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... Cancer Support Community Program Development: Health Promotion and Wellness Education Sharaya Sommers May 5, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR, CLT-LANA Running head: CANCER SUPPORT COMMUNITY 2 A Capstone Project Entitled Cancer Support Community Program Development: Health Promotion and Wellness Education Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Sharaya Sommers Doctorate of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date CANCER SUPPORT COMMUNITY 3 Abstract Literature findings showed that there was a need for occupational therapy with cancer survivors due to chronic symptoms from cancer treatment. The purpose of the Doctoral Capstone Project at Cancer Support Community was to increase awareness of occupational therapy, provide health promotion and wellness education to cancer survivors, and obtain grant funding for an occupational therapy program at Cancer Support Community. A needs assessment was filled out by thirteen cancer survivors. Advertisements were distributed to obtain a caseload for individual and group sessions. An occupational profile and the Canadian Occupational Performance Measure were used for evaluation in individual sessions. Most goals were met in individual sessions showing increased occupational performance and satisfaction with performance as a result of health promotion and wellness education. Formative and summative evaluations were used for group sessions to measure increased knowledge and workshop quality. The Goal Attainment Scale measured outcomes for the Health Promotion and Wellness Education Program and showed that individuals could benefit from services with a part-time caseload. Increased knowledge was a result of the educational workshops. A grant application was submitted to a grant to sustain an occupational therapy program for these cancer survivors. Occupational therapists must continue to meet the needs of underserved populations like the cancer survivorship population. CANCER SUPPORT COMMUNITY 4 Literature Review Those who have had cancer treatment are living longer, which is increasing the need for occupational therapy services due to lasting effects from treatment as well as physical impairments from cancer and comorbidities (Hunter, Gibson, Arbesman, & DAmico, 2017). The U.S. had approximately 14.5 million survivors of cancer in 2014, and that number is expected to increase to 18 million by the year 2022 (Hunter et al., 2017). Cancer can interrupt daily routines, work, leisure, social activities, and self-care (Hunter et al., 2017). Evidence shows that therapy services can benefit individuals before as well as after treatment while suggesting a multidisciplinary approach (Hunter et al., 2017). A multidisciplinary approach should include occupational therapy in important decisions in respect to population care for the betterment of this underserved population (Polo & Smith, 2017). There is a major lack of referrals for rehabilitation with the cancer population as well as obtaining the appropriate services needed for their condition (Hunter, Gibson, Arbesman, & DAmico, 2017). The young adult cancer population report a lack of services in the areas of emotional functioning, quality of life (QOL), work, and school (Sleight & Duker, 2016). The young adults expressed unmet needs within the areas of occupational therapy (OT), social support, physical therapy, and mental health (Sleight & Duker, 2016). Unmet needs for older adults include psychological distress and QOL (Sleight & Duker, 2016), which are areas where occupational therapists can help through meaningful occupational engagement. Cancer can also cause decreased activity participation and limitations within activity performance, in which occupational therapists can be of service (Hunter et al., 2017). Cancer survivorship is considered the time of diagnosis until the person is no longer living (Baxter, Newman, Longpre, & Polo, 2017). There is not only a lack of rehabilitation for CANCER SUPPORT COMMUNITY 5 survivors in treatment but also those in remission, which can exacerbate physical, emotional, and cognitive symptoms while limiting participation in meaningful activities (Baxter et al., 2017). Survivors, in turn, lose independence and self-efficacy (Baxter et al., 2017). Occupational therapy practitioners can incorporate physical activity into daily routines to increase wellness, QOL, and overall health (Hunter et al., 2017). Physical exercise can also decrease fatigue, increase functional performance, and improve sleep (Hunter et al., 2017). Occupational therapists should include symptom management strategies through occupation-based interventions including education, energy conservation, and problem solving (Hunter et al., 2017). More research is needed that goes beyond exercising and physical functioning to include occupational participation and meaningful activities (Hunter et al., 2017). OTs main role within the cancer population is ultimately increasing QOL through occupational engagement (Hunter et al., 2017). Cancer treatment targets the cancer tissue; however, the surrounding arteries, muscles, and nerves end up being collateral damage (Baxter et al., 2017). Given that individuals often have chronic symptoms and disabilities from cancer and cancer treatment, returning to ones previous vocation can also be difficult, and caregiver burden occurs if return to work is not an option due to chronic disabilities being a barrier (Baxter et al., 2017). Returning to work can be beneficial with recovery while having a sense of identity/purpose (Baxter et al., 2017). Cancer survivors, whether in treatment or in remission, are more likely to need assistance with Instrumental Activities of Daily Living (IADLs) and Basic Activities of Daily Living (BADLs) due to the symptoms they experience (Polo & Smith, 2017). Practitioners are responsible for providing health promotion and wellness services within cancer survivorship community settings to increase social participation, activity engagement, role productivity, and QOL (Polo & Smith, 2017). The action plan for occupational therapists CANCER SUPPORT COMMUNITY 6 includes bringing awareness to the survivorship population and the population need, using supportive documentation for OTs unique role in this survivorship setting, advocating for a larger OT role within this setting, and providing supportive documentation of intervention efficacy within health promotion and wellness programs (Polo & Smith, 2017). Occupational therapists are certified to provide valuable services to the cancer survivor population; however, occupational therapy is not seen in this community setting (Polo & Smith, 2017). A major reason why occupational therapy goes unrecognized is due to the majority of individuals who do not have a clear understanding of OTs role and the professions valuable services (Polo & Smith, 2017). Many services that are related to health promotion and wellness at Cancer Support Community (CSC) are already in place, which makes the value of occupational therapy decrease (Polo & Smith, 2017). Occupational therapists can do a broad range of interventions with individuals; this causes confusion of what OTs distinct role is (Polo & Smith, 2017). For example, CSC has a program involving a 12 week Moving Beyond survivorship program dedicated to helping individuals with managing symptoms, so they can achieve IADL completion. Occupational therapists did not create this program, nor are they a part of the team for this program; however, they are qualified for this specific type of program and would bring value to the team. A need exists for increased awareness for OT services and service reimbursement for survivors of cancer to increase occupational performance and QOL (Baxter et al., 2017). Occupational therapists must advocate for interventions related to self-management for acute and chronic conditions secondary to cancer and cancer treatment (Baxter et al., 2017). There are currently no OT services at CSC. Thus, the purpose of my Doctoral Capstone Project is to increase awareness of occupational therapy, provide health promotion and wellness education to CANCER SUPPORT COMMUNITY 7 the members of CSC, and obtain grant funding for an OT program to provide program sustainability. Specific Interventions Effective OT interventions specific to the cancer population include energy conservation, problem solving, monitoring lymphedema, pain management, sleep hygiene, yoga, expressive writing, mindfulness techniques, increasing range of motion and strength, work simplification, sex, and body image (Braveman, Hunter, Nicholson, Arbesman, & Lieberman 2017). Greater than 30% of individuals with a new cancer diagnosis experience cancer-related fatigue within the first 12 months, 75% experience cognitive deficits while receiving treatment, 38% experience peripheral neuropathy from multiple treatment agents, 33-50% experience pain, 80% develop lymphedema post-surgery in 3 years or less, and 60% experience psychological issues (i.e. distress and stress) (Baxter et al., 2017). Currently, OT is an emerging practice area in cancer survivorship; however, OT has been shown to be effective in this practice area through applying adaptation, remediation, restoration, and compensatory approaches within interventions (Sleight & Duker, 2016). The implication for occupational therapists at a community site should include a health promotion and wellness approach to promote meaningful exercise and activity so that chronic symptoms are managed and prevented (Hunter et al., 2017). Occupational therapists need to make sure they are also addressing mental health, occupational participation, social engagement, QOL, and symptom management so that all aspects of individuals are being met (Hunter et al., 2017). Hunter et al. (2017) looked at more specific interventions within this practice area. One finding was related to the cognitive rehabilitation approach which proved to increase overall attention and QOL (2017). There was also strong evidence supporting psychosocial interventions CANCER SUPPORT COMMUNITY 8 including stress management, expressive groups, life review, cognitive-behavioral interventions, mindfulness techniques, problem-solving, and education to decrease depression and anxiety (2017). Moderate evidence supports life reviews, expressive writing, self-management training, and stress management as interventions to increase QOL and provide psychosocial adjustments (2017). Moderate evidence found that sex was the preferred form of exercise; however, highintensity exercise is also supported- such as interval, home-based, and resistance exercises- for increasing functional performance in preparation of completing any activity that individuals need or want to do (Hunter et al., 2017). Theory The Model of Human Occupation (MOHO) uses a holistic approach to the OT process looking at the body and mind connection in relation to motivation through meaningful occupations (Cole & Tufano, 2008). This model encompasses a wide variety of illnesses and considers all ages of individuals (Cole & Tufano, 2008). The MOHO identifies what is meaningful to the individual through establishing the persons personal causation, interests, and values (Cole & Tufano, 2008). Interventions are individualized and relate to occupational performance, which may include modifications and adaptations (Cole & Tufano, 2008). Natural environments are ideal for interventions- especially those related to roles and habits (Cole & Tufano, 2008). The use of MOHO is supported within the community setting and is noted to positively challenge occupational therapists perspectives on different beliefs and ideas (Wimpenny, Forsyth, Jones, Matheson, & Colley, 2010). The MOHO may be challenging to incorporate into practice given its complexity, but the model has lasting and tangible benefits (Wimpenny et al., 2010). CANCER SUPPORT COMMUNITY 9 Lifestyle Redesign enacts and develops customized routines that promote health and include meaningful activities (Dieterle, 2014). Lifestyle includes ADLs, routines, IADLs, health status, mood, and habits (Dieterle, 2014). This is a client-centered theory focused on individuals or a group setting goals and creating an action plan so that the goals are attainable (Dieterle, 2009). Individuals become their own advocates for health promotion through identifying aspects of their routines and occupations that need altered for health-related goals (Dieterle, 2014). This can be as simple as drinking water instead of caffeinated beverages or deep breathing to relax (Dieterle, 2014). Lifestyle Redesign Theory also applies to the cancer population with a focus on leading a healthier lifestyle over time (Dieterle, 2009). Another focus of this theory would be on stress management and participating in meaningful activities to increase QOL (Dieterle, 2009). One main activity would be healthy eating, which will be incorporated with referrals to the cooking group with the other Doctorate of Occupational Therapy (OTD) student at CSC (Dieterle, 2009). Other considerations within this theory include pain management, ergonomics, energy conservation, organization, exercise, time management, and prevention (Dieterle, 2009). Lifestyle choices have been proven to have a strong effect on cancer, such as diet, exercise, hormone changes, smoking, sunlight exposure, etc. (Lee & Loh, 2013). Out of those lifestyle habits previously listed, physical activity is the main contributor to cancer control and QOL which can be done through meaningful occupational engagement; however, one must participate in all types of exercise for the greatest cancer-related outcomes (Lee & Loh, 2013). CANCER SUPPORT COMMUNITY 10 Screening and Evaluation Preplanning The OTD student and the vice president of CSC, Lora Hays, had a meeting one year prior to the DCE. Lora and the OTD student discussed many options for how OT could benefit the CSC population. Literature was well researched to identify aspects of the cancer survivorship population where occupational therapists could contribute within a community setting. All the literature found is listed in the literature review and validates the need for the occupational therapy profession practicing within a cancer survivorship community setting. CSC decided to take on two occupational therapy students, and the students discussed the similarities and differences in their roles before starting the Doctoral Capstone Experience (DCE). Needs Assessment Population health is considered the outcomes related to health within and distributed across a defined group of individuals (Braveman, 2016). Occupational therapists must analyze aspects of the population to determine needs related to occupational performance, and this can be done through a needs assessment evaluating the population level first and then the individual level or vice versa (Braveman, 2016). For group occupational therapy health promotion and wellness education sessions, individuals filled out a needs assessment in the form of a questionnaire at the first two educational workshops titled Cancer-Related Fatigue and How OT can Help Cancer Survivors. Not all attendees chose to complete the needs assessment, so those who attended Supper Club were also asked to fill the questionnaire. A total of twelve individuals completed the form. This needs assessment provided information related to needs found in the literature as well as feedback gathered from CSC stakeholders (i.e. vice president, president, and program and outreach coordinator) to provide themes of the overall needs specific CANCER SUPPORT COMMUNITY 11 to the cancer survivor population. Identifying the needs of this population helped determine what programs and information were needed for this population. Lastly, a distress screener that contained questions related to the OTs scope of practice were used to identify needs for multiple individuals as well as justify the need for grant funding an OT program. According to all the stakeholders involved at CSC and the evidence previously noted in the literature review, the CSC population needs OT services in the form of meeting physical, emotional, and psychological needs through occupational performance. Many individuals stated an interest in gardening; this will become available for the CSC members before the end of the DCE. The main theme among the needs assessments included a desire for increased occupational performance and participation. This looked different for every individual considering everyones habits, values, and interests vary (see Appendix A). The Goal Attainment Scale (GAS) outcomes are to be determined at the end of the DCE, and the Canadian Occupational Performance Measure (COPM) was supported throughout literature which justified its use during one-on-one sessions. GAS vs. COPM The GAS was used to measure overall progress in the Health Promotion and Wellness Program and the grant funding process for the OT program. The GAS is used at a population level whereas the COPM is used at the individual level (Doig, Fleming, Kuipers, & Cornweli, 2010). The GAS is more objective whereas the COPM is more subjective (Doig et al., 2010). Both tools effectively show progress with occupational performance and participation levels, which relate to community-based goals (Doig et al., 2010). Both have good responsiveness and sensitivity to any change as well as good ecological validity for real-life functioning (Doig et al., CANCER SUPPORT COMMUNITY 12 2010). Using both tools has proven to result in significant improvements with client-centered goals (Doig et al., 2010). The COPM is designed to prioritize and identify any problems with occupational changes that may occur over time; this is beneficial for chronic effects of cancer and cancer treatment (Nieuwenhuizen, de Groot, Janssen, Van Der Maas, & Becherman, 2014). The COPM identifies how satisfied individuals are with their occupational performance and which occupations are most meaningful (Nieuwenhuizen et al., 2014). A cancer-related community program called Camp Discovery had great success using the COPM to measure progress in satisfaction with occupational performance (Maher & Mendonca, 2018). The COPM is holistic and can be used for re-evaluation to measure progress throughout treatment from the perspective of the client (Nieuwenhuizen et al., 2014). This was beneficial for the doctoral project since the focus was on education with follow-up sessions discussing the implementation of strategies into everyday activities. The COPM also allowed the OTD student to take client reports and translate that information into measurable scores that could be used for goal setting. The goals within the GAS focus on program development, advocacy, and educational components of the doctoral experience (Koski & Richards, 2015). The GAS is appropriate for the doctoral capstone and other non-classroom experiences due to its method of quantitative measurements for assessing competence within the students individualized project goals (Koski & Richards, 2015). The GAS can also be used in a wide range of settings and has good sensitivity, test-retest reliability, and content validity (Koski & Richards, 2015). Individual and Group Sessions For individual sessions, the screening included education to individuals about OT-related services. Then, the individuals sought out services if they felt there were deficits within their CANCER SUPPORT COMMUNITY 13 occupational performance due to chronic cancer-related side effects. Clients were evaluated using the COPM and an occupational profile questionnaire, which provided a holistic view of the unique needs of the individual clients. The occupational profile was based off the AOTA occupational profile template. Individual sessions allowed for individualized treatment to target occupational barriers specific to every individual. Necessary supervision was given to the OTD students for the COPM evaluation until competency was reached. Group sessions were held in addition to individual sessions to address overarching cancer-related topics supported through evidence-based practice. The group sessions involved a formative and summative assessment for each educational session. The formative assessment was a pre-post Likert Scale survey which included questions to demonstrate increased knowledge after implementation of the educational workshops. The summative survey included questions about their satisfaction with the educational content and included open-ended questions asking what went well and what could have been improved. This was meant to improve the Health Promotion and Wellness Education Program as well as provide future occupational therapists with resources for continual improvement. Occupational Performance and Participation As the amount of cancer survivors continues to grow exponentially, activity performance, QOL, and participation in life roles are failing to be addressed whereas psychological and physical aspects of the individual are the focus (Hwang, Lokietz, Lozano, & Parke, 2015). This is important on the population and individual level in making sure all aspects of persons are being analyzed and synthesized during evaluation and throughout the OT process (Hwang et al., 2015). Some common psychosocial issues reported in the cancer survivorship community includes living with a constant caregiver shadow and fear that cancer will return (Hwang et al., CANCER SUPPORT COMMUNITY 14 2015). This is important for occupational therapy evaluation because these psychosocial issues result in decreased participation in meaningful activities including work and education (Hwang et al., 2015). Decreased QOL can be seen through the COPM evaluation and tends to be more severe in early survivorship (Hwang et al., 2015). The population, individual, and organizational levels of CSC need to be educated on the role of OT in the cancer survivorship community setting. The knowledge on how occupational therapists can help cancer survivors will justify the need for occupational therapists practicing in this setting (Polo & Smith, 2017). Some areas where occupational therapists are valuable include accommodations for chemobrain, fatigue, and emotional needs (Polo & Smith, 2017). These are occupational barriers in activity performance to look for during screening and evaluation (Polo & Smith, 2017). About half of cancer survivors report that their occupational performance and social participation were lowered overall due to fatigue (Polo & Smith, 2017). Also, meeting emotional needs will increase self-efficacy and overall QOL (Polo & Smith, 2017). Lastly, cancer-related cognitive deficits can interfere with functioning and thought processes within ones normal daily routines/roles and can be managed with the help of an occupational therapist (Polo & Smith, 2017). Community Setting vs. Other Practice Areas As previously stated in the literature review, there is a great lack of referrals for occupational therapy in community-based settings for cancer survivors. OT implications for community-based settings focus on advocating for the needs of the community population being served and advocating for access to services through supportive documentation (Polo & Smith, 2017). Advocating for OT services and the cancer survivorship population will close the gap and allow equal access among individuals where services are not readily available in community CANCER SUPPORT COMMUNITY 15 settings (Polo & Smith, 2017). When developing health promotion and wellness programs, the occupational therapist must be cognizant of state laws for planning interventions within the scope of practice as well as billing appropriate services under appropriate codes (Scaffa & Reitz, 2014). Within community settings, however, there is a serious concern with how OT services will be reimbursed (Polo & Smith, 2017). According to Reilly (1971) (as cited in Scaffa & Reitz, 2014), the occupational therapists role should transition from medical settings to the community with a focus on developing programs and experiences in an individuals natural community-based environment to increase adaptive competencies. Occupational therapists main roles within a community setting include increasing QOL by increasing independence with ADLs, meeting psychosocial and emotional needs, managing chronic symptoms/disabilities, and promoting healthy lifestyles and overall well-being (Polo & Smith, 2017). The focus of health promotion programs involves enabling individuals to gain increased control over their health with a strong preventative component for overall wellness (Scaffa & Reitz, 2014). According to Finn (1972) (as cited in Scaffa & Reitz, 2014), the occupational therapists role needs to expand in the community setting to assume roles such as a health agent, community organizer, advocate, program developer, and consultant. This was originally stated in the 1971 Eleanor Clarke Slagle Lecture and still reigns true in present day (Scaffa & Reitz, 2014). Taking on these roles beyond the therapist role at CSC will help the OTD student achieve the overall program goals. Implementation Phase Prior to the implementation of the program, a plethora of advertising