working to coordinate services between the health care centre, mental health community resources and local community services, Linda and others in the population living with a chronic mental health disorder would more likely experience “effective enablement” (Townsend& Polatajko, 2007).
Situation #1
Joe- worked with the occupational therapy student who was initially asked to see what could be done to enhance his writing skills. Additionally Joe expressed concern about going out in the community with his wheelchair because he was concerned about going over curbs and downhill; he would go outside more often if he had greater confidence in his abilities. A referral was sent to the local Wheelchair Skills Training Program, two dates for Joe to participate were received. Due to inaccessible and unreliable transportation Joe cancelled his appointment. In Situation #1, the aim was to facilitate Joe’s occupational engagement within his environment. Due to gaps in existing services regarding transportation, enablement to acquire wheelchair skills was hindered. Joe, according to the Canadian Model of Client-Centered Enablement (CMCE), experienced what has been called “missed enablement” (Townsend & Polatajko, 2007). Joe was unable to engage in education in terms of wheelchair safety due to a lack of coordination of services that hindered his overall engagement (Townsend & Poatajko, 2007).
Reflections
These two situations highlight the opportunities for occupation-based program development in primary health care. In Joe’s situation there is a continued need to promote primary health care and a coordination of services. Although services began with community-
6
occupational therapy now volume 11.3
based rehabilitation, a primary health care approach evolved by gathering resource information and advocating with members of the community to improve accessible transportation. The primary health care aspect “Occupational therapists have a role in primary health care by focusing on the occupational needs of populations, and on enabling occupational performance and engagement as a means of preventing injury and promoting health (CAOT, 2006). “ was the shift to a population approach with a focus on prevention of community dis-engagement by those using mobility devices that are not easily transported in regular buses or taxis, particularly for those on low incomes. In Linda’s situation, a psychosocial rehabilitation occupational therapy approach was extended into primary health care occupational therapy. Occupational therapy took a population perspective on access to community resources, and began to improve service access for prevention and community development. The project took the initiatives on primary health care from both the CAOT and Health Canada from theory to practice. Occupational therapy in primary health care can facilitate occupational engagement through the use of occupation-based programs. By using the enablement skills of an occupational therapist, focusing on the strengths of clients and the communities in which they live, and taking a population and prevention approach, occupational therapists are poised to advance health, well being and justice through occupation. The marginalization of communities affects the health of community members and the availability of services. The impact of this project has been the successful development of a collaborative relationship between the community health centre and an occupational therapy education program at Dalhousie University in Halifax, Nova Scotia. The collaboration has continued and a budget request for full time primary health care occupational therapy services is pending. The application of theory to practice, as seen in Joe and Linda’s situations, helped to build the business pro-
posal by highlighting the need for a preventive, population-based approach for underserviced clients. In the next phase of program development, stakeholders will be interviewed to further understand their occupational needs and the potential for occupationbased programming to enrich an existing primary health care service.
References:
Baum, C. (1998). Client-centred practice in a changing health care system. In M. Law (Ed.), Client-centered occupational therapy (pp. 29- 45). Thorofare, NJ: SLACK Inc. Canadian Association of Occupational Therapists (2003). Position statement on primary health care. Retrieved October 10, 2007, from http://www.caot.ca/index. cfm?ChangeID=2&pageID=188 Health Canada (2006). About primary health care. Retrieved June17, 2008 from http://www.hc-sc.gc.ca/hcs-sss/prim/ about-apropos-eng.php Heuchemer, B., & Josephsson, S. (2006). Leaving homelessness and addiction: Narratives of an occupational transition. Scandinavian Journal of Occupational Therapy, 13(3), 160-169. Lauckner, H., Pentland, W., & Patterson, M. (2008). Exploring Canadian occupational therapists’ understanding of and experiences in community development. Canadian Journal of Occupational Therapy, 74(4), 314-325. Perrin, K. & Wittman, P. P. (2001). Educating for community-based occupational therapy practice: a demonstration project. Occupational Therapy in Health Care, 13, 11-21. Schultz-Krohn, W., Drnek, S., Powell, K. (2006). Occupational therapy intervention to foster goal setting skills for homeless mothers. Occupational Therapy in Health Care, 20(3-4), 149-166. Townsend, E. A. & Polatajko H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa, ON: CAOT Publications ACE. Ward, K., Mitchell, J., & Price, P. (2007). Occupation-based practice and its relationship to social and occupational participation in adults with spinal cord injury. OTJR; Occupation, Participation & Health, 27(4), 149-156. Wilcock, A. A. (2005). Occupational science: Bridging occupation and health. Canadian Journal of Occupational Therapy, 72(1), 5-12. Wittman, P. P., & Velde, B. P. (2001). Occupational therapy in the community: What, why and how. Occupational Therapy in Health care, 13(3/4), 1-5.
