4/20/18

OCCUPATIONAL THERAPY
IN A PEDIATRIC
PRIMARY CARE SETTING
Jami Flick, MS, OTR/L & Anne H. Zachry, Ph.D., OTR/L

The session will describe a program where licensed

occupational therapists and master's level occupational
therapy students provide free developmental
screenings to infants and young children in local
pediatric medical practice.

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LEARNING OBJECTIVES

Learning Objective 1: Describe how developmental screenings can be

conducted by occupational therapists through a partnership with a primary care
pediatric practice.

Learning Objective 2: Discuss strategies for developing relationships and

bridging communication between occupational therapists, primary practice
physicians, and families.

GOALS OF THE PROGRAM

• Identify young children with possible developmental delays using the ASQ-3

• Support parents with obtaining early intervention (EI) services for those children
identified as “at risk” or “delayed”

• Improve parenting competence levels after educational/support sessions with the OT

faculty member and students.

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LITERATURE REVIEW

• The American Academy of Pediatrics (AAP) advocates identifying

delays before children reach 2 years (Council on Children With Disabilities et al., 2006).

• Primary care providers tend to under-detect developmental delays in

infants and young children (Radecki, Sand-Loud, O’Connor, Sharp & Olson, 2011).

• One study revealed that 71% of pediatricians do not use standardized

screening tools during well child visits (Sand, Silverstein, Glascoe, Gupta, Tonniges, & O'Connor, 2005).

LITERATURE REVIEW

• Pediatricians report that poor reimbursement, time limitations, and

limited staff are all barriers to using standardized screening tools (Council
on Children With Disabilities et al., 2006).

• In high poverty areas, transportation and finances prevent regular

pediatrician visits (Clifford, Squires, Yockelson, Twombly E, & Bricker, 2012)

Free digital photos.net_hin255

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LITERATURE REVIEW

• Nationally, 16-18% of children have disabilities (King, 2010).

• Less than 1/3 of cases are referred for intervention before

kindergarten age (King, 2010).

• Many children who are referred for Early Intervention services do not
end up receiving therapy due to poor follow-through by caregivers (Council
on Children With Disabilities et al., 2006).

LITERATURE REVIEW

• Intervention programs are more effective when initiated at a young age

(Adams &Tapia, 2013).

• Providing timely early intervention (EI) services for young children

identified as developmentally delayed improves both short-term and
long-term outcomes (Halfon, Inkelas, Abrams, & Stevens, 2005).

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LITERATURE REVIEW

• Families need guidance regarding the importance of early

intervention services.

• Due to barriers preventing pediatricians from conducting screenings,

we proposed the use of OT practitioners and students as a feasible
option for carrying out screenings in a primary care setting.

Photo Credit: istockphotos.com

GUIDING PRINCIPLES

• AOTA Centennial Vision

• Healthy People 2020
• Institute for Healthcare Improvement (IHI) Triple AIM
• Levels of Prevention
• Primary Care

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AOTA VISION 2025

Occupational therapy maximizes health, well-being

and quality of life for all people, populations and
communities through effective solutions that
facilitate participation in everyday living (AOTA, 2016).

HEALTHY PEOPLE 2020

Vision: A society in which all people live long, healthy lives.

Mission:
• Identify health improvement priorities
• Increase public awareness and understanding of the determinants of health,
disease, and disability and the opportunities for progress
• Provide measurable objectives and goals
• Engage multiple sectors to take actions to strengthen policies and improve
practices that are driven by the best available evidence and knowledge
• Identify critical research, evaluation, and data collection needs
(U.S. Department of Health and Human Services, 2017)

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SPECIFIC HP 2020 OBJECTIVES

• DH-20: Increase the proportion of children with disabilities, birth through age 2 years,
who receive early intervention services in home or community-based settings
• Baseline: 91.0 percent of children with disabilities, birth through age 2 years, received
early intervention services in home or community-based settings in 2007
• Target: 95.0 percent
• EMC-1(Developmental) Increase the proportion of children who are ready for school in
all five domains of healthy development: physical development, social-emotional
development, approaches to learning, language, and cognitive development
• EMC-2Increase the proportion of parents who use positive parenting and communicate
with their doctors or other health care professionals about positive parenting

SPECIFIC HP 2020 OBJECTIVES

• EMC-5(Developmental) Increase the proportion of children with ADHD who

receive recommended treatment

• MICH-29: Increase the proportion of young children with autism spectrum

disorder (ASD) and other developmental delays who are screened, evaluated, and
enrolled in special services in a timely manner

• MICH-31: Increase the proportion of children aged 0 to 11 years with special

health care needs who receive their care in family-centered, comprehensive, and
coordinated systems