methods for Health Promotion and Wellness Education services were used. The method that worked best was calling individuals from a roster of members that attended the cancer survivorship presentations CANCER SUPPORT COMMUNITY 16 last year presented by the University of Indianapolis students. During the initial session, interventions were provided via education near the end of the session if there was time after the evaluation. Individuals were encouraged to attend follow-up appointments that involved more hands-on interventions or discuss education in further detail. The OTD student demonstrated competency in evaluation and implementation of education under supervision of a licensed occupational therapist. All resources used to educate individuals were supported through research. According to the Indiana State Practice Law, OT students cannot provide OT services without supervision unless competency is demonstrated. Thus, the foundation of the health promotion and wellness program focused on educating individuals through a self-management approach. Educational handouts were created in relation to evidence found in research with compensatory strategies, stress management, energy conservation, peripheral neuropathy, and chemo brain for this population. Each member signed an agreement to demonstrate understanding that they were meeting with students who were not licensed occupational therapists. This agreement also included consent to educational intervention from the students with knowledge of the Indiana State Law criteria (see Appendix B). Leadership Skills Organizational skills were demonstrated through planning for group and individual sessions with members of CSC. Educational handouts were developed over specific cancerrelated topics in preparation for members who would potentially benefit from them. An organized schedule was created by the OTD student to include the grant writing process, individual/group sessions, gardening program, and various other duties to manage time efficiently throughout the DCE. Professional communication and marketing skills were also CANCER SUPPORT COMMUNITY 17 demonstrated by advocating for services through the companion (i.e. magazine calendar), flyers, phone calls, and word of mouth. Advertisements included examples of symptoms that have been researched within this population as well as a description of what occupational therapy is as a profession and what Health Promotion and Wellness Education services included. Individuals were made aware that services are being delivered by OTD students and that anything outside of education will be supervised by a licensed therapist prior to setting up the initial appointments. If individual needs were related to more traditional settings (i.e. outpatient) beyond health promotion and wellness services, then individuals were given a recommendation to obtain a doctors referral for those services. For example, an individual may need a physicians referral and order for the TENS machine for pain management due to chronic neuropathy pain. Other leadership skills included the ability to build rapport with individuals on a group and individual basis. Interpersonal and professional communication skills were needed when talking to the staff and CSC members. Confidence was shown when providing education to those who attended Health Promotion and Wellness education sessions. For individual and group sessions, accountability and punctuality was needed for appointments. Lastly, delegating responsibilities was demonstrated amongst staff members with different tasks. Staff Development Caseload was divided between two students for individual sessions. There were four individuals- not including the student- who were on the grant writing team and had extensive experience within grant writing. With this amount of people on staff, effective implementation was seen for the program as well as development of an occupational therapy program for sustainability purposes. Since students do not have enough competencies to provide interventions outside of education without supervision, the grant will be an excellent way to bring registered CANCER SUPPORT COMMUNITY 18 occupational therapists to CSC to expand upon the service availability for individuals as needed and to promote occupational justice. One of the GAS goals measured staff requirements based on the number of individuals on caseload to represent the number of hours the occupational therapist would need to fulfill. Discontinuation and Outcome Phase Formative and summative evaluations were used to measure increased knowledge and satisfaction with the group educational sessions. Almost all formative surveys indicated increased knowledge after the presentations using a pre-post Likert Scale measure. Most of the group sessions indicated improvements needed in making the information more generalized based on the summative surveys. For example, the cancer-related fatigue presentation included information mostly related to chemotherapy and radiation treatment; however, the neuroendocrine and carcinoid group of individuals indicated that their fatigue comes from a different type of medicine that most of them take for cancer treatment. Group sessions are now designed to be as generalized as possible whereas individual sessions are specific to the individual. Considering most of the Health Promotion and Wellness services were educational, quality of services was dependent upon the quality of evidence-based practice available. Substantial research goes into providing individuals with the newest and most consistent information so that participants can apply that information within daily life. The OTD students compiled all educational resources in a binder for future occupational therapists to utilize at this site. This will also add to sustainability of the occupational therapy program as well as improve the quality of services through patient feedback in the formative and summative surveys. CANCER SUPPORT COMMUNITY 19 Grant Funding and Distress Screener A grant will provide sustainability for the occupational therapy program at CSC. For the grant writing process, steps were taken to achieve outcomes based on the GAS criteria. Developing a skeleton proposal and cover letter were the beginning stages of funding an OT program at this site. Justification for funding an OT program at this community setting was included in the skeleton proposal in addition to the distress screener data collection to demonstrate the need for services at this site (see Appendix C). The target grant was decided on among the CSC and University of Indianapolis grant teams from a list of potential grants that the OTD student compiled. Most grants were found through the Infoed SPIN database, which is a global database with the largest selection of funding opportunities and uses a specific transmittal service to find the most accurate grants to fund specific needs. The submission letter was created after the grant meeting by the OTD student under the supervision of the grant teams. The skeleton proposal was reviewed by the University of Indianapolis and CSC grant writing teams to provide feedback for the final draft. After all materials for the grant application were finalized, they were submitted to the target grant that was chosen during the grant meeting. The grant will promote the emergence of occupational therapy at this setting to work on health promotion and wellness with the cancer survivors. The lack in OT services for cancer survivors occurs when there is a lack of awareness of OT and the benefits of OT services. Bringing in licensed occupational therapists and funding services through the grant will bring services to CSC beyond education to its members. Multiple grants were chosen as target grants to apply for funding for staff hours and the COPM assessment tool. The target grants included the Walmart Community Grant and the Firestarter Award. Both of these grants are looking to fund community-based programs and grant CANCER SUPPORT COMMUNITY 20 a max of $5,000 each. The Walmart Community Grant is focused on increasing quality of life within the community. The Firestarter award is looking for community-university partnerships to increase health equity, social health, and overall health. Vision 2025 Society is changing with an increased population growth of cancer survivors. This is increasing the need for occupational therapy services as noted in the literature review. Part of the Vision 2025 includes building OT programs for accessible services that are customized and culturally responsive (AOTA, 2016). Having OT emerge in this cancer survivorship community setting will promote equal access to services for an underserved population. To bring awareness to the need for OT services in cancer survivorship community settings, the OTD student will attempt to submit an article to an occupational therapy journal. This will ensure ongoing clientcentered evidence for vision 2025 as well (AOTA, 2016). COPM Findings Discontinuation officially took place when the DCE was over; however, individualized sessions required goals to be set in hopes that all individuals would meet their goals before that time. The individuals were encouraged to meet those goals and attend an average of three to four sessions total. Each individual had a long-term goal to increase their COPM performance or satisfaction scores by 2 points. Progress was measured at the final session by administering a reassessment with the COPM and comparing initial and final scores. Individuals were given strategies to help promote occupational performance, and the COPM scores were meant to provide evidence that these strategies helped increase their satisfaction with their increased occupational performance. The COPM score changes were not high enough to meet the longterm goal but individuals did make progress towards their long-term goal (see Appendix D). The CANCER SUPPORT COMMUNITY 21 low scores for the COPM were due to the fact that caseload started picking up later in the program giving the participants less time to show improvements. Earlier recruitment will be beneficial when trying to build a larger caseload and give individuals the time to show improvement for future practice. GAS Midterm Scores The GAS outcomes at midterm included a score of -1 (i.e. somewhat less than expected) for the goal of effective advertisement as evidenced by the number of individuals on caseload. The second goal included progress seen in individuals as a result of the health promotion and wellness education program, which has a score of 0 (i.e. expected level of outcome) at midterm. Lastly, the grant funding goal has a score of -1 (i.e. somewhat less than expected) meaning that a rough draft of the skeleton proposal is the only thing completed at the point of midterm. The scores were predicted to increase by the end of the DCE. See Appendix E for GAS midterm results. GAS Final Scores The GAS outcomes at the end of the program showed significant progress for the overall Health Promotion and Wellness goals. The GAS outcomes included a score of -1 (i.e. somewhat less than expected) for the goal of effective advertisement as evidenced by the number of individuals on caseload. There ended up being five individuals on caseload by the end of the DCE. The second goal included progress seen in individuals as a result of the health promotion and wellness education program, which has a score of +1 (i.e. somewhat more than expected). Most individuals only met their short-term goals. Lastly, the grant funding goal has a score of +2 (i.e. much more than expected) meaning that the grants were decided on among the grant writing CANCER SUPPORT COMMUNITY 22 teams and final draft skeleton proposals were submitted to the two target grants. See Appendix E for GAS results. Overall Learning Effective communication was used when recruiting clients over the phone or at different events. Communicating what occupational therapists do was difficult at a setting that does not have occupational therapy in addition to summarizing a broad profession. Also, the students role at CSC was communicated in a way where individuals understood what was being offered with the health promotion and wellness education. Family was communicated with on occasion when referring their family member to our services if they felt that person could benefit from individual sessions. There were no other health providers at this site; however, referring individuals to art therapy or individual counseling as needed was expected. Quality interactive discussions were held at the different workshops with small groups of cancer survivors and critical reasoning skills were needed to sort through the problems discussed with different topics that were mentioned. Lastly, professional communication was used when communicating needs to different staff at CSC. There were times of uncertainty in knowing how to word something professionally, so building those communication skills was good for future practice. The overall learned experience at this site was understanding how much work goes into starting a new program at a community setting where OT is needed. For example, grant writing will be a beneficial skill to have for future practice if that is needed. Starting a program involves a lot of continuous quality improvement as well, which will be beneficial with future practice with eliminating waste and improving quality of services. Learned experiences from mentors involved knowing different laws and ethics at a non-traditional setting where rules and regulations may not necessarily be set in place yet. Also, with a nonprofit organization it takes CANCER SUPPORT COMMUNITY 23 the entire staff to work together in preparing different rooms for support groups or working different phone shifts at the front desk. So even though the main responsibilities of the student were related to occupational therapy, other responsibilities were expected when working at a non-profit community setting. Leadership and Advocacy As a leader, there were specific professional skills needed when starting an OT program at CSC. Flexibility is needed at a non-traditional setting when helping other staff members suddenly. For example, giving a stress management and mindfulness presentation to a support group with a two-day notice. Also, discussing different grants at meetings takes communication skills beyond the entry-level. To gain clients on caseload or encourage them to openly discuss their occupational issues in a group and individual session, a leader must make sure they are portraying non-verbal and verbal communication that deems the occupational therapist approachable. Lastly, listening to client needs is a very important leadership skill when providing client-centered health promotion and wellness education. The majority of CSC staff and cancer survivors were unsure of what occupational therapists do; however, they would ask if occupational therapy was similar to physical therapy. The OTD student was constantly advocating for occupational therapy as a profession as well as for health promotion and wellness education. Individuals needed to understand what services were being offered to find appeal in participating in health promotion and wellness education for their benefit. Advocating for the cancer survivors needs was done by advocating for OT services at this site as well as obtaining grant funding. The skeleton proposal included this justification. In conclusion, cancer survivors often have residual symptoms years after cancer treatment. Occupational therapy as a profession is going unnoticed by primary care physicians CANCER SUPPORT COMMUNITY 24 and the public, which is resulting in lack of referrals for the cancer survivor community. Obtaining grant funding at this cancer survivorship community setting will not only meet the needs of the cancer survivors but also provide opportunities for higher education by sustaining a partnership with the University of Indianapolis. The students will have a therapist mentor to guide them through the OT process in a non-traditional setting. Therapists must continue to advocate for OT services in emerging practice areas for underserved populations to promote occupational justice and QOL. Also, evidence needs to be expanded in the area of community practice with cancer survivors to increasingly show that a need exists for occupational therapy. CANCER SUPPORT COMMUNITY 25 References American Occupational Therapy Association. (2016). AOTA unveils vision 2025. Retrieved from https://www.aota.org/AboutAOTA/ vision-2025.aspx Baxter, M., Newman, R., Longpre, S.M., & Polo, K.M. (2017). Occupational therapys role in cancer survivorship as a chronic condition. American Journal of Occupational Therapy, 71(3), 1-7. doi: 10.5014/ajot.2017.713001 Braveman, B. (2016). Population health and occupational therapy. American Journal of Occupational Therapy, 70, 1-6. doi: 10.5014/ajot/2016.701002 Braveman, B., Hunter, E. G., Nicholson, J., Arbesman, M., & Lieberman, D. (2017). Occupational therapy interventions for adults with cancer. American Journal of Occupational Therapy, 71(5), 1-5. doi: 10.5014/ajot.2017.715003 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Dieterle, C. (2009, February 12). Occupational therapy practice: Lifestyle redesign [video file]. Retrieved from https://www.youtube.com/watch?v=t9QJfnw40XY Dieterle, C. (2014). Lifestyle redesign programs. In C. Fratantoro & P. Waltner (Eds.), Occupational therapy in community-based practice settings (pp. 377-389). Philadelphia, PA: F.A. Davis Company. Doig, E., Fleming, J., Kuipers, P., & Cornweli, P. L. (2010). Clinical utility of the combined use of the Canadian occupational performance measure and goal attainment scaling. American Journal of Occupational Therapy, 64, 904-914. doi: 10.5014/ajot.2010.08156 Hunter, E. G., Gibson, R. W., Arbesman, M., & DAmico, M. (2017). Centennial topicsSystematic review of occupational therapy and adult cancer rehabilitation: Part 1 impact CANCER SUPPORT COMMUNITY 26 of physical activity and symptom management interventions. American Journal of Occupational Therapy, 71. doi: 7102100030. https://doi.org/10.5014/ajot.2017.023564 Hunter, E. G., Gibson, R. W., Arbesman, M., & DAmico, M. (2017). Centennial Topics Systematic review of occupational therapy and adult cancer rehabilitation: Part 2. Impact of multidisciplinary rehabilitation and psychosocial, sexuality, and return-to-work interventions. American Journal of Occupational Therapy, 71(2), 1-8. doi: 10.5014/ ajot.2017.023572 Hwang, E. J., Lokietz, N. C., Lozano, R. L., & Parke, M. A. (2015). Functional deficits and quality of life among cancer survivors: Implications for occupational therapy in cancer survivorship care. American Journal of Occupational Therapy, 69, 1-9. doi: 10.5014/ajot.2015.015974 Koski, J. & Richards, L. G. (2015). Brief Report- Reliability and sensitivity to change of goal attainment scaling in occupational therapy nonclassroom educational experiences. American Journal of Occupational Therapy, 69, 1-5. doi: 10.5014/ajot.2015.016535 Lee, J.E. & Loh, S.Y. (2013). Physical activity and quality of life of cancer survivors: A lack of focus for lifestyle redesign. Asian Pacific Journal of Cancer Prevention, 14(4), 25512555. doi: 10.7314/APJCP.2013.14.4.2551 Maher, C. & Mendonca, R. (2018). Impact of an activity-based program on health, quality of life, and occupational performance of women diagnosed with cancer. American Journal of Occupational Therapy, 72, 1-8. doi: 10.5014/ajot.2018.023663 Nieuwenhuizen, M. G., de Groot, S., Janssen, T. W. J., van der Maas, L. C. C. (2014). Canadian occupational performance measure performance scale: Validity and responsiveness in CANCER SUPPORT COMMUNITY 27 chronic pain. Journal of Rehabilitative Research and Development, 51(5), 727-746. doi: 10.1682/JRRD.2012.12.02 Polo, K. M. & Smith, C. (2017). Taking our seat at the table: Community cancer survivorship. American Journal of Occupational Therapy, 71, 1-5. doi: 10.5014/ajot.2017.020693 Scaffa, M.E. & Reitz, S.M. (2014). Occupational therapy in community-based practice settings (2nd ed.). Philadelphia, PA: F.A. Davis Company. Sleight, A. G., & Duker, L. I. S. (2016). Toward a broader role for occupational therapy in supportive oncology care. American Journal of Occupational Therapy, 70, 1-8. doi: 10.5014/ajot.2016.018101 Wimpenny, K., Forsyth, K., Jones, C., Matheson, L., & Colley, J. (2010). Implementing the model of human occupation across a mental health occupational therapy service: Communities of practice and a participatory change process. British Journal of Occupational Therapy, 73(11), 1-10. CANCER SUPPORT COMMUNITY 28 Appendix A Needs Assessment 1. What do you consider to be meaningful activities to you even if you have trouble doing them? 2. What cancer-related symptoms do you experience? 3. What activities do you find difficult doing related to self-care if any? 4. What are some values and interests of yours? 5. What roles do you play (i.e. mother, caregiver, etc.) and what barriers are making those roles difficult? 6. How have your performance in daily activities/occupations changed over time? CANCER SUPPORT COMMUNITY 29 Appendix B Participant Name:_____________________________________ Doctor of Occupational Therapy Student:______________________________ I understand that if I participate in any programs sponsored by Cancer Support Community Central Indiana (CSC-CI), I am responsible for ascertaining my physical and emotional ability to participate. I waive any claims that I may have against CSC-CI by virtue of participation in this program and any other programs offered to me in the future. I also authorize the use any photos taken during this program to be used by CSC-CI for future advertising and marketing of the program. I understand that all individual health promotion and wellness education is completed by occupational therapy doctoral student interns and are supervised by a licensed occupational therapy practitioner. Cancer Support Community (CSC) offers health promotion and wellness education to explore ways to optimize health through appropriate routine and participation in meaningful occupation. Educational sessions are available to members of CSC. We ask that each participant for health promotion and wellness education is aware of the following: 1. CSC and University of Indianapolis doctoral students do not provide medical advice or assistance 2. We make every effort to begin and end sessions on time as scheduled 3. The staff members who provide this service keep all information confidential with the following exceptions mandated under Indiana State Law: a. Serious threats of violence toward another individual b. Suspected abuse or neglect of children, the elderly, or an individual with a disability c. Serious indication of harming ones self d. Legal requests from a court of law 4. Each participant accepting this education must sign this form I have read and understand the above information. _________________________________________ Signature of Participant __________________ Date CANCER SUPPORT COMMUNITY 30 Appendix C Figure 1C. Cancer Support Community Distress Screener 15 Data. This data is out of 75 individuals who completed the Distress Screener 15. The different legends represent the ratings of concern on a Likert Scale for four different questions related to occupational therapys scope of practice with cancer survivors at CSC. Answering none means there is no concern in the four different areas of life, and answering very serious indicates severe concern. The data collection represents the surveys taken from 01/01/2017 to 03/08/2018. Approximately 56% of individuals answered with greater severity of overall concern, indicating a need for occupational therapy services. CANCER SUPPORT COMMUNITY 31 Appendix D Table 1D. COPM Scores at Initial Evaluation and Discharge Client Initial Assessment Score Performance Satisfaction 1 5.8 2 5.2 3 5.8 4 6.6 5 6.8 Average Score Change 7.2 3 4.8 6.2 4.6 Reassessment Score Performance Satisfaction Score Change Performance Satisfaction 6.4 7.4 7.4 7.2 NA 0.6 2.2 1.6 0.6 `NA 1.25 7.2 8 6.4 7.6 NA 0 5 1.6 1.4 NA 2 CANCER SUPPORT COMMUNITY 32 Appendix E Table E1. Goals Toward Developing an Occupational Therapy Program at Midterm Goal Attainment Scale Goal 1: Health Promotion and Wellness Education services will be advocated for through flyers, social media, magazine advertisements, and word of mouth with success evidenced by amount on caseload by April 27th, 2018. Much less -2 than expected No members of CSC on caseload. Goal 2: The Health Promotion and Wellness Education program will prove effective in group/individual sessions and will meet the criteria of medically necessary at this setting through progress seen in individuals and the majority of goals being met by April 27th, 2018. Goal 3: The grant writing team will collaborate with the OTD student in writing and submitting a grant application/letter to fund an OT program at CSC by April 27th, 2018. Members made no improvements. This task did not get completed. Somewhat There are 0-5 members Members made insignificant less -1 of CSC on caseload per improvements. than week. expected The skeleton grant proposal rough draft is written. Expected There are 6-10 members level of CSC on caseload per week. 0 of outcome The skeleton grant proposal final draft is written and approved through UIndy grants office and CSC grants office. Somewhat more +1 than expected The majority of CSC members increased knowledge in group sessions but did not meet goals in individual sessions. There are 11-20 members The majority of CSC A target grant is of CSC on caseload per members increased identified among the week. knowledge in group sessions grant writing team. and only met STGs with individual sessions. Much more There are 21+ members of CSC on caseload per +2 week. than expected The majority of CSC A full grant proposal is members increased written and submitted to knowledge in group sessions targeted grant. and met all goals in individual sessions. CANCER SUPPORT COMMUNITY Comments: There are currently six individuals on caseload. The best form of recruitment was calling through a phone roster from the Cancer Survivorship educational session attendees from last year. 33 All group sessions have The skeleton proposal shown increased knowledge. takes the longest Individual sessions have not amount of time in the gotten to the point of grant funding process. intervention yet. Table E2. Goals Toward Developing an Occupational Therapy Program at Final Goal Attainment Scale Goal 1: Health Promotion and Wellness Education services will be advocated for through flyers social media, magazine advertisements, and attendance to various events with success evidenced by amount on caseload by April 27th, 2018. Much less -2 than expected No members of CSC on caseload. Goal 2: The Health Promotion and Wellness Education program will prove effective in group/individual sessions and will meet the criteria of medically necessary at this setting through progress seen in individuals and the majority of goals being met by April 27th, 2018. Goal 3: The grant writing team will collaborate with the OTD student in writing and submitting a grant application/letter to fund an OT program at CSC by April 27th, 2018. Members made no improvements. This task did not get completed. Somewhat There are 0-5 members Members made insignificant less -1 of CSC on caseload per improvements. than week. expected The skeleton grant proposal rough draft is written. Expected There are 6-10 members level of CSC on caseload per week. 0 of outcome A target grant is identified among the grant writing team. The majority of CSC members increased knowledge in group sessions but did not meet goals in individual sessions. CANCER SUPPORT COMMUNITY Somewhat more +1 than expected 34 There are 11-20 members The majority of CSC of CSC on caseload per members increased week. knowledge in group sessions and only met STGs with individual sessions. The skeleton grant proposal final draft is written and approved through UIndy grants office and CSC grants office. Much more There are 21+ members of CSC on caseload per +2 week. than expected The majority of CSC members increased knowledge in group sessions and met all goals in individual sessions. A full grant proposal is written and submitted to targeted grant. Comments: The long-term goal included the 2-point increase in COPM scores, which individuals did not meet. There needs to be extended time for individuals to show that much progress. The grant sources will contact us and let us know whether or not they will fund the occupational therapy program or not. Individuals would set up appointments and would either not show up or not call back. Otherwise, the caseload would have been rated at about a zero.  ...