read full colour version @ www.caot.ca
7
Melissa Howey, Tania Angelucci, Dawn Johnston and Elizabeth Townsend Inclusion of occupation-based programs in primary health care increases the availability of services that contribute to comprehensive, quality primary health care and to occupational community development (Lauckner, Pentland, & Patterson, 2008). In this article we illustrate how a theoretical understanding of occupation and enablement may be applied to develop primary health care occupational therapy. ronment with a focus on clientAbout the authors – centred occupations (Wittman & Melissa howey, MSc(OT), is an occupational theraVelde, 2001). pist at the Vancouver The difference between the General Hospital two approaches is the focus on Vancouver, British Codisability and illness prevention in lumbia. primary health care and the remeTania Angelucci, MSc(OT), diation or rehabilitation of existis an occupational ing disability or illness through therapist in the Living Sky community-based occupational School Division in North Battleford, Saskatchewan. therapy. In the past twenty years there has been a shift from institu- Dawn Johnston, MSc(OT), is an occupational theration-based, remedial occupational pist for Harbourstone therapy to community-based Enhanced Care Sydney in remedial occupational therapy. Cape Breton, Nova Scotia. Now the shift is extending Elizabeth Townsend, PhD., occupational therapy into primary OT (C), Reg. NS, is a Profeshealth care within the community, sor and the Director of redefining health as physical, the School of Occupationmental, and social well-being al Therapy at Dalhousie University in Halifax, Nova rather than simply the absence of Scotia. disease (Perrin & Wittman, 2001). Community-based occupational therapy aims to remediate the impact of everyday life changes in a client’s community, including changes within the multiple systems of clients: psychological, emotional, physical and social, by using occupations that clients define as meaningful (Ward et al., 2007). Primary health care occupational therapy aims to enable clients to live and interact within their community, preventing disability and illness (Ward et al., 2007). Primary health care’s focus on building healthy and supportive communities goes beyond individualized disability and illness prevention to improve the physical, social, and institutional environment (Baum, 1998). Improving the environment for occupational engagement assists in creating healthy surroundings that contribute to future health, well-being and justice (Townsend & Polatajko, 2007). The lack of a healthy environment has a negative impact on physical and mental health (Wilcock, 2005). With an increasing shift to primary health care and increasing attention on prevention and (inter)dependence, there is an increased need and opportunity for occupational therapy services to enrich the services available through primary health care (Baum, 1998).
read full colour version @ www.caot.ca 5
Occupation-based primary health care
Primary health care places attention on health promotion, disease prevention, and identifies needs to increase access to services for all individuals (Health Canada, 2006). The goal of primary heath care is to provide preventative services as opposed to reactive services that focus on the diagnosis and treatment of illness and injury. Primary health care encompasses services beyond traditional health care to include education, income, housing, and environment (Health Canada, 2006). Client-centred, occupation-based health care has been the implicit if not explicit theoretical foundation for remedial occupational therapy for many years (Townsend & Polatajko, 2007). Occupational therapists have a role in primary health care by focusing on the occupational needs of populations, and on enabling occupational performance and engagement as a means of preventing injury and promoting health (CAOT, 2003). This involves responding to the occupational needs of clients. Practitioners use a combination of enablement skills in adapting communities and programs, and advocating for health promotion programs that emphasize occupational engagement (Townsend & Polatajko, 2007). The aim is to provide more population health, illness prevention, chronic disease management, and health promotion by all professions (Heuchemer & Josephsson, 2006). It is within the primary health care context that occupational therapists have increasingly had the opportunity to develop and deliver community-based services at a primary level of care.
Community-based and primary health care occupational therapy
Both community-based and primary health care occupational therapists work with clients in their envi-
Occupation-based primary health care: An example
Situation #2
In collaboration with a community primary health care centre, occupational therapy students generated a business proposal aimed at enhancing primary health care services for community members. The program goal was to enable target populations within the community to increase their occupational engagement and community participation in the areas of: • Safety and independence • Re-engagement into the community and daily occupations • Capturing their potential • Social inclusion Based on a community needs assessment conducted by talking with the staff of the community health centre and members of target populations, options for specific occupation-based programs were discussed. Two client situations are presented in which the primary health care needs were for transportation, communication, community support and safety. These examples of occupationbased primary health care implemented by one of the authors are presented here; the aim in both situations was to increase participation through facilitating occupational re-engagement.
Linda- worked with the occupational therapy student on enhancing Linda’s exercise routine and setting daily goals. Linda was provided with routine planning agenda sheets to write down daily goals the night before; when waking up in the morning there was a concrete list of things to accomplish. The occupational therapy student accompanied Linda to YMCA on a day pass to try exercise equipment and see what Linda could do; Linda enjoyed the gym and is now thinking about joining a community network that offers a YMCA membership for individuals living in the community with mental stresses. Situation #2 is a second example of an occupationbased program implemented to assist in Linda’s sense of accomplishment and to facilitate change for the future. The approach began by capitalizing on Linda’s strengths to ensure successful completion of goals (Schultz-Krohn, Drnek, & Powell, 2006). Linda seemed to accomplish her objectives by setting goals that were important to her. The sense of accomplishment was taken forward to facilitate community engagement both within the mental health community and the community at large. By collaborating with Linda, coaching her to achieve her goals, working to coordinate services between the health care centre, mental health community resources and local community services, Linda and others in the population living with a chronic mental health disorder would more likely experience “effective enablement” (Townsend& Polatajko, 2007).