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INSTITUTE FOR HEALTHCARE

IMPROVEMENT: TRIPLE AIM

IHI Triple AIM:

• Improving the patient experience of care
(including quality and satisfaction);
• Improving the health of populations; and
• Reducing the per capita cost of health care.
(Berwick, Nolan, & Whittington, 2008)

IHI TRIPLE AIM

• Address a range of community determinants of health

• Empower individuals and families
• Broaden the role and impact of primary care and other community
based services
• Assure a seamless journey through the whole system of care
throughout a person’s life
• IHI Triple AIM video

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INFLUENCE OF IHI TRIPLE AIM ON

OCCUPATIONAL THERAPY

• Push for occupational therapists to be more involved in community-

based practice, primary care, and population health
• Increased education and training in health promotion, prevention,
and health literacy in all health care programs
• Emphasis on interprofessional education
• Changed the reimbursement system from ”fee for service” to “fee
for value”
• More research on health outcomes and cost effectiveness in OT

LEVELS OF PREVENTION

Interventions that aim to reduce risks or threats to health.

• Primary - prevent condition, disease, or injury before it
ever occurs
• Secondary - reduce the impact of a condition, disease or
injury that has already occurred
• Tertiary – limit impact of an ongoing illness or injury that
has lasting effects
(Institute for Work & Health, n.d.)

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WHY OT?

“Occupational therapists and occupational therapy assistants

support and promote the development and engagement of
infants, toddlers, and preschoolers, and their families or other
caregivers, in everyday routines.”
(AOTA, 2014)

OT IN PRIMARY CARE
OTs unique contribution to primary care is our knowledge of how habits
and routines cam impact health and wellness.

Barriers to occupational participation:

-Behavior
-Development
-Cognition
-Physical, Emotional, Social, & Psychological

OT can provide interventions to address those issues and foster

occupational participation. (AOTA, 2014)

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EARLY STEPS PROJECT

• OT faculty and OT students (supervised) provided free developmental

screenings to underserved infants and children to identify early
developmental delays and provide referrals for therapy services.

• Parents of the children who scored at-risk or below age expectation were
provided with a handout of strategies and a list of free support services to
promote the development of speech/language, motor, and social skills .

DETAILS

• Grant- ASQ-3 & work-study students

• Connection with a pediatrician
• Introduction to business manager of clinic
• Space – pediatrician’s office, hallway, kits, files (Adjust days to when space is available)
• Office manager- scheduling
• Carry out screenings – students score
• Modified Checklist of Autism in Toddlers- Revised (MCHAT)- 16 to 30 months
• PSOC (Parenting Sense of Competence Scale)
• Review the results with parent(s)
• Summary of results to pediatrician
• Referral(s)
• Follow-up

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PSOC

• Parenting Sense of Competence Scale- Efficacy Subscale

• Parenting Efficacy- The degree to which a parent feels confident and
effective in handling parenting challenges (Johnston & Marsh, 1989).

• Scores range from 9 to 54. The higher the score, the greater the
competence/efficacy.
• Sufficient internal consistency reliability, Cronbach’s alpha .76 (Johnston &
Marsh, 1989).

PSOC

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ASQ-3
• Age Range- 1–66 months
• 21 questionnaires screen children from 1 month to 66 months
• High reliability & validity
• 5 skill areas addressed:
Communication
Gross motor
Fine motor
Problem Solving
Personal-social
(Squires, Bricker, & Potter, 2009)

LET’S PRACTICE!

(Squires, Bricker, & Potter, 2009)

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RESULTS

(Squires, Bricker, & Potter, 2009)

REFERRAL(S)

(Squires, Bricker, & Potter, 2009)

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EARLY STEPS
PRELIMINARY INFORMATION

The Memphis Children’s Clinic averages 12 referrals to EI services annually.

The clinic does not follow up on EI referrals to see if parents have initiated
services.

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EARLY STEPS DATA

• 55 caregivers (60 children)

• PSOC baseline data for all 55 caregivers
• Complete data for 30 caregivers at 6-months follow-up.

EARLY STEPS DATA

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EARLY STEPS DATA

• Shapiro-Wilk was used to assess normality (p=0.0118). Normality was rejected and the Sign test was performed to examine
paired differences in PSOC scores from baseline to 6 months.
• The paired difference between PSOC at baseline and 6 months is statistically significant (p=0.0005) with a median
(interquartile range) of 2.5 (0, 4) indicating that on average scores increase over time from baseline to 6 months.

ACKNOWLEDGEMENTS

• Thanks to Dr. Tamekia Jones for support with the statistical analysis.
• Thanks to Dr. Phyllis Richey for the research design recommendations.

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QUESTIONS?

REFERENCES
AVAILABLE AT: HTTP://BIT.LY/2HKT7DK

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