... Running head: BRIDGING HEALTHCARE PROFESSIONALS Bridging the Gap Between Healthcare Professionals, Families, and Alzheimers disease Ashley Barber University of Indianapolis 1 Running head: BRIDGING HEALTHCARE PROFESSIONALS 2 Abstract The focus of this mixed methods experience was to explore the gap between healthcare professionals, families, and residents with Alzheimers disease (AD) in order to establish meaningful connections and provide quality care. Due to the inadequate supply of healthcare professionals adequately trained to treat individuals with AD (Warshaw & Bragg, 2014) as well as nursing staff expressing difficulties when communicating with individuals with AD (Yang, 2017), it is a valuable area to address the lack of knowledge for healthcare professionals. This experience was held at Cumberland Trace memory care unit, Cherished Memories. Data was collected through observation hours on Cherished Memories and surveys completed by staff members and family. Surveys were developed, one for staff members and one for residents family members, in order to address their concerns. Staff survey results indicated staff members had concerns regarding effective communication strategies, stages of AD, and caregiver burnout. Family member surveys indicated they had a basic knowledge of AD but had a desire to learn more about the disease itself as well as additional components including communication strategies, therapy options, caregiver resources, and stages of AD. These results led to an educational in-service for staff members on Cherished Memories and a family care packet for residents family members. Sustainability was created through discussion with Cherished Memories unit manager. Findings are relevant for those who are developing educational programs for staff members working directly with elderly adults and family members who are impacted by AD. Keywords: Alzheimers disease, communication, healthcare, memory care Running head: BRIDGING HEALTHCARE PROFESSIONALS 3 Background As Baby Boomers enter adulthood, risks for medical illness and new diagnoses increase. The most common of these diagnoses is Alzheimers disease (AD). Alzheimers disease affects individuals over the age of 65 and accounts for sixty to eighty percent of dementia cases (Alzheimers Association, 2018). Throughout this paper, Alzheimers disease will be referred to as AD. According to Alzheimers Association (2018), AD is defined as a type of dementia, which causes problems with memory, thinking, and behavior. There are two primary changes in the brain indicative of Alzheimers disease. These abnormal structures are identified as tangles and plaques (Alzheimers Association, 2018). The number of cases of AD is growing exponentially and projected to triple by 2050 (Warshaw & Bragg, 2014). Therefore, it is important for both healthcare professionals and family members to understand the disease, as well as mechanisms to effectively stay connected with individuals impacted. There is currently an inadequate supply of specialist for geriatrics or dementia, especially physicians and nurses, which indicates an even greater push for healthcare professionals to be educated on Alzheimers disease both on site and in educational programs (Warshaw & Bragg, 2014). It has been determined by previous research that healthcare professionals experience caregiver burden when caring for individuals with AD and healthcare professionals, often nurses and nursing aides, express difficulty effectively communicating with these individuals (Yang, 2017). This creates a valuable area of study to address the lack of knowledge for healthcare professionals, as well as family and loved ones, who directly interact with these individuals. This experience focused on providing educational training to nurses, nursing aides, and activity staff within a Memory Care Clinic as well as create a family care informative packet for potential residents families, in order to enhance quality of care, knowledge of AD, and ability to Running head: BRIDGING HEALTHCARE PROFESSIONALS 4 stay connected with these residents. The literature review was geared toward providing communication strategies, behaviors, and environmental modifications for healthcare professionals to utilize with individuals with AD. This disease can be a very complex condition and appears in various forms and stages. According to Alzheimers Association (2011), healthcare professionals and families of individuals with AD have been pinpointed for lack of education. Contributing factors include: lack of public awareness, insufficient research funding, difficulties with diagnosis, poor dementia care, inadequate treatment, unprepared caregivers, illequipped communities, and mounting costs (Alzheimers Association, 2011, p. 3). Lack of public awareness leads to negative stigmas, including the commonly used phrase, its a part of aging. Individuals avoid seeking medical help when experiencing these symptoms because of this hazardous mindset (Alzheimers, 2011). As noted by an individual from Roseville, CA in the Alzheimers Association (2011), if we are going to get through the next 20 or 30 years watching baby boomers with Alzheimers increasingly burden their children with disease they cannot control we absolutely have to invest in the research to find good treatment options (p. 8). Insufficient research leads to difficulties diagnosing individuals with Alzheimers disease. When individuals seek out medical attention and answers to symptoms, physicians are often challenged through serious communication barriers, which inhibits the ability to correctly diagnose (Alzheimers Association, 2011). Individuals with AD feel unable to effectively communicate with healthcare professionals, evident by receiving insensitive or negative feeling at times (Alzheimers Association, 2011). The majority of this miscommunication stems from lack of knowledge and specialized training. Research has proven that many facilities that these individuals end up residing are not adequately trained to handle behaviors including anxiety, aggression, or repetitive actions (Alzheimers Association, 2011) therefore leading to a greater Running head: BRIDGING HEALTHCARE PROFESSIONALS 5 reason to educate families on proper care. These topics will be further investigated to examine the impact of lack of education on quality of care provided. Literature Review This experience focused on creating a holistic view of the resident through both the family members and healthcare professionals. This experience was conducted at Cumberland Trace, a skilled nursing facility owned by CarDon, comprised of rehab to home, assisted living, memory care, and long term care residents. This facility utilizes the Allens Cognitive Model to determine the stage of the progression for an individual with AD. This model was developed by Claudia Allen, MA, OTR, FAOTA in the 1960s, and was mainly utilized within the mental health setting. The model has since evolved into several other practice settings, including skilled nursing facilities (Jackson, n.d). This tool is used to identify cognitive functions inhibited and still preserved in order to provide the best care possible. Allens Cognitive Model focuses on three components including process skills, context, and analysis of activity demand (Cole & Tufano, 2008). In order to allow the individual to thrive, the clinician analyzed several components, including: task demand, task environment, extrinsic and intrinsic factors, and brain conservation. This model takes a slightly different approach to dementia, expanding on the skills an individual can still functionally perform independently and offers caregivers a way to improve quality of life and enhance quality of care (Cole & Tufano, 2008). Person-EnvironmentOccupation Model of Occupational Performance model, otherwise known as the PEOP, was utilized during this experience in order to further develop a holistic approach to care. This model depicts a diagram of three elements (person, environment, occupation), all of which overlap in the middle, to depict the congruency between each element (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996). The congruency in the center of the model dictates how well these three Running head: BRIDGING HEALTHCARE PROFESSIONALS 6 elements work together in formulating occupational performance (Law et al., 1996). For this experience, the model helps identify the gap and lack of education between the healthcare professionals, the resident, and the family members. Understanding Alzheimers Alzheimers Disease is a progressive disease, meaning it gradually worsens over time. There is currently no cure for this disease, but research still continues (Alzheimers Association, 2018). According to Alzheimers Association (2018), there are three stages: early, middle, and late. Characteristics that make up the early-stage include word-finding issues, losing or misplacing valuable objects, and increased trouble with planning (p. 5). It is important to note, individuals in the early stage may still function independently. Factors that make up the middlestage include: forgetfulness of personal events, unable to recall address, phone number, high school, confusion about orientation, changes in sleep pattern or bladder control, increased wandering, or behavioral/personality changes (p. 8). During this stage, many individuals become frustrated or angry due to having difficulty expressing thoughts or performing daily routines. During the late-stage, one can identify characteristics such as need round-the-clock assistance with daily activities and personal care, lose awareness of recent experiences, changes in physical abilities, difficulty communicating, and conversations can be extremely limited (p. 10). In order to have an effective conversation with these individuals, it is essential to understand the nature of the disease. Having a background in the nature of the disease and the characteristics of each stage are necessary to provide thorough and effective care for these individuals. Staff Education and Concerns Running head: BRIDGING HEALTHCARE PROFESSIONALS 7 Healthcare professionals are primary hands for many individuals with Alzheimers disease and provide constant care for those within nursing facilities. It is important to understand frustrations, desires, and concerns about knowledge regarding the care of patients. Allens Cognitive Model is intended to offer a simplistic way to individualistically reach out. In a study completed by Ahmad (2014), it was determined that nurse participants lack knowledge in dementia care and are unaware of how to communicate, both verbal and nonverbal, and limited to no resources on methods for improving communication. Authors of Improving Staff Attitudes to Patients with Dementia (n.d) concluded that the following words were commonly discussed amongst nurses who work with memory-impaired individuals; upsetting, difficult, and time consuming. Wang, Hsieh, & Wang (2013) determined that nurses experienced difficulty communicating with these individuals. Nurses reported there was different dialogue between nurse and patient, suggesting the nurse did not understand patient needs. The lack of language consensus means no protocol has been developed to distinguish behavior or persuade an individual to participate in an activity. This article also noted nurses reported difficulty assessing emotions and understanding needs. The authors concluded the lack of patient centered care or providing holistic care appears to be a major cause of these challenges (Wang, Hsieh, & Wang, 2013). Kolanowski, Van Haitsma, Penrod, & Yevchak (2015) defined person-centered care as emphasizing and recognizing the individual persons self-determination, choices, worth, and unique set of values, views, histories, and interests (p 1). To perform person-centered care, it is important to see the individual behind the disease (Ericson-Lidman, Larsson, & Norberg, 2013) rather than treat them as an individual with Alzheimers disease. Research completed by Robison & Pillemer (2007) reported coworkers on Special Care Units demonstrate a better relationship with their coworkers. This article also indicated staff members working directly Running head: BRIDGING HEALTHCARE PROFESSIONALS 8 with patients with dementia require social support due to increased caregiver burnout. Caregiver burnout is defined by Web MD (2018) as a state of physical, emotional, and mental exhaustion that may be accompanied by a change in attitude from positive and caring to negative and unconcerned (p. 1). Burnout is a hot topic for nurses and could possibly contribute to the lack of effective communication skills and quality of care. Rating scales such as, The Maslach Burnout Inventory was created to address burnout. This scale was initially directed towards human services and educational institutions in order to address emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach, Jackson, & Leiter, 1996). This scale requires individuals to provide feedback based on a rating scale of how often they have these feelings to determine the level of burnout. When caring for individuals with AD it is crucial to demonstrate effective care communication. This process begins with fully understanding the needs, desires, and concerns of all healthcare professionals, who interact with these individuals on a daily basis. Communication After understanding the process and functioning cognitive level of the individual, becoming familiar with communication strategies is beneficial to remove burden from health professionals, as well as loved ones or caregivers (Alzheimers Association, 2011). In order to effectively communicate with individuals with AD, one must have a basic knowledge of how each stage affects ability to process phrases and reciprocate conversation through word finding (Alzheimers Association, 2018). Research has acknowledged person-centered care as a popular type of care that many facilities are striving to accomplish (Lanzi et al., 2017). Several research articles agreed that to begin communicating with these individuals, one must allow extra time for them to process the information or direction given and respond appropriately (Lanzi, Burshnic, Running head: BRIDGING HEALTHCARE PROFESSIONALS 9 & Bourgeois, 2017; Dementia 4, 2016). According to Ahmad (2014), it is important to continue communicating with these individuals utilizing humanistic characteristics in order to be personable about their well being. Humanistic characteristics include being holistic, providing choice, being positive, offering acceptance, empathy, caring for the individual, and understand coping. When communicating with these individuals, utilize short sentences, familiar vocabulary, use a warm tone, and smile during conversation (Dementia, 2016; Family Caregiver Alliance, n.d). When speaking to someone in the mid-later stages of dementia, it is best to avoid questions, rather use statements (Dementia, 2016). Hopper (2011) agreed that using simple, active declarative sentences work best. For example, stating, the physician is finished, rather than adding adjectives and other pronouns. Hopper (2011) recognized that asking yes/no questions facilitated a better understanding than open-ended questions and being able to repeat and rephrase sentences was helpful when communicating with these individuals. According to Lanzi et al (2017) residents should be encouraged to write and draw to communicate needs in order to decrease burden of receptive language abilities and frustration. Hopper (2001) determined the success of caregiver-patient interactions depend greatly on the caregivers flexibility with communication skills. These findings indicated families and healthcare professionals must understand how to effectively communicate during all stages of Alzheimers disease. Behaviors The notion that individuals with AD express behaviors out of anger is a common misconception. Behaviors can be dealt with appropriately if professionals and loved ones understand how to distinguish or handle them. When communication becomes difficult and nearly impossible for many of these individuals, alternate ways must be found to express needs, Running head: BRIDGING HEALTHCARE PROFESSIONALS 10 concerns, and feelings, which may be represented in the form of various behaviors (Vargo, 2017). According to Dewing (2010) these behaviors can indicate an unmet need such as pain, toilet, water, food, or environment. These actions can be a response to an action done by other residents, healthcare professionals, or family members (Dewing, 2010). Behaviors such as repetitive question asking can indicate that the individual is confused or fears being abandoned by caregivers. This train of thought can be re-directed by healthcare professionals by responding to questions regarding the topic in order to distract them (Hopper, 2001). Specific movements, environments, and needs can trigger disruptive vocalizations; therefore, it is best to attempt to understand what is causing these utterances (Hopper, 2011). Healthcare professionals have a tendency to look for answers utilizing pharmacological interventions rather than seeking out alternative solutions (Vargo, 2017). Nurses may feel the agitated behavior is a direct correlation with dementia, but it can also be combined with the persons pre-dementia, current personality, coping strategies, severity of the cognitive impairment, and environmental factors (Dewing, 2010). As healthcare professionals and family members, it is impossible to change an individuals behavior. Therefore, it is a must for the professional or family to be self-aware and cognizant of behavior or modify the environment to distinguish the behavior (Family Caregiver Alliance, n.d; Ahmad, 2014). Many behaviors may be able to be distinguished or solved by environmental modifications. Environment An environment either allows one to thrive or leads to challenges. To facilitate successful interactions amongst residents and staff, the environment must be set up in a comforting fashion. For individuals with AD, the environment is crucial for success and ability to fully thrive. The environment can have several effects on an individual, but promoting safety, Running head: BRIDGING HEALTHCARE PROFESSIONALS 11 leading to greater independence, and home-like environments are important aspects to contribute to quality of life (Alzheimers Association, 2009; Koren, 2010). In order to obtain safety, independence and the home-like atmosphere, the staff and architecture layout must be a thoroughly analyzed and planned (Koren, 2010). The physical environment features ideal for these individuals include more privacy, silent electronic and hidden exits, and a variety of common spaces (Koren, 2010, pg. 709) as these have been proven to correlate with decreased aggression and depression and enhance sense of freedom (Zeisel, Silverstain, Hyde, Levkoff, Laton, Holmes, 2003). Having a quiet pace of life, plenty of light, and obvious bold signs of direction and labeled common locations, such as kitchen or bathroom, are additional aspects that contribute to a safe environment (Nursing Times, 2016). Special Care Units (SCUs), are known for specialized activity programs, special care training, restrictions to those necessary, and a thriving environment (Robison & Pillemer, 2007). With these individuals, familiarity is key to understanding needs, wants, and desires based on behaviors; therefore, striving to keep the same nurses, and care team is a significant distinction for this unit (Robison & Pillemer, 2007). Summary of Literature Review The purpose of this experience was to explore the gap between healthcare professionals, families, and residents with Alzheimers disease in order to establish meaningful connection and provide quality care. To accomplish that purpose, it was important to first understand the staff educational needs as well as address family members concerns through intentionally distributing surveys. After gaining a clear understanding of nurses and family member concerns, nurses were provided with educational tools and information regarding communication strategies, caregiver burnout tips, and other needs they reported were necessary while potential residents family members were provided with a packet containing information about Cherished Memories. This Running head: BRIDGING HEALTHCARE PROFESSIONALS 12 provided both the staff and family members a better understanding of how to properly and effectively care for individuals with AD. Methodology - Screening and Evaluation This experience focused on addressing the lack of knowledge for both families and healthcare professionals about AD in order to decrease lack of awareness and ensure a holistic approach to care. This study utilized a mixed methods approach through a combination of both observation and surveys in order to determine the needs of the facility and the perspective of individuals, specifically family members and nursing/activity staff. First, the student set aside several observation hours of Cherished Memories in order to better understand the unit itself, the environment, and humanistic interactions. Next, the student surveyed the nursing and activity staff on the memory care unit in order to determine the needs and concerns of nursing staff when caring for individuals with AD, followed by analyzation of the feedback given while the second portion of the experience began. To address the second portion, the student surveyed current residents family members in order to gain a clear understanding of their personal concerns. Nurse surveys provided