Situation #1
Joe- worked with the occupational therapy student who was initially asked to see what could be done to enhance his writing skills. Additionally Joe expressed concern about going out in the community with his wheelchair because he was concerned about going over curbs and downhill; he would go outside more often if he had greater confidence in his abilities. A referral was sent to the local Wheelchair Skills Training Program, two dates for Joe to participate were received. Due to inaccessible and unreliable transportation Joe cancelled his appointment. In Situation #1, the aim was to facilitate Joe’s occupational engagement within his environment. Due to gaps in existing services regarding transportation, enablement to acquire wheelchair skills was hindered. Joe, according to the Canadian Model of Client-Centered Enablement (CMCE), experienced what has been called “missed enablement” (Townsend & Polatajko, 2007). Joe was unable to engage in education in terms of wheelchair safety due to a lack of coordination of services that hindered his overall engagement (Townsend & Poatajko, 2007).
Reflections
These two situations highlight the opportunities for occupation-based program development in primary health care. In Joe’s situation there is a continued need to promote primary health care and a coordination of services. Although services began with community-
6
occupational therapy now volume 11.3
based rehabilitation, a primary health care approach evolved by gathering resource information and advocating with members of the community to improve accessible transportation. The primary health care aspect “Occupational therapists have a role in primary health care by focusing on the occupational needs of populations, and on enabling occupational performance and engagement as a means of preventing injury and promoting health (CAOT, 2006). “ was the shift to a population approach with a focus on prevention of community dis-engagement by those using mobility devices that are not easily transported in regular buses or taxis, particularly for those on low incomes. In Linda’s situation, a psychosocial rehabilitation occupational therapy approach was extended into primary health care occupational therapy. Occupational therapy took a population perspective on access to community resources, and began to improve service access for prevention and community development. The project took the initiatives on primary health care from both the CAOT and Health Canada from theory to practice. Occupational therapy in primary health care can facilitate occupational engagement through the use of occupation-based programs. By using the enablement skills of an occupational therapist, focusing on the strengths of clients and the communities in which they live, and taking a population and prevention approach, occupational therapists are poised to advance health, well being and justice through occupation. The marginalization of communities affects the health of community members and the availability of services. The impact of this project has been the successful development of a collaborative relationship between the community health centre and an occupational therapy education program at Dalhousie University in Halifax, Nova Scotia. The collaboration has continued and a budget request for full time primary health care occupational therapy services is pending. The application of theory to practice, as seen in Joe and Linda’s situations, helped to build the business pro-
posal by highlighting the need for a preventive, population-based approach for underserviced clients. In the next phase of program development, stakeholders will be interviewed to further understand their occupational needs and the potential for occupationbased programming to enrich an existing primary health care service.
References:
Baum, C. (1998). Client-centred practice in a changing health care system. In M. Law (Ed.), Client-centered occupational therapy (pp. 29- 45). Thorofare, NJ: SLACK Inc. Canadian Association of Occupational Therapists (2003). Position statement on primary health care. Retrieved October 10, 2007, from http://www.caot.ca/index. cfm?ChangeID=2&pageID=188 Health Canada (2006). About primary health care. Retrieved June17, 2008 from http://www.hc-sc.gc.ca/hcs-sss/prim/ about-apropos-eng.php Heuchemer, B., & Josephsson, S. (2006). Leaving homelessness and addiction: Narratives of an occupational transition. Scandinavian Journal of Occupational Therapy, 13(3), 160-169. Lauckner, H., Pentland, W., & Patterson, M. (2008). Exploring Canadian occupational therapists’ understanding of and experiences in community development. Canadian Journal of Occupational Therapy, 74(4), 314-325. Perrin, K. & Wittman, P. P. (2001). Educating for community-based occupational therapy practice: a demonstration project. Occupational Therapy in Health Care, 13, 11-21. Schultz-Krohn, W., Drnek, S., Powell, K. (2006). Occupational therapy intervention to foster goal setting skills for homeless mothers. Occupational Therapy in Health Care, 20(3-4), 149-166. Townsend, E. A. & Polatajko H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa, ON: CAOT Publications ACE. Ward, K., Mitchell, J., & Price, P. (2007). Occupation-based practice and its relationship to social and occupational participation in adults with spinal cord injury. OTJR; Occupation, Participation & Health, 27(4), 149-156. Wilcock, A. A. (2005). Occupational science: Bridging occupation and health. Canadian Journal of Occupational Therapy, 72(1), 5-12. Wittman, P. P., & Velde, B. P. (2001). Occupational therapy in the community: What, why and how. Occupational Therapy in Health care, 13(3/4), 1-5.
read full colour version @ www.caot.ca
7