feedback for personal concerns therefore allowing the student to develop educational in-services to alleviate many of those concerns. Following the feedback from the family members, topics were discussed in order to begin creating a family care packet. All portions of the methods were conducted at Cumberland Trace, a skilled nursing facility that hosts the Cherished Memories memory care unit. Initiating the Experience The speech therapist, unit manager, and director of Lifespan therapy at Cherished Memories initiated this experience after obtaining several observations of caregivers and families demonstrating a lack of knowledge about dementia and the skills it takes to care for these Running head: BRIDGING HEALTHCARE PROFESSIONALS 13 individuals. When informally interviewing and discussing this experience with both the speech therapist and the unit manager, they offered insight about their own experiences while at Cumberland Trace. They expressed the need for education about dementia and the deficits that are attached with the disease as well as communication strategies, to all staff members, specifically nursing and activities staff on the memory care unit because they directly care for these individuals daily. Both individuals reported observing nurses demonstrating frustration and agitation with their patients when completing self-care tasks, all of which most likely stemmed from poor communication skills (J. Saldana & J. Hollis, personal communication, Jan 11, 2018). As Jonathan, the memory care unit manager, said during an initial interview, I observed just the other day one of my nurses becoming frustrated when trying to get a resident to sit down on the toilet and I had to go over and provide her a teaching moment by cueing the resident of 1, 2, 3, sit down (J. Hollis, personal communication, Jan 11, 2018). These observations were consistent with findings in the literature. Poor communication skills with individuals with AD has led to frustration and agitation for nursing staff which can further result in decreased quality of care (Yang, 2017). The literature has also indicated that nurses in skilled nursing facilities experience caregiver burnout more often due to the level of care they provide (Yang, 2017) therefore caregiver burnout was intentionally addressed in the surveys. Based upon the students interviews and direct observations, intentional data collection from the staff members was necessary. Participants Nursing staff, activity staff, and residents family members were directly involved in this experience. Purposive sampling was used to recruit participants to complete the survey. Inclusion criteria for nursing and activity staff included being a member of the staff on Running head: BRIDGING HEALTHCARE PROFESSIONALS 14 Cherished Memories. When choosing residents loved ones to complete the survey, the student allotted one from each family due to attempting to attract a variety of feedback. The unit manager served as a guide to delegate which family members should receive the survey. Evaluation Tools After this informal assessment, paper surveys were distributed to the nursing and activity staff on the memory care unit to further investigate the concern. The survey consisted of 13 questions, utilizing a rating scale to verify comfort level of caring for individuals with dementia as well as level of burnout with his/her job. Questions were loosely adapted by two existing surveys, Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996) and Sense of Competence in Dementia Care Staff (Schepers, Orrell, Shanahan, Spector, 2012). The first portion of the survey was geared towards the level of burnout staff members were currently experiencing whereas the second part of the survey was geared toward addressing staff members comfort level and confidence when caring for these individuals. The Maslach Burnout Inventory is a rating scale for individuals to report how often he/she experiences various feelings of exhaustion, depersonalization, and personal accomplishment (Maslach et al., 1996). The Sense of Competence in Dementia Care Staff questionnaire targets the healthcare professional for how confident, on a scale of not at all to very much, they feel when communicating, caring, engaging, dealing with behaviors, etc (Schepers, Orrell, Shanahan, Spector, 2012). This questionnaire allowed staff members to anonymously be open about their comfort level when caring for individuals with AD, which in turn lead to an understanding of where the gap is when caring for individuals with dementia. See Appendix B for a select few sample questions from each section of the survey. Running head: BRIDGING HEALTHCARE PROFESSIONALS 15 To address the second portion of the purpose of this experience, a separate survey was developed for residents family members. This survey consisted of nine questions utilizing yes/no format and open-ended questions in order to gain insight of family members knowledge of dementia/Alzheimers as well as their knowledge of what this facility and Cherished Memories has to offer their loved one. These questions were formed based upon what the site mentor and unit manager wanted to know about their residents family members knowledge of AD and their perception of their own skills regarding training and communication. Open-ended questions were chosen in order to allow family members to express their own thoughts and experiences when caring for an individual with dementia as well as provide suggestions for topics that they would have been interested to learn more about prior to enrolling their loved one in the Cherished Memories program. The Goal Attainment Scale (GAS) was utilized to measure effectiveness of this experience; specifically the family care packet, nursing in-services completed, and number of activity boxes completed. The GAS is an effective form of measuring outcomes for therapeutic intervention because it allows therapist to adjust for accountability and document therapeutic change (Ottenbacher & Cusick, 1990). Therapeutic change occurs specifically through Allens Cognitive Model for this experience by providing interventions focused on education for nurses and family members. This scale still allows measurability for success and adaptations to be made if necessary (Ottenbacher & Cusick, 1990). Hartman, Borrie, Davison, & Stolee (1997) determined that the GAS is an effective tool to use with the mental health population, specifically a special care unit. In the study completed by Hartman et al. (1997), the scale was utilized to set individualized functional client goals and keep track of the individuals progress therefore giving reason to utilize this tool during this experience to keep the students personal Running head: BRIDGING HEALTHCARE PROFESSIONALS 16 goals clearly stated and allow for progress to be monitored. This outcome tool was chosen in order to effectively track the progress of the family care packet, activity boxes, and nursing inservices. This outcome tool provided clear feedback about the success of each goal. See Appendix A for GAS for this experience. Procedure The evaluation process consisted of observing the memory care unit and distributing surveys to the nursing and activity staff, and residents loved ones. The process began with daily observations of Cherished Memories in order to understand the difference between the memory care unit and a typical unit in the facility including the environment, activities, mealtime, and the program layout. In regards to the environment, observations were focused on how the unit was laid out, especially residents rooms, mealtime, security within the unit, common area, and activity room. Observations were focused toward the activity room in order to observe interactions between the activity staff member and the residents as well as determining if appropriate activities were given to residents. When observing residents rooms and the other architectural layout of the unit, the student focused on things such as privacy, space, lighting, noise, assistance, and security. Other observations were geared toward certain individuals, specifically nursing and activity staff members. These observations were key in developing educational trainings due to these individuals directly caring and interacting daily with individuals with AD. These individuals were pinpointed for observations due to research and previous interviewees stating nursing staff members have a difficult time communicating with individuals with AD. These observations also gave light to possible caregiver burnout experienced by staff members evident by conversation and facial expressions. Although the focus for this experience was to discuss the Running head: BRIDGING HEALTHCARE PROFESSIONALS 17 family care packet and nursing in-services, providing appropriate activities for the residents based on dementia stage was one goal added to this experience therefore consuming a big portion of the remaining observation hours. The second portion of the process began by distributing the surveys to the nursing staff. Due to the unit only having three registered nurses and two nurse aides, not including weekend staff, and one activity staff, nine surveys were provided in a concealed binder at the nurse station. Surveys were to be completed anonymously within seven days but due to limited responses, the deadline was extended another five days. A total of five surveys were returned to the binder prior to the deadline. Data analysis began for the nurse surveys while the resident family members surveys began to be distributed. These surveys were distributed in a slightly different manner due to convenience. Surveys were either distributed via unit manager during care plan meetings or the student when interacting with family members on the unit. Ten surveys were distributed with intentions of receiving all ten surveys back within a couple weeks however only nine were returned. The feedback and information received better-equipped nurse in-services and family care packet. The staff member questionnaire allowed the student to identify where the gap is when caring for these individuals as well as identify the level of caregiver burnout being experienced by these nurses. The family members surveys allowed for the family care packet to be family/resident focused and include information the family finds valuable to know prior to admitting their loved one into the memory care unit. This experience solely focused on specific individuals knowledge about Alzheimers whereas this may be not apply to other settings. Setting Comparison Running head: BRIDGING HEALTHCARE PROFESSIONALS 18 This type of cognitive approach is comparable to a variety of settings but also can be contrasted to several other settings. For this specific setting, this experience was focused toward functional cognitive performance therefore impeding ability to independently complete everyday activities, both ADLs and IADLs otherwise known as Allens Cognitive Model. Allens Cognitive approach looks at the role of habits and routines, the effect of physical and social contexts, and the analysis of activity demand (Cole & Tufano, 2008). Mental health is an area of practice in which occupational therapists work to address an individuals mental capability to successfully complete everyday activities. According to Castaneda, Olson, & Radley (2013) mental health incorporates any and all of the following: adapting the environment, develop leisure activities, facilitate skills for independent living, and provide ADL training. Another setting that addresses cognition through the lens of the Allen Cognitive approach is acute rehabilitation through practitioners identifying individuals deficits and attempting to return the patient back to their baseline or as functional as possible in their daily life. Setting Contrast Many practice settings identify cognitive impairments and further investigate how they impacted the individual's ability to independently complete their daily tasks but each facility may do so in a different manner. Acute care is a setting that addresses cognition for safety purposes but does so through the use of Toglia rather than Allen. Toglias approach looks at cognition through the lens of restoring cognitive dysfunction (Cole & Tufano, 2008). Disability defined in the Toglia model is defined as unable to process and organize information, lack of previous knowledge, and unable to apply performance skills in varying situations (Cole & Tufano, 2008). Practitioners in this facility may not specifically look for dementia but certainly look at cognition in order to determine if he/she is safe to return home alone or if they require supervision during Running head: BRIDGING HEALTHCARE PROFESSIONALS 19 specific ADLs/IADLs. Research determined that acute care focuses on mental health and cognitive factors in addition to other physical symptoms (AOTA, 2017). Cognition plays a key role when determining if individuals are capable of returning home but not always the prime focus for all settings. Implementation Phase Interpreting the Needs Assessment Knowledge gained from observation hours spent in Cherished Memories indicated a need for nurse in-services regarding communication strategies, differentiating stages, and handling behaviors. Observations included viewing inappropriate activities or games being given to individuals. For example, an individual in the mid-stage of dementia was provided a puzzle to complete independently. An individual in the mid-stage of dementia does not have the cognitive function to be able to complete a puzzle independently; rather, they need assistance for beginning the puzzle and several cues. Observations that involved the staff include the following: staff approaching individuals with no facial expression, staff having no intention of telling the resident the plan for where he/she is being taken, and aggressive transfers with no verbal instruction. Several staff members struggled with effectively communicating with many patients, as indicated by rarely engaging in a conversation with an individual who presented in the late stage, repeating the same phrase rather than re-phrasing, and looking at another staff member for direction. Staff members often talked to these older adults as if they were children evident by, Roger, buddy, can you sit down or their tone of voice would change into the baby talk voice. Lastly, an observation noticed was staff did not understand how to handle behaviors. For example, when a patient continuously stood up, the nursing staff repeatedly told him to sit down but never redirected him to an alternate activity. Whenever residents became upset or sad, Running head: BRIDGING HEALTHCARE PROFESSIONALS 20 staff often did not always take the time to acknowledge their feelings. For example, several residents would have emotional breakdowns or demonstrate a variety of behaviors and instead of addressing the behavior, staff members found a way for the resident to soothe themselves such as sitting in front of a window. Several nurses did not properly address wandering. Rather than redirecting the individual to an activity, they would allow the individual to wander or sleep for hours. Staff members expressions indicating annoyance or frustration included eye rolling, crossing arms, and allowed the resident to continuously ask the same question over and over. On several accounts, nurses indicated frustration through side conversations with other nurses or facial expression. For example, Figure 1 depicts, an observation viewed on several accounts. Observations allowed the student to visualize interactions but the surveys would provide personal feedback from the staff. Surveys demonstrated over half of nursing and activity staff experience some emotional drainage throughout some portion of their workday but seventy-five percent denied exhibiting these feelings when caring for residents. These surveys concluded that the nursing staff feels confident and comfortable performing their work but a small percentage indicated challenges keeping a positive behavior and engaging individuals in activities. Although nurse surveys did not capture a large picture of where the gap was when caring for individuals with AD, the students observations helped clarify and close in the gap. Several observations did not correlate with the results of the surveys. For example, nurses reported they felt they can effectively communicate with individuals with AD but several of the students observations indicated otherwise. Another observation that contradicted what the surveys specifically asked was how effectively do you feel about handling a behavior in a person with dementia. Many of the nurses indicated they can handle behaviors pretty well while the Running head: BRIDGING HEALTHCARE PROFESSIONALS 21 observations indicated it may lean a little more to not-so-well. The investigator found a similarity between both observation and surveys, which was the decreased positivity with several nurses when caring for residents. Nurses explicitly stated this in the survey but facial expression and side conversations were noted during observation hours to indicate decreased positivity. A second similarity that was found between the surveys and the observations was that staff members felt emotionally drained frequently throughout their workday. Feedback given from residents family members provided valid information pertaining to their own knowledge of AD. As the results depict in Appendix D and E, family members found it crucial to focus on what the unit and the facility has to offer regarding memory care. Due to each category showing a need, the student decided to touch upon most topics. From this information, the family care packet focused on communication strategies, resources, the process of Alzheimers and stages, possibilities for therapy, as well as how appropriate activities will be included in the memory care unit. This information indicated that the family care packet should have a family and resident focus. In-Service Information gathered from the needs assessment indicated a need for nurse in-services and a family informational care packet. The student determined that the nurse in-services will be initially directed towards the staff members on Cherished Memories and will discuss the following topics: Alzheimers Disease statistics, the importance to healthcare professionals, the stages of dementia and deficits, effective communication strategies, common behaviors, and tips/resources about caregiver burnout. This in-service utilized a PowerPoint in order to easily disseminate the information gathered as well as videos and scenarios to assist in the ease of learning various approaches to caring for individuals with AD. Former research by Kolanowski Running head: BRIDGING HEALTHCARE PROFESSIONALS 22 et al. (2015) demonstrated that individuals, particularly nursing staff, retain and learn new information quicker and more efficiently when introduced through hands on or interactive learning. The in-service was held one time for the staff members on Cherished Memories due to the limited number of staff members. Following the in-service, each individual completed a short post-survey in order to determine the amount of knowledge gained from the in-service and to receive feedback based on the presentation itself and content. The in-service was held one other time for other nursing staff members available to further educate society and healthcare professionals. Staff education was a large component of this DCE experience but education in general for all society is even more important. Staff was directly educated on AD, effective communication strategies, behaviors, and burnout strategies through in-services. These inservices directly facilitated staff education in order to create better care for individuals with AD. Family Care Packet The feedback provided by residents family members surveys provided a sneak peek of societys knowledge of AD. The following are topics that were discussed in the family care packet: understanding memory impairment, stages of Alzheimers Disease, why memory care, environment, daily scheduled activities, staff qualifications, activities of daily living, mealtime, behaviors, therapy options, and caregiver resources. Attached to the packet is a Life Story Questionnaire created by CPI dementia care specialist (2016) to gather previous social history, routines, and interests about the resident in order to facilitate a more person centered care residency. This family care packet remained focused on the positive treatment received at Cumberland Trace and what the memory care unit entails. This packet continued to allow family members to understand the architectural design of the unit, structured routine provided, and additional treatment the unit and staff offer to residents. The family care packet directly Running head: BRIDGING HEALTHCARE PROFESSIONALS 23 facilitated education on Alzheimers Disease to society but the packet also indirectly educated the staff. This packet will continue to facilitate staff and society education therefore holding staff members to higher standards of care. Family members will have greater knowledge, possibly generating further questions for the nursing staff. The staff members may utilize this packet as a reference and to answer these upcoming questions of potential residents family members. Outcomes To address the outcomes of this experience, the Goal Attainment Scale (GAS) was reviewed in order to determine if goals were met. When reviewing the GAS, all goals were accomplished at the level of more than expected. Refer to Appendix G for table depicting score correlating with the final outcome results. Although the initial plan was to only educate the staff members of Cherished Memories, other nursing staff members of long term care were also provided with this information. The family care packet went above and beyond the original goals due to adding the additional social history questionnaire as well as additional components, as previously stated, within the packet. In order to achieve each goal, modifications were made regarding timeline, content, & communication style. In regard to activity boxes, the timeline was shifted due to a variety of complications. Activity boxes consisted of materials and instructions that were appropriate for each dementia stage. For example, for the yellow stage (middle), one activity box includes a matching game with pictures demonstrating correct set up and specific instructions for the staff members to use in order to know exactly how to present the activity for the resident to understand. The boxes were initially intended for group use; however, the unit manager indicated the benefits of addressing individual activities instead. With this shift came several Running head: BRIDGING HEALTHCARE PROFESSIONALS 24 other responsibilities including researching the stages of dementia utilized by Cumberland Trace and better grasping the deficits and needs of all three stages (green, yellow, red). This shift affected the cost, time, and number of activities required to create the boxes. Due to the increase in activities, there was an increase in instructions, therefore an overall increase in time needed to properly write out the instructions. With the modifications to the boxes, extra time was allotted for development of an action plan for costs and time. To create an adequate number of activities for each color, continuous research was necessary to determine what type of activities would be appropriate. Several websites provided information regarding appropriate activities (Alzheimers Association, 2017; Vargo, 2017). Activities were also based from the speech therapist wants and desires from her own previous research. Few modifications were made to the nurse in-service due to receiving positive feedback through post survey. Rather than only hosting the in-service for staff members on Cherished Members, the information was provided to the long-term care team members as well. Staff members were acknowledged for receiving additional training regarding dementia after completing the in-service. Although there were minimal post surveys completed, results indicated staff members were accepting and grateful for the information provided and also provided feedback indicating the information will be helpful in their career. Every staff member who attended reported learning something new during the in-service that he/she feels comfortable using in their career, feeling more comfortable with the three stages of dementia, can better communicate with individuals with dementia, and feel better about distinguishing behavior. Each individual also reported the scenarios being helpful. The family care packet was utilized to address the concerns of the residents family members and to educate them about Cumberland Trace Memory Care. Several components went Running head: BRIDGING HEALTHCARE PROFESSIONALS 25 into this packet; therefore, modifications were required. Initially, the surveys were to be reviewed and completed via phone call but quickly changed due to site supervisor strongly feeling family members would not give honest feedback. The creation of the care packet was delayed due to a delay in the needs assessment survey. With this delay, the student decided to continue creating the packet but to add in family members information and suggestions after completing the rough draft. The timeline was continuously pushed back due to inconsistency and delay of feedback throughout the process. Due to the packet being reviewed by both the supervisor and unit manager, it took increased time but was necessary in order to implement the completed packet to the standards of both individuals. Sustainability The student continuously reviewed and brainstormed how to encourage the staff members of Cumberland Trace to continue utilizing the nursing in-service information, activity boxes, and family care packet following the completion of the experience. The student created a binder including the following items: research articles from the in-service, the Power Point from the in-service, and quick tips/hints for effective communication strategies for each stage that will be available to the staff members on Cherished Memories. Research has proven that individuals retain and learn more through scenarios and videos therefore the student provided the video links within the binder (Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015). These specific videos addressed bathroom or shower scenarios, depression, or anger scenarios are here to be quick reference. The student discussed with the unit manager and supervisor about the possibility of utilizing the information from the in-service for new employee training at Cumberland Trace. The unit manager agreed to utilize the resource binder for new employee training. To ensure the activity boxes are continuously used post upon completion of this DCE, Running head: BRIDGING HEALTHCARE PROFESSIONALS 26 the student provided step by step instructions printed on a notecard outside the box rather than demonstrating and teaching the activity staff member currently in Cherished Memories. By leaving step by step instructions, the activity will be readily available for nurses, family members, staff members to easily pick up an activity box and know exactly how to present the activity to the individual without the need to be trained. Lastly, to create sustainability with the family care packets, the student discussed with the unit manager about creating a distribution process during initial care plan meetings. The student strongly believes the unit manager will stick to distributing these packets because he is one of the main individuals who influenced the creation of these packets. The site mentor strongly believes that the family care packets will be carried over to other CarDon sites in order to facilitate knowledge about Memory Care units (J. Saldana. Personal communication, Jan 2018). After speaking to Jonathan, he agreed to distribute the packet during initial family care plans or as he sees fit. Society Needs This experience solidified the need for education and training on Alzheimers Disease be offered to staff members working with this population. Not only for this facility and memory care units, but all staff members who directly work with older adults. Workers should be educated and trained on proper techniques for caring with individuals with dementia. As research has already proved, nursing staff and physicians have repeatedly reported facing challenges when caring for individuals, specifically when communicating and addressing behaviors (Dewing, 2010). In order to begin facilitating this type of care and creating person centered practice, staff members must be aware of residents past history including family history and behavior triggering information (Kolanowski, Van Haitsma, Penrod, Hill, Yevchak, 2015). With residents past history, staff members will be able to resonate and connect with Running head: BRIDGING HEALTHCARE PROFESSIONALS 27 residents in order to establish a trustworthy relationship. Research has also stated that by providing educational in-services, aides felt more confident and comfortable communicating with individuals with AD therefore decreasing negative emotions (Sprangers, Dijkstra, & Romijn-Luijten, 2015). This experience skimmed the surface of advocacy for this population but its a start to beginning the process. This experience directly advocated for individuals with AD by educating their caregivers and daily caretakers on the disease, effective communication strategies, how to handle challenging behaviors, and resources to assist in the caregivers own health and wellbeing. Although this experience focused on beginning the advocacy and educating process at Cumberland Trace, it is with great hope that the knowledge will be spread through other memory care units owned by CarDon. By providing education and training to the staff members of Cumberland Trace about AD and how to properly care for these individuals, Cherished Memories will hopefully be better equipped with educated and knowledgeable staff members. With educated and knowledgeable staff members, better care will be given to the residents. By creating a family care packet, the residents family members at Cumberland Trace will be more knowledgeable on AD therefore decreasing the lack of public awareness. By educating more individuals, especially loved ones who are directly impacted by AD, the hope is that these individuals will then turn to society to spread their own knowledge and education in order to create a chain of events leading to an awareness of disease. Leadership Several aspects of this experience allowed the student to utilize leadership skills. The key leadership components included communication, responsibility, and selfmotivation. Throughout this experience, effective communication was an essential part of initiating the needs assessment and implementing the in-services for staff members. Obstacles Running head: BRIDGING HEALTHCARE PROFESSIONALS 28 were handled each time through professional and open communication with the unit manager and supervisor. Miscommunication and misconstrued focus of the DCE resulted in several weeks passing by before the in-service was finally schedule. Through self-advocacy and open communication, the issues were resolved. Since this experience is new to both the university and the facility, being able to professionally advocate and describe this DCE experience is a large part of creating a successful experience. Responsibility and self-motivation determined the success of this experience because of the experience being solely based on how well established goals were, as well as how responsible the student was at completing tasks on time. Both of the supervisors had busy schedules; therefore, meeting time was limited and often included minimal detail. The student discovered that with several questions and verbalizing needs and desires, the feedback given was more beneficial. With each obstacle came increased responsibility to keep on task and balance time management with each task. Discussion Overall Learning Cumberland Trace is one of the skilled nursing facilities that host an in-house memory care unit. This DCE focused on bridging the gap between individuals with AD, healthcare professionals, and family members through advocacy and providing educational trainings and knowledge to all parties. Positive outcomes were noted regarding the advancement of the memory care unit and the educational documents provided to healthcare professionals and families. Staff members of Cherished Memories voiced positive feedback through post survey and positive feedback from supervisors regarding family care packet therefore indicated a successful experience. This experience created a snapshot of the importance for healthcare Running head: BRIDGING HEALTHCARE PROFESSIONALS 29 professionals and families to be properly educated on AD. Overall, this experience accomplished what the OT student had in mind. This experience required a variety of skills to effectively complete the desired outcome. Communication is key to accomplishing a large goal. A variety of different communication styles were necessary in effectively achieving each goal. The student had to effectively communicate with staff members, supervisors, residents, residents family members, and other personal when completing each goal. Communication skills are how a solid foundation for a relationship was built between the supervisor and the student. All communication via email, face-to-face, and non-verbal gestures was professional and respectful of the other profession. When communicating, demonstrating clear and concise needs and desires was imperative to creating the desired outcome. Through collaboration and effective communication, goals were established and successfully accomplished. The outcomes would not have been accomplished without successful communication between all individuals. Limitations When reviewing the goal attainment scale to address the status of each goal, limitations were highlighted. Only receiving 50% (n=5) of surveys back from Cherished Memories staff members was the main limitation during this experience due to surveys designed to provide the student with the needs of the unit. The lack of responses could be contributed to by the limited number of staff members per shift therefore increasing responsibilities and caseload for each staff member to pass along the word. The limited response may have interrupted the course of action by not effectively describing the needs of the unit. Another limitation noted was the limited number of post-surveys received following the in-service on Cherished Memories therefore inhibiting feedback. The minimal number of attendees could influence limited Running head: BRIDGING HEALTHCARE PROFESSIONALS 30 response. Due to timeline shift for family care packet, there was not enough time post completion to verify satisfaction with potential residents family members. Further Advancement As indicated throughout this paper, there is a need for advocacy with individuals with AD in order to bridge the gap between healthcare professionals, family members, and these individuals. With the diagnosis expected to exponentially grow in the upcoming years, that places a large focus on the need for knowledgeable practitioners and family members. This experience attempted to begin the advocacy process at Cumberland Trace in order to emphasize the importance of training and education for healthcare professionals and family members. The need for further advancement for properly educating/training individuals is essential in preparing for the future. By excluding this population and refusing to acknowledge the decrease in amount of adequately educated individuals to treat and care for individuals with AD, as healthcare facilities, it will be doing injustice to the family members who trust the healthcare provider to properly care for their loved one. Failure to continue education on AD will only create disheartening and ill-equipped facilities to care for this population. It is imperative to continue educating current and future nurses about the disease process, effective communication, appropriate activities, structured routines, mealtimes, and simply how to treat them like a person rather than for the unfortunate disease with no cure. In order to treat the individual, we need to see him/her for themselves rather than the disease (Ericson-Lidman, Franklin Larsson and Norberg, 2013) and with nurses continuously reporting feeling incompetent when communicating and treating residents with AD (Wang, Hsieh, & Wang, 2013; Ahmad, 2014; Kolanowski, Van Haitsma, Penrod, & Yevchak, 2015) it becomes a constant battle to maintain this perspective. Therefore, facilities bear a great responsibility to provide educational trainings Running head: BRIDGING HEALTHCARE PROFESSIONALS 31 to staff members in order for them to effectively begin treating the individual. It all will begin with acknowledging the lack of awareness and understanding of the disease. With the growth of Alzheimers disease only expected to continue growing, it is essential our healthcare professionals are well equipped with the proper knowledge to provide quality care. The purpose of this experience was to explore the gap between healthcare professionals, families, and residents with Alzheimers disease in order to establish meaningful connection and provide quality care. To fulfill this purpose, concerns of both healthcare professionals and family members of Cherished Memories were identified then answered with educational trainings and documents. Educational in-services were provided to staff members in order to adequately equip them with necessary knowledge to effectively care for individuals with AD. A family care packet was developed for potential new residents family members in order to educate on the stages of the disease as well as the details about memory care. Positive feedback was given from both staff members and supervisors regarding educational in-services and family care packet. Information retrieved for in-services will be provided to new employees and the packet will continue to be distributed to potential new residents family members. This exploratory experience will assist in bridging the gap in order to begin advocating for individuals with AD and create a holistic approach to care. Running head: BRIDGING HEALTHCARE PROFESSIONALS 32 References Ahmad, M. N. (2014). Efficacy of communication among nurses and elderly patients suffering from the dementia of Alzheimer type. (Electronic dissertation or thesis). 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Retrieved from https://www.crisisprevention.com/Blog/July-2016/Allen-Cognitive-Disabilities-Model Running head: BRIDGING HEALTHCARE PROFESSIONALS 34 Kolanowski, A., Van Haitsma, K., Penrod, Hill, N., & Yevchak, A. (2015). Wish we would have known that! Communication breakdown impedes person-centered care. The Gerontologist, 55(1), S50S60. doi:10.1093/geront/gnv014 Koren, M. (2010). Person-centered care for nursing home residents: The culture-change movement. Health Affairs, 29(2), 1-6. doi: 10.1377/hlthaff.2009.0966 Lanzi, A., Burshnic, V., & Bourgeois, M. (2017). Person-centered memory and communication strategies for adults with dementia. Topics in language disorders, 37(4), 361-374. Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The personenvironment-occupation model: A transactive approach to occupational performance. Canadian journal of occupational therapy, 63(1), 9-23. Ottenbacher, K.J., & Cusick, A. (1990). Goal attainment scaling as a method of clinical service evaluation. The American Journal of Occupational Therapy : Official Publication of the American Occupational Therapy Association,44(6), 519-25. Maslach, C., Jackson, S., & Leiter, M. (1996). Maslach Burnout Inventory. (3 ed.). Palo Alto, rd CA: Consulting Psychologists Press. Recognizing Caregiver Burnout. (2018). Web MD. Retrieved from https://www.webmd.com/women/caregiver-recognizing-burnout#1 Robison, J., & Pillemer, K. (2007). Job satisfaction and intention to quit among nursing home nursing staff: Do special care units make a difference? Journal of Applied Gerontology, 26(1), 95-112. Schepers, A., Orrell, M., Shanahan, N., Spector, A. (2012). Sense of competence in dementia care staff (SCIDS) scale: Development, reliability, and validity. International Psychogeriatrics, 24(7), 1153-1162. https://doi.org/10.1017/S104161021100247X Running head: BRIDGING HEALTHCARE PROFESSIONALS 35 Sprangers, S., Dijkstra, K., & Romijn-Luijten, A. (2015). Communication skills training in a nursing home: effects of a brief intervention on residents and nursing aides. Clinical Interventions in Aging, 10, 311319. http://doi.org/10.2147/CIA.S73053 Vargo, S. (2017). Approaching Alzheimer's Disease through Non-Pharmacological Interventions. (Electronic Thesis or Dissertation). Retrieved from https://etd.ohiolink.edu/ Wang, J., Hsieh, P., & Wang, C. (2013). Long-term Care Nurses' Communication Difficulties with People Living with Dementia in Taiwan. Asian Nursing Research. 7. 99103. doi:10.1016/j.anr.2013.06.001. Warshaw, G., & Bragg, E. (2014). Preparing the health care workforce to care for adults with alzheimers disease and related dementia. Health Affairs, 33(4), 633-641. doi: 10.1377/hlthaff.2013.1232 Zeisel, J., Silverstein, N., Hyde, J., Levkoff, S., Lawton, M., & Holmes, W. (2003). Environmental correlates to behavioral health outcomes in alzheimer's special care units, The Gerontologist, 43(5), 697711 https://doi.org/10.1093/geront/43.5.697 Yang, D. (2017). Stress and burnout in demanding nursing home care. (Electronic thesis or dissertation). Retrieved from http://www.theseus.fi/bitstream/handle/10024/131893/Yang_Di.pdf;jsessionid=4028A2C 49A0401DF72510954DDF3D044?sequence=1 Running head: BRIDGING HEALTHCARE PROFESSIONALS 36 Appendix A Table 1 Students Goal Attainment Scale Note. This Goal Attainment Scale (GAS) was utilized to address each component throughout this experience. The scale is effective in determining if each established goal has been met as expected, less than expected, or more than expected. It allowed the student and supervisors to determine the progress of the experience as well as make adjustments as necessary. Running head: BRIDGING HEALTHCARE PROFESSIONALS 37 Appendix B Table 2 Sample Survey Questions for Staff Members Note. These survey questions were utilized to determine the level of burnout experienced by staff members on Cherished Memories. These survey questions were loosely adapted from the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996) and the Sense of Competence in Dementia Care Staff (Schepers, Orrell, Shanahan, Spector, 2012). Running head: BRIDGING HEALTHCARE PROFESSIONALS Figure 1. Experiences of nurses caring for individuals with alzheimers disease. This figure illustrates an observation of two nurses feeling frustrated and agitated when caring for individuals with dementia. 38 Running head: BRIDGING HEALTHCARE PROFESSIONALS 39 Appendix D Table 3 What do Residents Family Members Want to Know? Note. This graph depicts the results based upon the responses received from the residents family members surveys. As indicated above, several topics are of interest for family members. Due to the high response in each of categories except environmental adaptations, he family care packet will encompass each of these categories. Running head: BRIDGING HEALTHCARE PROFESSIONALS Appendix E Table 4 Residents Family Members Knowledge of Alzheimers Disease Note. The graph above depicts the results from the yes/no questions asked about loved ones knowledge of Alzheimers and how well they were educated by healthcare professionals. As shown above, Cumberland Trace effectively educates their residents family members but education falls short outside of the facility. 40 Running head: BRIDGING HEALTHCARE PROFESSIONALS 41 Appendix F Table 5 Goal Attainment Scale Results Note. This Goal Attainment Scale (GAS) depicts the final outcome results. This image indicates all goals were achieved above expectations.  ...

... An Operations Approach Toward Improved Patient Outcomes in Skilled Nursing Facilities Curtis Clem, OTS May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Julie Bednarski, MHS, OTD, OTR Running head: IMPROVED OUTCOMES IN SNF 1 A Capstone Project Entitled An Operations Approach Toward Improved Patient Outcomes in Skilled Nursing Facilities Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Curtis Clem Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 IMPROVED OUTCOMES IN SNF Section I: Abstract A capstone experience was completed to fulfill academic requirements for a doctoral degree in occupational therapy. The primary goal of the doctoral capstone experience was to develop advanced leadership and administrative skills within the profession of occupational therapy. To accomplish this goal, operational strategies were implemented to adapt to the care delivery system in the skilled nursing facility (SNF) environment to achieve optimal clinical and operational performance. A review of current literature revealed that transformations in healthcare have yielded increased demands for SNFs to demonstrate quality services and datasupported evidence of reduced hospital readmission rates. Results from the literature review and a needs assessment indicated the need to develop an outcome tool that therapists can use to measure hospital readmission risks for patients who discharge from SNFs to home. From an operations perspective, the outcome tool helps to delineate the SNF organization from its competitors, market quality metrics to establish partnerships with hospitals, and fulfill healthcare system requirements. Clinical use of the outcome tool also aims to assist in the identification of potential system and population issues, and to verify consistent provision of high quality care. This capstone paper summarizes the development and implementation processes of the outcome tool, describes plans for continuous quality improvement, and highlights administrative and leadership skills gained throughout the doctoral capstone experience. IMPROVED OUTCOMES IN SNF 3 Section II: Background Information and Literature Review Purpose The purpose of the doctoral capstone experience was to develop advanced leadership and administrative skills in the skilled nursing facility (SNF) practice setting. This section introduces the theoretical basis used to guide the project completed during the experience, describes major changes in the healthcare system, and introduces the implications for SNFs to adaptively respond to the healthcare changes. Theoretical Basis An operations-based approach for the doctoral capstone experience was directed toward quality improvement of therapy practice to yield better patient outcomes and, in turn, improve business performance. Theories used to organize the approach were the Organizational Development (OD) theory and the Interorganizational Relations (IOR) theory. The OD theory relates to the development of strategies that facilitate organizational effectiveness (Cummings, 2004). OD encourages continuous improvement of knowledge and skills to adapt to the changes of complex environments (Butterfoss, Kegler, & Francisco, 2008; Cummings, 2004). Organizational change occurs through a four-step cycle: diagnosis, action planning, intervention, and evaluation of progress (Butterfoss et al., 2008). The IOR theory is rooted in the principle that collaboration among organizations generates more comprehensive and more effective methods to overcome complex issues (Butterfoss et al., 2008). Frameworks used to guide an operational approach to therapy services included transformational leadership and quality improvement. IMPROVED OUTCOMES IN SNF 4 Literature Review According to healthcare experts, SNFs may experience the need for significant operational changes in the near future, which could also impact operative strategies in therapy (Optima Healthcare Solutions [OHS], 2017). Operational changes in the SNF setting can largely impact older adult populations and the quality of services they receive. Centers for Medicare and Medicaid Services (CMS) reported over 55 million Medicare Part A beneficiaries in the United States (U.S.); over 46 million of which were older adults and nearly 9 million had disabilities (CMS, 2015). A literature review was performed to gather information on the healthcare reform that may impact therapy services within SNFs, and to identify effective strategies that therapy administrators may use to generate adaptive responses to healthcare system changes. EBSCOhost and Ovid research databases were used to search evidence discussed in this paper. Other literature that was not identified through the research databases included: proposed Medicare changes and trends via Federal Register documents, CMS innovations website, and other reliable reports. The literature review was limited to studies that included or related to therapy services within SNFs. Healthcare system changes. An improvement in the quality of healthcare services and an overall reduction of costs are two topics that have become major focal areas in healthcare (Strunk, 2014). As a result, initiatives that have been employed by CMS officials have produced greater demands for operational modifications within SNFs. (Strunk, 2014). As part of cost reduction, decreases in average length of stay (LOS) and hospital readmission rates have become primary components for SNFs. IMPROVED OUTCOMES IN SNF 5 One method CMS officials have proposed to reduce costs in SNFs is through a new value-based payment system, the Resident Classification System Version 1 (RCS-1) (42 CFR 488, 2017; CMS, 2018b). The RCS-1 has been proposed to replace the current case-mix classification model with a single payment based on the complexity levels of Medicare beneficiaries and the resources needed for treatment (42 CFR 488, 2017; CMS, 2018b). Also through the proposed RCS-1, CMS strives to further reduce healthcare costs by decreasing LOS through an adjustment factor that gradually decreases the reimbursement rate after 14 days (42 CFR 488, 2017). With an average LOS of 20.1 days in Indiana and 18.3 days in the U.S. in 2016 (22.89 days within the SNF organization), this could largely impact the revenue of SNF organizations (PEPPER Resources, 2017). Though the final rule has not been published, the proposed RCS-1 is an example of CMSs efforts to redirect healthcare professionals focus toward the needs of the patient and eliminate clinical decisions that are primarily based on financial profits (Strunk, 2014). Bundled payment models have been another method for cost reduction by incentivizing organizations to provide high quality services to Medicare beneficiaries within a shortened LOS. The Bundled Payment for Care Improvement Advanced and the Comprehensive Joint Replacement bundled payment model are two current examples that support this movement (42 CFR, 510, 2017; CMS, 2018a). With bundled payment models, CMS aims to improve coordination of care and minimize duplicate or unnecessary services, promote evidence-based practice, and promote financial accountability from healthcare providers (CMS, 2018a; McHugh et al., 2017). As another major component of cost control, reduced hospital readmission rates has become a priority for the healthcare reform in the U.S. (Alper, O'Malley, & Greenwald, 2017; IMPROVED OUTCOMES IN SNF 6 Herbold & Larson, 2016; Huckfeldt, Mehrotra, & Hussey, 2016; Ottenbacher et al., 2014; Rahman, McHugh, Gozalo, Ackerly, & Mor, 2016). With an average cost of more than $10,000, acute care hospitals aim to reduce costs through utilization of post-acute care (e.g. SNFs). The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) initiative will require, and incentivize, healthcare providers for verification that their services have led to decreased hospital readmissions, or endure financial repercussions (OHS, 2017). As a result, researchers and healthcare organizations have worked to identify factors that are associated with increased risk for hospital readmissions (Pedersen, Meyer, & Uhrenfeldt, 2017). These risk factors will be further discussed later in the paper. Though cost reduction can benefit the healthcare system, it can also threaten the financial viability of SNFs and the quality therapy services in the SNF setting. For example, as a result of therapy reimbursement restrictions under the RCS-1, patients may not receive the amount of therapy services and intensity they need to achieve optimal outcomes (OHS, 2018). Also, the pressure to decrease LOS could result in premature discharges; patients may be discharged to home before they are safe in their home environments (OHS, 2018). Patients who are discharged prematurely may have greater risks for hospital readmission which, in turn, could yield increased costs due to hospital readmission. Other challenges in SNFs. In addition to cost reduction efforts, other changes in healthcare have led to greater operational difficulties for SNFs. Recent changes to the conditions of participation (CoPs), which contains the requirements SNFs must meet to maintain eligibility for Medicare and Medicaid reimbursement, will intensify scrutiny and requirements for SNFs (42 CFR 405, 2016; OHS, 2017). Increased requirements for quality assurance, including a datasupported quality assurance and performance improvement (QAPI) program, add to the pressures IMPROVED OUTCOMES IN SNF 7 on SNFs to justify costs for patient care. If CoPS standards are not met, SNFs risk financial penalization as well as loss of Medicare/Medicaid eligibility (42 CFR 405, 2016; OHS, 2017). Greater demands for SNFs could lead SNF administrators to set more requirements for therapy departments (OHS, 2017). Another challenge SNFs have experienced is a decrease in occupancy. From 2012 to 2016, occupancy in SNFs declined more than 5% (CliftonLarsonAllen, 2017a, 2017b). Healthcare providers are becoming increasingly pressured to guide consumers toward community- and home-based services, and away from SNFs (CliftonLarsonAllen, 2017b). As a result, therapy caseloads in SNFs have been increasingly composed of adults who are older, frailer, and have greater medical complexities (Buurman et al., 2016). The natural progression of aging and complex conditions could limit rehabilitation potential, which could impact perceptions of therapy quality (Buurman et al., 2016). One study found that, during a 1-year follow-up, 74% of Medicare beneficiaries who were admitted to SNFs made minimal to no improvement; 70% of which experienced frailty upon admission (Buurman et al., 2016). Lastly, growth in competition among SNFs has become a challenge faced by organizations. Quality improvement efforts such as the CMS Five-Star Quality Rating System and the Skilled Nursing Facility Quality Reporting Program measure have been implemented to increase healthcares transparency of service quality. Hospitals can use such tools to gather information to determine specific SNFs to recommend to their patients. Trends have shown that hospitals generally direct their patients to SNFs that provide high quality and cost-efficient care (Herbold & Larson, 2016). Implications. For SNFs to achieve sustainability in a competitive market with increasingly difficult demands, therapy providers need to demonstrate exceptional oversight of IMPROVED OUTCOMES IN SNF 8 quality patient care that is measurable and is supported by data. Sufficient data management will allow therapy providers to adjust practice strategies to maintain clinical excellence and financial viability (OHS, 2018). As stated by Teresa Chase (2012), President and CEO of American HealthTech, Cash is still king, but theres a new queen in town and her name is data. In support of the use of data to determine quality of care, Seema Verma, CMS administrator, has highlighted future plans for CMS to focus outcome measures (Slabodkin, 2017). Therapy practitioners can use outcome tools can to establish benchmarks and measure effectiveness of therapy services (Shah et al., 2013). Data collected from outcome tools can also be shared with hospitals to establish collaborative care networks (Shah et al., 2013). Expansion of care networks can lead to increased recommendations of the SNF organization and, in turn, generate revenue. Section II Summary Transformations of the healthcare system have created strains for SNFs, which has yielded increased demands for therapy departments; therapy practitioners are pressured to produce optimal patient outcomes under increasingly difficult circumstances. These changes have created various challenges for SNFs to achieve clinical excellence and maintain financial viability. With cost control and quality care being a primary focal points among healthcare organizations, upstream care providers (e.g. hospitals) need to be able to ensure that their patients safely and efficiently transition across levels of care. Patient outcomes are a major area for determining quality care and, since therapy can largely impact these outcomes, SNF administrators may turn to therapy practitioners to provide data that reflects high quality performance. The reviewed literature indicates a gap in the use of an interdisciplinary outcome IMPROVED OUTCOMES IN SNF 9 tool that is inclusive of the patient gains through participation in therapy services, which limits insight into the need for and quality of skilled therapy. Research of regulations, trends, and other transformations in the healthcare system, as well as their impact on operational strategies within SNFs, contributed to the goals of the doctoral capstone. Leadership skills were enhanced through a challenge of the current processes and identification of innovative solutions to create an adaptive response to the external environment. Administrative skills were increased through the acquisition of knowledge that is required to successfully navigate the processes for creating an adaptive response. The next section explains the evaluation and development process of the doctoral capstone. Section III: Evaluation & Development of the Outcome Tool Needs Assessment A needs assessment was performed to determine operational needs of the SNF organization in correspondence to changes in the healthcare system. Interviews were performed with therapy administrators of the SNF organization. The director of clinical coordination, whose primarily role was to establish and maintain partnerships with hospitals, also participated in the interview process. Discussions were related operational plans to successfully meet the demands of current healthcare changes. One pertinent need that was acknowledged was related to standards under the SNF VBP initiative, which will require SNFs to provide data that show decreased hospital readmission rates. Another identified need was to provide hospitals with data that demonstrates patients reduced risks for hospital readmission as part of participation in skilled therapy services. Thus, results from the needs assessment indicated a primary need to gather data that represent the relationship between patient outcomes and decreased hospital readmissions. Data will be used meet two primary needs of the SNF organization: 1) meet IMPROVED OUTCOMES IN SNF 10 requirements under SNF VBP initiative and 2) provide hospitals with valuable information that shows reduced readmission risks that are attributed to participation in therapy. To efficiently gather data, therapy administrators expressed the need for implementation of an outcome tool that measures common functional areas that are associated with hospital readmission. A plan was established to use this outcome tool jointly with the functional status outcome tools that were already used within the therapy department. This section describes the action planning phase by explaining the rationale for an outcome tool and the processes completed to identify appropriate items to include in the outcome tool. Rationale for Outcome Tool As mentioned the previous section, SNFs are experiencing increasingly difficult circumstances such as pressures to reduce LOS and hospital readmissions within populations that are older, frailer, and more commonly have medical complexities (Alper et al., 2017; Buurman et al., 2016). Also, efforts from healthcare professionals to expand community reintegration have put pressure on the SNF organization to increase the percentage of patients discharged to home (37.15% of patients in the SNF organization were discharged to home in 2017). These demands have led to greater challenges for SNFs to demonstrate effective treatment. For example, the increased commonality of patients with complex conditions in SNFs, in addition to reduced LOS, may limit patient rehabilitation, which raises concern for how SNFs will justify costs for therapy services. Therefore, SNFs must be able to warrant the superiority of their therapy services not only over their competitors, but also over other settings that may be more affordable. Possible limitations to rehabilitation efficiency regarding patient functional status indicate the need for the SNF organization to demonstrate improvement of other patient areas, such as overall safety within functional tasks. New circumstances that will make it more IMPROVED OUTCOMES IN SNF 11 difficult to show significant improvements in functional status warrant the need for the SNF organization to show hospitals that their therapy services are still high quality and include purposeful efforts to reduce hospital readmissions. If therapists are unable to measure readmission-related outcomes as part of intervention planning, the SNF organization may experience difficulties to decrease hospital readmission rates. Research Methods to Identify Hospital Readmission Risk Factors To gain evidence of major hospital readmission risk factors, a review of research articles was completed via EbscoHOST and Ovid research databases. Risk factors identified in the evidence were then separated by medical-related factors and risk factors that could be addressed within the therapy scopes of practice. Inclusion criteria. The inclusion criteria for the selection of an outcome tool included hospital readmission risk factors that fall within the scopes of practice for occupational therapy (OT), physical therapy (PT), or speech therapy (ST). Scopes of practice were specified by the SNF organization, and were congruent with the practice guidelines set by the professional associations for each discipline. Exclusion criteria. Exclusion criteria consisted of factors that are not manageable through therapy services or are not factors that are addressed within the scopes of therapy practice (e.g. age, gender, race, comorbidities). Other than hospital readmission rates and LOS, metrics that have been used to assess SNF performance included: percentage of patients discharged to the community, average emergency department visits, quality of transitional care, average amount paid per day, and average amount paid per discharge (Herbold & Larson, 2016; Shah et al., 2013; Strunk, 2014). These factors that did not meet the inclusion criteria are not IMPROVED OUTCOMES IN SNF 12 discussed in this paper. Therefore, risk factors mentioned in this paper refer only to those related to therapy. Although risk factors unrelated to therapy practice are not included in this paper, it should be acknowledged that populations within SNFs more commonly experience other risk factors such as frailty, comorbidities, and less stable conditions (Simmons et al., 2016), and it is important that practitioners consider all factors that impact patients health and safety in practice. Readmission factors included in the outcome tool are not inclusive of therapy; the factors are customized to the needs of the organization. Hospital Readmission Factors To ensure that the content of data collected from the outcome tool is effective for marketing the organizations quality of care to partnered hospitals, it is important understand quality metrics that are valued by the hospitals. This paragraph describes the selected readmission risk factors used to guide the establishment of the tool. Factors identified in this paragraph were generalized and grouped into factors that may include multiple components. For example, inadequate patient support after discharge may refer to an insufficient home environment, lack of caregiver abilities, or other dynamics. Functional disability, cognitive impairment, fall risk, and premature discharge were familiar risk factors frequently mentioned in the literature, and have historically been major areas to address on therapy outcome tools (Alper et al., 2017; Bernatz, Tueting, & Anderson, 2015; Callahan, 2015; DePalma et al., 2013; Falvey et al., 2016; Pedersen et al., 2017). Researchers have also found that more than 30 million adults lack basic health-related skills (Cloonan, Wood, & Riley, 2013), and patients who return to home with unmet needs in daily activities are 66% more likely to experience readmission (DePalma et al., 2013). Inadequate patient support after discharge, poor health literacy, and low quality IMPROVED OUTCOMES IN SNF 13 discharge instructions have also been shown to increase readmission risk (Alper et al., 2017; Cloonan et al., 2013; DePalma et al., 2013). Lastly, polypharmacy difficulties have shown to affect readmission rates (Alper et al., 2017; Simmons et al., 2016). Though the number of medications patients are prescribed is not decided by therapy practitioners, researchers have found that readmissions are partially due to poor medication management (Alper et al., 2017; Simmons et al., 2016). These identified factors were considered during a search for outcome tools that already exist to measure readmission risks. Gaps of Existing Outcome Tools Research of existing outcome tools was completed to identify tools that met the inclusion criteria. Though CMS has implemented a rating system to measure quality of care in SNFs, the rating system has not been a comprehensive measure of the quality of therapy services, which is a major area of healthcare costs in the SNF setting (42 CFR 409, 2017; Lage, Rusinak, Carr, Grabowski, & Ackerly, 2015; Silverstein, Findley, & Bode, 2006). Therapy practitioners within SNFs need an interdisciplinary tool that can be used concurrently with other outcome tools and quality measures to further reflect improvements patients health as a result of therapy services. Several tools were found that measure common risk factors for hospital readmission, such as the LACE index scoring tool and the HOSPITAL score (Donz et al., 2016; van Walraven, 2010). These measures did not meet the needs of the SNF organization, as they have been designed to measure medical-related items and do not incorporate areas within the scope of therapy practice. Other tools include some therapy-related items in addition to medical-related items, but are difficult to differentiate what has led to changes in patient outcomes. Lastly, several tools commonly used in therapy practice were identified that assess patient outcomes regarding functional abilities to perform physical and cognitive tasks. However, increased IMPROVED OUTCOMES IN SNF 14 complexities within the SNF population in combination with reduced LOS may impact rehabilitation potential. Use of outcome tools that only measure patients functional abilities may create difficulty for the SNF organization to demonstrate significant improvement for patient outcomes and may provide inaccurate measurements of the benefits received from therapy. A major gap within the reviewed outcome tools was the measurement of patient support levels after discharge. Although some tools include items that measure patient social support (e.g. living with caregiver), caregiver abilities are not included. This gap creates the uncertainty that the patient will be safe when receiving assistance from a caregiver at home; the caregiver may also have limitations that largely impact the ability to assist the patient. Despite exhaustive research, no tool met the criteria for the needs of the SNF organization. As a result, therapy administrators proposed the creation of a customized outcome tool. Development of the Evaluation of Potential Readmission Factors (EPRF) Purpose. The purpose of the EPRF is to measure safety impairment levels within functional areas that are associated with hospital readmission. Scores on the EPRF are used to predict hospital readmission risk for patients after discharge from a SNF to the home environment. The tool is not intended to be inclusive of all risk factors related to hospital readmission, but is a basic measurement of safety concerns with select functional areas. Use of the tool allows the organization to gather and analyze data to determine if therapy services yield reduced risks of hospital readmission. Thus, data that are indicative of reduced risk can be shared with hospitals to sustain or expand partnerships, while data that do not indicate reduced risks can assist to identify gaps in practice. IMPROVED OUTCOMES IN SNF 15 Design. The EPRF is designed for use with adults participating in OT, PT, and/or ST in a SNF setting upon initial evaluation and discharge evaluation. The EPRF consists of five sections (nine items) that are general areas associated with hospital readmission: (1) Functional Mobility (fall risk and transfers), (2) Self-Care (toileting, feeding and eating), (3) Functional Cognition (functional cognitive skills), (4) Home Environment (home assessment), and (5) Caregiver Return Demonstration (functional mobility assistance and self-care assistance). Items are scored on a scale of 1 to 7; higher scores indicate greater safety impairment. The original content and design of the EPRF was modified throughout the development process to meet the needs of the SNF organization. An instructions manual was also created to guide accurate scoring and interpretation. This manual can be found in Appendix A. Functional mobility. The Functional Mobility section is separated into two areas: fall risk and transfers. Fall risk is further separated into two items: fall risk during pre-ambulatory mobility or ambulation, and fall risk during wheelchair mobility. The fall risk items were separated according to variations in functional mobility; some patients may function at standing/walking level and others may function at wheelchair level. Only one of the fall risk items is completed; whichever item is more appropriate for the patients functional level. The Occupational Therapy Practice Framework, 3rd edition (OTPF-III) was used to identify various aspects of functional mobility to be included in this section (American Occupational Therapy Association [AOTA], 2014). (Pre)ambulatory fall risk. Development of performance-based scoring criteria was initiated to gather insight into the patients fall risk. However, during the development process, therapy administrators expressed concern that extensive training would be required if a new outcome tool with different scoring criteria was used to measure each item, and explained the IMPROVED OUTCOMES IN SNF 16 need for a scoring structure that was familiar to therapists. Therefore, this item was structured based on the content of three existing assessment tools: the Berg Balance Scale (BBS), the Tinetti Performance Oriented Mobility Assessment (POMA), and the Timed Up and Go (TUG) test, which were selected in accordance with physical therapists familiarity with these assessment tools.. Scores for fall risk on BBS, Tinetti POMA, and TUG test are used to help score this item (Berg, Wood-Dauphinee, Williams, & Maki, 1992; Lusardi et al., 2017; Podsiadlo & Richardson, 1991; Shumway-Cook, Brauer, & Woollacott 2000; Tinetti, 1986). Current evidence supports the use of the selected assessment tools to determine falls risk (Berg et al., 1992; Conradsson et al., 2007; Downs, 2015; Lusardi et al., 2017; Nordin, Rosendhal, & Lillemor, 2006; Sterke, Huisman, van Beeck, Looman, & van der Cammen, 2010). Wheelchair mobility fall risk. The score for this item indicates the patients fall risk and safety impairment with wheelchair mobility. Scoring is based on six criteria: wheelchair control, management of wheelchair parts, door management, dynamic sitting balance, weight shift, and awareness of limbs. Criteria for scoring were established based on various factors that may be associated with falls, and based on factors identified in the OTPF-III (AOTA, 2014). Transfers. This item is scored based on a global assessment of transfers across various contexts. Safety impairment can be scored for this item with or without caregiver assistance. For example, if a patient who requires maximal assistance to transfer but there are no concerns for safety when caregiver provides assistance for the patient, the item would be receive a score of 1 (no concerns for safety). There are three tasks that serve as scoring criteria for this item: proper setup of transfer surfaces and/or assistive equipment (if applicable), proper body mechanics used throughout transfer, and movement quality (controlled movement). Criteria IMPROVED OUTCOMES IN SNF 17 included in this item were established through an activity analysis of transfers collaboratively performed with the therapy administrators. Self-Care. There are many existing tools commonly used in therapy practice that assess self-care such as the Resident Assessment Instrument (RAI) 3.0, the Functional Independence Measure (FIM), and the Barthel Index (BI) (CMS, 2017; Keith, Granger, Hamilton, & Sherwin, 1987; Mahoney & Barthel, 1965). However, these tools measure improvement in skills. As discussed previously, patient rehabilitation potential in SNFs may be limited. With the possibility of little skill improvement in self-care within a shortened LOS, SNFs still need to be able to demonstrate that their services reduce the risk for hospital readmission. Therefore, this section was designed to measure patient safety impairment levels with or without assistance from a caregiver. This section is separated into two items: toileting, and feeding and eating. Although others areas of self-care have shown to be factors for hospital readmission (Milnac & Feng, 2016), the section was narrowed down to these two items based on interview results from the needs assessment; the director of clinical coordination explained that the organizations partnered hospitals were mostly concerned with these two self-care areas in relation to hospital readmission. Additionally, Milnac & Feng (2016) described several studies in which toileting and feeding/eating were functional skills that researchers found to be typically preserved until later stages of dementia, whereas other self-care impairments (e.g. bathing and dressing) were found in earlier stages. This is important to note because safety impairment in these basic selfcare tasks may further emphasize the need for sufficient patient support. Similar to the item that assesses safety with transfers, these items can be scored with or without caregiver assistance. IMPROVED OUTCOMES IN SNF 18 The FIM and OTPF-III were referenced to help establish criteria and language for both items in this section (AOTA, 2014; Keith et al., 1987). Toileting. There are three tasks that serve as scoring criteria for this item: clothing management before toileting, perineal hygiene, and clothing management after toileting. These criteria do not apply to patients who use a medical device. If a medical device is used, score this item based on patient/caregiver abilities to setup and manage device safely and appropriately. Feeding and eating. There are six tasks that serve as scoring criteria for this item: appropriate use of utensils (with or without assistive devices), oral transport (food is transferred efficiently into mouth), appropriately-sized bites to avoid choking, chewing (the patient sufficiently chews and manages food in mouth), pacing of bites (does not overfill mouth), and regular diet (there is a safety concern for aspiration if the patient is on a modified diet). These criteria do not apply to patients who use a medical feeding device. If a medical feeding device is used, score this item based on patient/caregiver abilities to setup and manage device safely and appropriately. Functional cognition. Cognitive impairment and medication management skills were two hospital readmission factors identified in the literature that influenced the design of this item (Alper et al., 2017; Bolina, Jones, Koshman, Heintz, & Sadowski, 2016). Functional cognitive skills. Functional cognitive skills are scored based on a global assessment of the patients problem solving skills, self-awareness, goal-directed behavior, selfmonitoring of performance, and adjustment of performance as appropriate for task performance. Scores for this item describe the amount of supervision/assistance the patient requires for safety with functional tasks. For example, a score of 3 on the EPRF indicates that the patient requires supervision for medication management. The initial structure for scoring IMPROVED OUTCOMES IN SNF 19 functional cognitive skills was separated into simple and complex tasks, and was heavily weighted on the assessment of medication management skills. However, similar to scoring fall risk, therapy administrators expressed the need for therapists to conveniently score this area using familiar tools. The Blessed Dementia Scale (BDS), the Global Deterioration Scale (GDS), and the Allen Cognitive Levels (ACL) were common tools that occupational and speech therapists were familiar with to assess functional cognitive skills and, therefore, were used as references to help establish language and criteria for scoring this section (Allen, 1985; Blessed, Tomlinson, & Roth, 1968; Reisberg, Ferris, de Leon, & Crook, 1982). The EPRF instructions explain that scores on one assessment tool may not directly translate into scores on another assessment tool, but may provide similar insight into the patients functional cognitive skills. Home environment. Premature discharge, poor health literacy, and inadequate patient support were the three hospital readmission factors identified in the literature that influenced the implementation of this item into the EPRF. This item is scored based on the patients safety impairment with performance and/or accessibility of items, with or without caregiver assistance. In correspondence to the needs of a familiar and easy-to-use tool, the EPRF score for this item is converted from the therapy departments home assessment tool. The home assessment tool includes the patients perspective regarding safety, living situation, physical assessment of the home, and recommendations made by therapists to ensure patient safety. Caregiver return demonstration. This section is only completed if the patient will require caregiver assistance in the home environment, and has a caregiver available to provide assistance. Similar to the Home Environment section, creation of this item was influenced by premature discharge, poor health literacy, and inadequate patient support as hospital readmission factors. If the patient is unable to safely complete tasks without caregiver assistance, therapists IMPROVED OUTCOMES IN SNF 20 need to ensure that caregiver is able to provide the patient with safe and sufficient assistance. Thus, the items in this section are scored based on the safety of the caregiver. There are two items within this section: functional mobility assistance and self-care assistance. Both items have the same scoring criteria: proper setup and use of assistive devices/equipment (if applicable); caregiver demonstration of proper body mechanics to prevent injury when providing patient assistance; positioning and handling of patient is appropriate, safe, controlled, and secure to prevent patient injury; and communication between patient and caregiver is clear and effective. Criteria for scoring were established as a result of a collaborative activity analysis that was completed with the therapy administrators. Total score. All items on the EPRF are added together to calculate the total score. The total score is used to measure the patients overall risk for hospital readmission. Seven score ranges were established after collaborative decision making with the therapy administrators. Section III Summary Changes in the healthcare system have led to greater importance of the oversight of patient outcomes. Hospital readmissions and shortened LOS have become major focus areas of cost reduction and are primary operational factors used to determine quality of services within SNFs. Increased discharges to home as part of cost control accentuate the importance for practitioners to be able to comprehensively determine patient and caregiver needs and measure outcomes to ensure patient safety in the home environment at the time of discharge (Boulding, Glickman, Manary, Shulman, & Staelin, 2011; Falvey et al., 2016). Hospital readmission factors that can be addressed and improved upon in therapy included: functional disability, cognitive impairment, fall risk, premature discharge, and inadequate patient support. IMPROVED OUTCOMES IN SNF 21 Outcome tools can help therapy administrators track changes in patient function, benchmark standards for functional changes among facilities, and improve overall quality of care. Many outcome tools were identified in which healthcare providers can use to demonstrate quality of services and justify healthcare costs. However, some of these tools provide limited insight into the quality of care in therapy; measurements may be unrelated to therapy services or may be difficult to attribute patient improvement specifically to participation in therapy (Strunk, 2014). Additionally, SNFs may experience difficulty in distinguishing the organization from its competitors if oversight of patient care is limited to skill levels. Development of an outcome tool that allows the SNF organization to shows safety improvement for patients who plan to discharge to home environments will allow administrators to verify quality of care, market quality metrics to hospitals, and meet healthcare requirements. The purpose for development of the EPRF was to collect data that contribute to a more comprehensive measure of therapy services and their causal effect on patient outcomes for reduced readmission risks. To meet goals of the doctoral capstone experience, improvement of leadership and administrative skills were achieved through the development of an outcome tool that allows the SNF organization to create an adaptive response to current day healthcare changes. The next section explains the implementation process of the EPRF. Section IV: Implementation To improve operational performance, effective leadership is required and includes the initiation of adaptive responses, support of innovative practice strategies, and provision of resources and training necessary for staff to achieve proficiency (Phipps, 2015). This section explains the modifications made to the EPRF and describes the plan for implementation of the IMPROVED OUTCOMES IN SNF 22 tool into the organizations therapy departments. Collaboration with therapy administrators occurred throughout the planning process to develop an efficient implementation plan. Setting and Population The EPRF was created to be used for adults during initial and discharge therapy evaluations in the SNF setting. For convenience of documentation, the EPRF was built into the electronic documentation software currently used throughout the SNF organization. Administration of the EPRF and interpretation of scores are to be performed by occupational therapists, physical therapists, and speech-language pathologists. Selection of Facilities for a Trial Phase To determine practicality and to identify potential issues with tool use, a two-week trial phase occurred in a sample population consisting of two SNFs within the organization. A dual step selection process was performed to determine trial facilities. For the first step, facilities were ranked according to the percentage of full-time therapists on staff. Logic for this was to ensure all therapists in the selected facilities received proper training, and to avoid trial of the EPRF in facilities that regularly utilized contract and part-time therapists who had not been acclimated to appropriate use of the tool. For the second step, therapy administrators assessed performance efficiency of facilities during the previous year. This was completed by therapy administrators through an internally developed performance analysis tool. The purpose the second step was to ensure the trial phase occurred within collaborative environments in which therapists were more likely to use the outcome tool effectively. The two facilities with the highest percentage of full-time staff and best performance rankings were selected to participate in the trial phase. IMPROVED OUTCOMES IN SNF 23 Staff Development Prior to start of the trial phase, therapy practitioners within the two trial facilities received training on the EPRF to ensure accurate administration, scoring, and interpretation of the tool. Therapy supervisors received digital copies of the outcome tool prior to the scheduled training date to distribute to therapists. To minimize therapist burden and facility scheduling strains, training occurred via a 30-minute group conference call. Attendance for the conference call included the occupational therapy doctoral student, therapy administrators, and therapists (OT, PT, ST) within the two trial facilities. The conference call began with explanations on current and future challenges in SNF that have led to the development of an outcome tool. Communication of the importance and purpose of the vision can help colleagues recognize tangible results and connect their goals with the overarching vision (Phipps, 2015). Establishment of therapists understanding for implementation of a new outcome tool aimed to not only promote participation, but to also support staff development. Training included familiarization with outcome tool items, administration and scoring instructions, and scoring interpretation. To ensure competency in the use of the EPRF, therapists were provided with opportunities to ask questions for clarification and to provide feedback for improvement in the tool. Therapists were encouraged to implement evidence-based practice techniques related to test items on the outcome tool. As explained by Phipps (2015), effective leadership and creation of a collaborative environment can be achieved by supporting others ideas and receiving constructive feedback. Trial Phase and Trial Phase Follow-Up After therapist training occurred, a two-week trial phase was initiated. Therapists were instructed to use the EPRF instructions manual and clinical reasoning to problem-solve through IMPROVED OUTCOMES IN SNF 24 administration, scoring, and interpretation of the tool. If therapists had difficulty with use of the tool, the facility therapy supervisor(s) assisted with answering questions. If supervisors were unable to provide assistance, therapy administrators and the doctoral student were available to answer questions regarding use of the EPRF throughout the trial phase. At the end of the two-week trial phase, hard copies of surveys were distributed to therapists at the trial facilities. The surveys were used to collect ordinal feedback data on the benefits and issues related to use of the outcome tool. Completed surveys were collected, and modifications were made to the EPRF instructions in accordance with feedback results to increase clarity and scoring accuracy. Implementation Phase The duration of the doctoral capstone ended at the time in which the implementation phase commenced. However, a plan was made to ensure the implementation phase was carried out efficiently. After modifications to the instructions were finalized, a plan was devised to implement the EPRF into all twenty-two facilities. Similar to the trial phase, group training was planned to occur via conference calls with each facility and opportunities were provided to ensure accurate and appropriate use of the EPRF. Assimilation phase. Although efforts were taken to develop an easy-to-use outcome tool with clear instructions, an assimilation phase was created within the first two weeks of the implementation phase to ensure good understanding and appropriate use of the outcome tool. The purpose of this phase was to make therapy supervisors, who received in-depth training on the outcome tool, readily available within each facility to help solve potential issues with clinical use of the outcome tool and to help minimize inaccuracies in administration and scoring. Therapy supervisors received instruction to assist therapists if questions developed regarding IMPROVED OUTCOMES IN SNF 25 appropriate use of the outcome tool. However, if questions or problems regarding the outcome tool were not able to be solved within facilities, a plan was established for the respective regional therapy administrator provided assistance. Issues that occurred were to be recorded by the designated therapy supervisor within each facility and reported to the corresponding regional therapy administrator. A plan for analysis of issue reports from supervisors was established to be completed at the end of the two-week assimilation phase for therapy administrators to identify common issues with clinical use of the tool. The analysis would allow administrators to determine if modifications to the instructions manual were necessary to provide therapists with further clarity to enhance scoring accuracy. Section IV Summary The EPRF was developed and designed in accordance with the needs of the therapy organization. Collaboration with therapy administrators, clinical coordinators, and therapists throughout the implementation process helped to ensure comprehensiveness of the tool and to generate effective use in practice. Strategies to facilitate staff development consisted of: education on current and future challenges in SNF settings from an operations perspective, training for use of a new outcome tool as part of an adjustment process to healthcare transformations, and promotion of evidence-based practice strategies to achieve optimal outcomes. Leadership skills to facilitate effective service provision were implemented by: collaboration with therapy staff throughout the development and implementation processes; assurance that the vision and strategies to achieve goals are upheld; and support of therapy staff according to needs, ideas, and feedback for successful use of the outcome tool. Leadership skills were also utilized through a focus on external systems, analysis of how the systems impact practice, and promotion of collaborative efforts to generate adaptive responses. Utilization of IMPROVED OUTCOMES IN SNF 26 these skills aligned with two major goals of the doctoral capstone: to learn strategies for improvement of business performance, and to contribute to internal professional development to improve patient outcomes. The next section describes plans for continuous quality improvement and establishment of psychometric properties of the tool. Section V: Discontinuation and Outcomes Continuous quality improvement of the EPRF supports accurate and purposeful oversight of factors that are associated with hospital readmission. Ongoing plans to improve the EPRF is essential to ensure the tool is administered and scored accurately and consistently, to foster sustainability of the tool in therapeutic practice, and to generate effectiveness at the operations level. In other words, improvement of the EPRF supports efforts to increase overall quality of care and, in turn, improve business performance. This section describes methods for continuous improvement of the EPRF and further illustrates plans for future implementation of the tool throughout all facilities. Modifications for Improvement Several modifications of the EPRF occurred in accordance with the needs of the SNF organization. Test items, criteria of test items, scoring structure, and instructions for administration and scoring are major areas that were adjusted throughout the development process. Inclusion of therapists throughout the development process has been, and will continue to be, important throughout the implementation phase to achieve optimal practicality. Minimal therapist burden is important to ensure that clinical use of the tool is pragmatic and efficient, and does not interfere with the quality of services or with the operations of therapy departments. As explained in the previous section, one strategy to identify needs for improvement of the tool was IMPROVED OUTCOMES IN SNF 27 through feedback from therapists. Analysis of ordinal data that were collected via surveys will assist therapy administrators to determine appropriate adjustments. Revisions to the EPRF were also made to maximize benefits from an operations perspective. Data gathered from the tool help to identify potential gaps in practice, and allows therapy administrators to clearly and conveniently share important information regarding quality trends in practice with hospital administrators. As a result, data-supported efforts to reduce hospital readmissions can ultimately lead to increased frequency of recommending patients to the SNF organization. Effectiveness of meetings with hospitals will be measured twofold; by higher rates for acquisition of new partnerships at end-of-year report and by an increased annual percentage of partnership renewals. Administrative Sustainability Plan Specific plans for continuous improvement and future research have been established to ensure usefulness of the EPRF in therapeutic practice. Data collection. Data collection will occur throughout the implementation phase. Collected data will consist of initial evaluation scores, discharge evaluation scores, and overall change in score. A data management platform will be used to obtain and compile data from the electronic documentation system; data will be automatically collected. The purpose of this phase is to gather information that will be used in a study to determine psychometric properties and practicality of the outcome tool. Study. It is necessary to analyze reliability to determine if the tool produces consistent results. Interrater reliability will allow the researcher to determine the consistency of appropriate scoring among different therapists. Establishing validity is also necessary to determine accuracy in measuring what the outcome tool is designed to measure. Criterion validity will provide the IMPROVED OUTCOMES IN SNF 28 researcher with information regarding the accuracy of the tool in predicting levels of risk for hospital readmission. Measurement of reliability and validity will be performed by a graduate student as part of a doctoral capstone experience. Therapy administrators will provide oversight of the research process. If poor psychometric properties are identified, modifications may need to be made to the outcome tool, and further study will be performed to reassess properties. Additional aspects of future research design will be determined by therapy administrators. Response to Societys Needs As efforts for cost reduction in healthcare have continued to grow, hospital readmission rates and reduced LOS have become key areas for quality measurement of SNFs. These transformations in healthcare have led to increased pressures within SNFs; demands to produce better outcomes at lower costs and within shorter timeframes. As stated in the literature review, increased medical complexities and other demographic trends within SNFs indicate that a return to prior level of function may not be as feasible with shorter LOS. This raises the possibility that patients will return to home before it is safe to do so, which increases the likelihood of hospital readmission and, therefore, may be a threat to perceived quality of SNFs. These changes highlight the need to provide comprehensive therapy services for both the patient and the caregiver regarding safety in the home environment. In addition to existing efforts for patient rehabilitation, results from the initial assessment will allow therapists to determine priority areas to be addressed as part of readmission prevention. Thus, the EPRF supports a therapeutic approach to business viability and clinical excellence by meeting major demands of the healthcare system, as well as the assurance of patient safety. IMPROVED OUTCOMES IN SNF 29 Measurable Outcomes Goals for the doctoral capstone experience included contribution to: improvement of business performance and quality of care, establishment of an outcome tool that enhances data collection relevant to outcome areas that are valued by upstream networks, and internal professional development. The measurable outcome for these efforts is the outcome tool itself. As part of business performance improvement, an outcome tool that has been developed in response to current healthcare trends creates opportunities for the SNF organization to set itself apart from its competitors. To help improve occupancy, therapy administrators can use the tool to market the organizations quality services. Efforts for internal development, such as training therapists for appropriate use of the outcome tool, was measured through surveys from therapists and issue reports from therapy supervisors. Section V Summary Phipps (2015) stated that changes within a system support businesses with innovation and quality. Continuous quality improvement is critical to the operations and viability of the SNF organization. Therefore, ongoing improvement of the outcome tool is important to successfully generate an adaptive response to healthcare transformations while upholding standards for exceptional care. Plans for sustainability and dissemination of the outcome tool assist with this process by building internal capacity and providing guidance for use of objective data to improve business performance. Improvement of administrative and leadership skills has occurred through: consideration of external systems and their effect on internal practice strategies, initiation of an innovative approach to generate an adaptive response to current healthcare trends, acquisition of knowledge through collaboration with therapy administrators, and contribution to internal development (Phipps, 2015). 30 IMPROVED OUTCOMES IN SNF Section VI: Overall Learning The purpose of the doctoral capstone was to develop advanced leadership and administrative skills. This was achieved through implementation of strategies that are adaptive to the care delivery system. This section explains methods used for professional interaction throughout the doctoral capstone and summarizes the overall learning experience. Professional Interaction Throughout the experience, professional interaction was consistently utilized with the operations team (SNF administrators, therapy administrators, clinical coordinators, therapy supervisors, rehab coordinators), as well as OT, PT, and ST practitioners. Professional interaction was essential to ensure all team members had a clear understanding of healthcare trends and their implications for the need to create an outcome tool. Effective interaction helped team members share knowledge and ideas which, in turn, helped to identify methods for development and implementation that were most efficient. Written communication. Written communication via email was the most commonly used form of interaction throughout the experience, as this method was most efficient for the varied availability of team members. Emails were exchanged with the therapy administrators on a daily basis, and included updates on research findings and development of the outcome tool, topics regarding operations and plans for implementation, and external factors that could influence the design or implementation of the EPRF. Written communication with therapy practitioners was performed through detailed explanations for the purpose of the outcome tool, and through descriptive instructions for administering and scoring the tool. To establish a collaborative effort for tool development, therapists completed surveys to provide feedback IMPROVED OUTCOMES IN SNF 31 regarding practicality of the tool. All forms of written communication were proofread to verify that communication was carried out in a clear, concise, and professionally acceptable manner. Verbal communication. Verbal communication with a regional therapy administrator occurred in-person on a weekly basis. Similar to written communication, topics of discussion included research findings, the developmental process of the outcome tool, plans for implementation, potentially influential external factors, and updates on goals and objectives for the doctoral capstone experience. Outlines of discussion topics were created prior to the weekly meetings to ensure that the meetings were efficient, productive, inclusive of important areas of the doctoral capstone experience, and respectful of the administrator's. Verbal communication with SNF administrators, therapy administrators, clinical coordinators, therapy supervisors, and rehab coordinators occurred at operations meetings throughout the duration of the doctoral capstone experience. Verbal communication with all team members was carried out in a manner that was well-organized, concise, sensitive to the varying level of knowledge within the audience, and clearly articulated main points. Nonverbal communication. Nonverbal communication can directly impact how audiences perceive information. Nonverbal communication was used to create a positive and receptive atmosphere. Methods that were used on a daily basis to enhance professional interaction included, but were not limited to: proper body language, dress, and appearance; as well as appropriate facial expressions, eye contact, and tone of voice. Other forms of nonverbal communication such as gestures were used to enhance the audiences interest and engagement during a presentation of the outcome tool at an operations meeting. IMPROVED OUTCOMES IN SNF 32 Experiential Learning In preparation for future practice as an occupational therapist, the doctoral capstone experience has provided me with opportunities that have contributed to the acquisition of new knowledge. Throughout the doctoral capstone experience, I have gained knowledge of: operational strategies for improvement of business performance, strategies for effective collaboration of team members to maximize efficiency across all levels of operation, methods for internal professional development, and establishment of an outcome tool that enhances data management of patient outcomes. A major area that was emphasized throughout the experience, regardless of the topic at hand, was a comprehensive consideration of factors that could influence the process or outcomes of certain efforts. External factors that were acknowledged in the development of the outcome tool included, but were not limited to: laws and regulations that influence therapy practice within SNFs, increasingly extensive efforts for cost reduction in healthcare, trending interests and methods that hospitals use to measure quality of care and cost control within SNFs, the current payment structure and potential changes to the reimbursement system for SNFs, services and amenities offered by competitors, and existing outcome tools. Common internal factors that required consideration consisted of, but were not limited to: trends in patient outcomes and average LOS, population trends, needs of the SNF organization in response to healthcare transformations based on results for a needs assessment, current practice strategies such as evaluation and intervention processes, as well as productivity goals and scheduling. Procurement of these skills has contributed to my overall improvement as a future healthcare professional. For example, from a clinical perspective, acknowledgement of all influential aspects could mean the consideration of why it may be unsafe for a caregiver to provide IMPROVED OUTCOMES IN SNF 33 assistance to a client during a caregiver training session: patient- or caregiver-related factors that contribute to safety concerns, potential results that create safety concerns, and many other components that are important to acknowledge. From an operations perspective, consideration of all aspects may translate to an exploration of how a therapy department can improve practice strategies to generate better patient outcomes. In short, a comprehensive examination of all components- internal and external- that could potentially impact the process or the outcomes is imperative to successful and effective implementation of practice strategies. Another major area of knowledge gained through the doctoral capstone was related to the involvement of all appropriate team members to successfully carry out effective operational strategies. In relation to the outcome tool, strategic discussions with administration and clinical team members generated an understanding that allowed development and implementation processes to be more efficient and practical. Also, operational strategies may not always be carried out as originally planned. For example, revisions to the EPRF occurred regularly in response to 1) therapy administrators needs for an outcome tool that requires minimal training time and 2) therapists need for a tool that minimizes therapist burden. A collaborative approach toward quality improvement also allows team members to share knowledge and thoughts that may not have been known or considered by other members. Thus, inclusion of all team members generated a comprehensive understanding of how the implementation of a new outcome tool could affect the SNF organization at all levels of operation. As a future therapist, this experience will contribute to my understanding of reasons for operational changes within therapy departments. IMPROVED OUTCOMES IN SNF 34 Leadership and Advocacy Skills Leadership skills. The doctoral capstone experience has also yielded substantial improvements in administrative, leadership, and advocacy skills. Administrative skills have improved through increased knowledge of healthcare regulations and their effect on therapy operations within the SNF setting. Also, the doctoral capstone experience allowed me to exercise and improve upon multiple aspects of transformational leadership such as: inspiring a shared vision, challenging the status quo, establishing a clear vision of the future of the SNF organization, modeling, and enabling other to act (Phipps, 2015; Snodgrass, 2011). Advocacy skills. Advocacy skills were enhanced across multiple levels of care. Patient advocacy skills were utilized and improved upon, as the primary purpose for development of the outcome tool was to ensure patient safety. Additionally, with aims to reduce healthcare costs, the outcome tool supports responsible stewardship of the patients Medicare benefits. Advocacy skills for caregivers were enhanced through assessment of caregiver safety while providing assistance to the patient, and promotion of improved caregiver education. Advocacy skills for therapists were enhanced through efforts to increase documentation of measurable outcomes and to minimize therapist burden regarding clinical use of the outcome tool. Lastly, improvement of advocacy skills for the SNF organization occurred through the creation of an outcome tool to enhance business performance through improved data management of patient outcomes and other operational factors (e.g. reimbursement claims). Conclusion As a result of changes within the healthcare system, SNFs are experiencing increasingly difficult circumstances to demonstrate quality services and meet healthcare requirements (e.g. provide data that indicate reduced hospital readmission rates). 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Creating a network of high-quality skilled nursing facilities: Preliminary data on the postacute care quality improvement experiences of an accountable care organization. Journal of American Geriatrics Society, 63(4), 804-805. doi: 10.111/jgs.13351 Lusardi, M. M., Fritz, S., Middleton, A., Allison, L., Wingood, M., Phillips, E., & Chui, K. K. (2017). Determining risk of falls in community dwelling older adults: A systematic review and meta-analysis using posttest probability. Journal of Geriatric Physical Therapy, 40(1), 1-36. doi: 10.1519/jpt.0000000000000099 Mahoney, F. I. & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61-65. Retrieved from http://www.strokecenter.org/wpcontent/uploads/2011/08/barthel_reprint.pdf IMPROVED OUTCOMES IN SNF 41 McHugh, J. P., Foster, A., Mor, V., Shiel, R. R., Trivedi, A. N., Wetle, T., & Tyler, D. A. (2017). Reducing hospital readmissions through preferred networks of skilled nursing facilities. Health Affairs, 36(9), 1591-1598. doi: 10.1377/hithaff.2017.0211 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 81 Fed. Reg. 68688. (4 October 2016). (to be codified at 42 CFR 405, 431, 447, 482, 483, 485, 488, 489). Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model, 82 Fed. Reg. 39310. (17 August 2017). (to be codified at 42 CFR 510, 512). Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020, 82 Fed. Reg. 36530. (4 August 2017). (to be codified at 42 CFR 409, 411, 413, 424, 488). Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities: Revisions to Case-Mix Methodology, 82 Fed. Reg. 20980. (4 May 2017). (to be codified at CFR 409, 488). Milnac, M. E. & Feng, M. C. (2016). Assessment of activities of daily living, self-care, and independence. Archives of Clinical Neuropsychology, 31(6), 506-516. doi: 10.1093/arclin/acw049 IMPROVED OUTCOMES IN SNF 42 Nordin, E., Rosendahl, E., & Lillemor, L. O. (2006). Timed "Up & Go" test: Reliability in older people dependent in activities of daily living- Focus on cognitive state. Physical Therapy, 86(5), 646-655. doi: 10.1093/ptj/86.5.646 Optima Healthcare Solutions. (2017). Top 2018 trends for therapy providers [White Paper]. Retrieved from http://go.optimahcs.com/ty/white-paper/top-2018-trends-for-therapyproviders Optima Healthcare Solutions (2018). RCS-1: Strategies for success [White Paper]. Retrieved from https://www.optimahcs.com/resources/rcs-1-faq-strategies-for-success/ Ottenbacher, K. J., Karmarkar, A., Graham, J. E., Kuo, Y. F., Deutsch, A., Reistetter, T. A., & Granger, C. V. (2014). Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients. Journal of American Medical Association, 311(6), 604-614, doi: 10.1001/jama.2014.8 Pedersen, M. K., Meyer, G., Uhrenfeldt, L. (2017). Risk factors for acute care hospital readmission in older persons in Western countries: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 15(2), 454-485. doi: 10.11124/JBISRIR-2016-003267 PEPPER Resources. (2017). National-level data reports [Data set]. Retrieved from http://www.pepperresources.org/data Phipps, S. (2015). Leading with vision. Special Interest Section Quarterly: Administration & Management, 31 (4), 1-4. Retrieved from https://www.aota.org/~/media/Corporate/Files/Secure/Publications/SIS-QuarterlyNewsletters/AM/AMSIS_Dec_2015.pdf IMPROVED OUTCOMES IN SNF 43 Podsiadlo, D. & Richardson, S. (1991). The Timed Up & Go: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 14(2):142 148. doi: 10.1111/j.1532-5415.1991.tb01616.x Rahman, M., McHugh, J., Gozalo, P. L., Ackerly, D. C., & Mor, V. (2016). The contribution of skilled nursing facilities to hospitals readmission rate. Health Services Research, 52(2), 656-675. doi: 10.1111/1475-6773.12507 Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139(9), 1136-1139. doi: 10.1176/ajp.139.9.1136 Shah, S. Tartaro, C., Chew, F., Morris, M., Wood, C., & Wuzzardo, A. (2013). Skilled nursing facility functional rehabilitation outcome: Analysis of stroke admissions. International Journal of Occupational Therapy & Rehabilitation, 20(7), 352-360. Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go test. Physical Therapy, 80(9), 896-903. doi: 10.1093/ptj/80.9.896 Silverstein, B., Findley, P. A., & Bode, R. K. (2006). Usefulness of the nursing home quality measures and quality indicators for assessing skilled nursing facility rehabilitation outcomes. Physical Medicine and Rehabilitation, 87(8), 1021-1025. doi: 10.1016/j.apmr.2006.05.001 Simmons, S. F., Bell, S., Saraf, A. A., Coelho, C. S., Long, E. A., Jacobsen, J. M. L., & Vasilevskis, E. E. (2016). Stability of geriatric syndromes in hospitalized Medicare beneficiaries discharge to snkills nursing facilities. Journal of the American Geriatric Society, 64(10), 2027-2034. doi: 10.1111/jgs.14320 IMPROVED OUTCOMES IN SNF 44 Slabodkin, G. (2017, October 30). CMS focus on meaningful measures faces hurdles. Health Data Management. Retrieved from https://www.healthdatamanagement.com/news/cmsannounces-new-meaningful-measures-initiative Snodgrass, J. (2011). Leadership development. In K. Jacobs & G. L. McCormack (Eds.), The occupational therapy manager (5th ed.) (pp. 265-278). Bethesda, MD: AOTA Press. Strunk, E. (2014). Standardizing rehab outcome measures [White Paper]. Retrieved from http://www.consonushealth.com/wpcontent/themes/consonus/assets/REHAB/Problem6/6CoriginalStandardizing_Rehab_Out come_Measures.pdf?x95358 Sterke, C. S., Huisman, S. L., van Beeck, E. F., Looman, C. W., & van der Cammen, T. J. (2010). Is the Tinetti Performance Oriented Mobility Assessment (POMA) a feasible and valid predictor of short-term fall risk in nursing home residents with dementia? International Psychogeriatrics, 22(2), 254-263. doi: 10.1017/s1041610209991347 Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34(2), 119-126. doi: 10.1111/j.15325414.1986.tb05480.x van Walraven, C., Dhalla, I. A., Bell, C., Etchells, E., Stiell, I. G., Zarnke, K., & Forster, A. J. (2010). Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Canadian Medical Association Journal, 182(6), 551-557. doi:10.1503/cmaj.091117 45 IMPROVED OUTCOMES IN SNF Appendix A. Evaluation of Potential Readmission Factors Users Manual Measurement of Safety Impairment in Factors Associated with Hospital Readmission Version 1.0 Created by Curtis Clem April, 2018 Acknowledgements: Michaela Watson Lynn Lopossa Julie Bednarski 46 IMPROVED OUTCOMES IN SNF Purpose The Evaluation of Potential Readmission Factors (EPRF) is an outcome tool to measure changes in safety impairment. Specifically, the EPRF measures changes in safety impairment of factors that are associated with hospital readmission. The EPRF is used for patients who are planned to return to their home environments. The tool is not intended to be inclusive of all risk factors related to hospital readmission, but is a basic measurement of safety concerns with select functional areas. Use of the tool supports collection and analysis of data to determine if therapy services yield reduced risks of hospital readmission. The EPRF is a measure of safety impairment; items are scored based on how safe activities are performed. The EPRF is not meant to be used to measure functional skill impairment. General scoring instructions are further explained on page 3. Administration The EPRF is to be used to assess adults and older adults participating in occupational therapy, physical therapy, and/or speech therapy in a skilled nursing facility. The EPRF is used to measure change in safety impairment from the date of initial evaluation to the discharge evaluation date. It is recommended that the EPRF is administered by occupational therapists, physical therapists, and speech-language pathologists. However, therapists may obtain reliable reports from caregivers, therapy assistants, or other healthcare team members (e.g. a nurse or physician) to assist with accurate scoring. Test environments are not limited to the designated therapy area or the patients room, but efforts should be made to simulate the patients home environment. The EPRF consists of five sections (nine items). Items can be administered in any order. All items must be scored. If the patients stay ends unexpectedly, clinical judgment may be used to score test items. If clinical judgment is used, documentation must reflect clear reasoning for the score(s). 47 IMPROVED OUTCOMES IN SNF Scoring Structure Scoring criteria may vary within test items. Score Description G-Code 1 = Good No concerns for safety. CH 2 = Fair plus Safety concerns with 1-19% of the activity. CI 3 = Fair Safety concerns with 20-39% of the activity. CJ 4 = Fair minus Safety concerns with 40-59% of the activity. CK 5 = Poor plus Safety concerns with 60-79% of the activity. CL 6 = Poor Safety concerns with 80-99% of the activity. CM 7 = Poor minus Safety concerns with 100% of the activity. CN 8 = Not applicable Activity is not applicable to patient or patients daily living. Note: A score with a decimal is rounded up, regardless of the decimal amount (e.g. 19.1% impairment is scored as 20% impairment). IMPROVED OUTCOMES IN SNF 48 Scoring Instructions All test items must be scored. Clinical judgment may be used to score items that are not observed, unless specified otherwise in item-specific instructions. Items are scored on a scale of 1 to 7. Higher scores indicate greater safety impairment; a score of 1 indicates no safety concerns and a score of 7 indicates safety concerns for 100% of the activity. An additional score option of 8 is available for items that are not applicable to the patient. For example, if a patient is unable to walk due to paralysis, Item 1.1a would be scored as an 8. Item 1.1b would then be scored, as this item is more appropriate for the patients condition. Documentation should reflect why the item is not applicable. A score of 8 has no value to the total score. The EPRF is built into the electronic documentation system. Each item will be scored for the patients prior, current, and anticipated safety impairment. The current score is the only scoring category that affects the total score. Brief descriptions for each score value can be viewed by hovering the cursor over the score value. Detailed scoring criteria and descriptions are provided under each EPRF item to help determine percentage ranges of safety impairment. Scores indicate levels of safety impairment. Scores are based on criteria for each item that measure how safely tasks are performed with or without a caregiver (this is further clarified in each item). Note: If the therapist is unable to determine if the patient has a caregiver who can provide safe and appropriate assistance, score the item(s) without caregiver assistance. If the word and is stated in the criteria, all criteria must be met. If the word or is stated in the criteria, only one of the criteria must be met. Scores are not affected by the time it takes to complete tasks or by the use of adaptive equipment/devices, unless specified otherwise. Item(s) Not Completed Due to Safety Concern If an item is not attempted due to medical or safety concerns, the item is scored as 7. The safety of the patient and/or caregiver should not be at risk when administering and scoring items. Item(s) Not Observed If an item is not observed, a reliable report may be obtained from the patients medical chart, the patient (if cognition is intact), the patients caregiver(s), or a care team member who has observed the task(s). If a report cannot be obtained, clinical judgment may be used to score the item as accurately as possible. Documentation should reflect how the score was obtained. Inconsistent Performance is Observed If the patient demonstrates fluctuating or inconsistent levels of safety when performing certain test items, the score should reflect the patients lowest level of safety. 49 IMPROVED OUTCOMES IN SNF Section 1: Functional Mobility 1.1a) (Pre)Ambulatory Fall Risk ! USE THIS ITEM OR ITEM 1.1b TO ASSESS FALL RISK. DO NOT USE BOTH ITEMS TO SCORE FALL RISK. USE CLINICAL JUDGMENT AND THE DESCRIPTION BELOW TO APPROPRIATELY SELECT ONE. This item is used to assess fall risk if the patient has intact motor function in the lower extremities. If motor function of the lower extremities is not intact, or the patients baseline is at wheelchair level, score this item as 8 and use item 1.1b to accurately score the patients fall risk. A score of 7 reflects that motor function is intact, but the patient is unable to perform any of the tasks required for standing and/or walking. The score for this item indicates the patients fall risk with sitting balance, standing balance, and/or ambulatory tasks without assistance from a caregiver. Scoring To guide scoring for this item, Table 1 displays scoring examples of other tools including: Berg Balance Scale and Tinetti Performance Oriented Mobility Assessment (POMA). If the patient is not ambulatory but stands for functional tasks, it is recommended to use the Berg Balance Scale for this item. If the patient is ambulatory, it is recommended to use the Tinetti POMA. Table 1 EPRF Berg Balance Scale 1 = Low fall risk 56 2 = Low fall risk 41-55 3 = Moderate fall risk 31-40 4 = Moderate fall risk 21-30 5 = High fall risk 11-20 6 = High fall risk 1-10 7 = Complete impairment 0 8 = Not applicable. Item is scored using item 1.1b. Tinetti POMA 28 25-27 22-24 19-21 10-18 1-9 0 Note: Table 1 displays examples used to guide scoring fall risk; clinical judgment should be used while scoring this item. Scores on one outcome tool may not directly translate into scores on another outcome tool, but may provide similar insight into the patients fall risk. For example, interpretation for a score of 41 on the Berg Balance Scale is not the same as interpretation for a score of 23 on the Tinetti POMA. Rather, Table 1 displays examples to guide scoring for the level of fall risk. IMPROVED OUTCOMES IN SNF 50 1.1b) Wheelchair Mobility Fall Risk ! USE THIS ITEM OR ITEM 1.1a TO ASSESS FALL RISK. DO NOT USE BOTH ITEMS TO SCORE FALL RISK. USE CLINICAL JUDGMENT AND THE DESCRIPTION BELOW TO APPROPRIATELY SELECT ONE. This item is used to assess fall risk if the patient does not have intact motor function in the lower extremities, or if the patients baseline function is at wheelchair level. If motor function of the lower extremities is intact, or the patient does not/will not require a wheelchair at baseline, score this item as 8 and use item 1.1a to accurately score the patients fall risk. The score for this item indicates the patients fall risk and safety impairment with wheelchair mobility without caregiver assistance. Scoring Criteria There are six scoring criteria for this item: (1) Wheelchair control: safely and effectively propels (manual wheelchair) or steers (power wheelchair) the wheelchair for at least 50 feet (2) Management of wheelchair parts: locks/unlocks wheel locks appropriately (e.g. before transfer), manages footrests appropriately (e.g. before transfer), etc. Note: Management of wheelchair parts is not limited to wheel locks and footrests. (3) Door management: closes and opens doors (e.g. bathroom door) at wheelchair level to enter and exit rooms safely and effectively (4) Dynamic sitting balance: good balance when reaching outside base of support (forward, laterally, etc.) at shoulder and ground level Note: Score is not affected by restricted upper extremity mobility that limits reach. (5) Weight shift: ability to shift weight periodically (e.g. to prevent pressure sores) (6) Awareness of limbs: good awareness of limbs during wheelchair mobility (e.g. arm/hand does not hang outside of armrest) 1 = Good. No concerns for safety 2 = Fair plus. Concerns for patient safety with 1-19% of wheelchair mobility 3 = Fair. Concerns for patient safety with 20-39% of wheelchair mobility 4 = Fair minus. Concerns for patient safety with 40-59% of wheelchair mobility 5 = Poor plus. Concerns for patient safety with 60-79% of wheelchair mobility 6 = Poor. Concerns for patient safety with 80-99% of wheelchair mobility 7 = Poor minus. Concerns for patient safety with 100% of wheelchair mobility 8 = Not applicable. Item is scored using item 1.1a. IMPROVED OUTCOMES IN SNF 51 1.2) Transfers The score for this item reflects the patients safety impairment for transfers with or without assistance from a caregiver. This item is scored based on a global assessment of transfers across various contexts. Documentation should reflect the type of transfer. Circumstances for Scoring Patient has a caregiver and requires assistance: Score the patients safety impairment for transfers with caregiver assistance. For example, if a patient who requires maximal assistance to transfer receives safe and appropriate caregiver assistance, and there are no concerns for safety, the item would be scored as 1. Contrarily, if the therapist has concerns for the patients safety when receiving assistance from the caregiver, the score should reflect the safety impairment percentage accordingly. Patient does not require caregiver assistance: Score should reflect the patients safety impairment without assistance. Patient requires assistance but does not have a caregiver, or the caregiver is not present at initial evaluation: Score the amount of safety concerns for the patient to complete the activity. For example, if a patient requires minimal physical assistance to safely complete a transfer (requires assistance for 25% of effort), the item would be scored as 3. Patient has a caregiver, but the caregiver is not present at discharge evaluation: Score the patients safety impairment based on the most recent time patient transfer with caregiver assistance was observed. Scoring Criteria There are three scoring criteria for this item: (1) Setup: proper setup of transfer surfaces and/or assistive equipment (if applicable) (2) Body mechanics: patient uses proper body mechanics to transfer (3) Movement quality: movement is controlled throughout 1 = Good. No concerns for patient safety. 2 = Fair plus. Concerns for patient safety with 1-19% of transfers. 3 = Fair. Concerns for patient safety with 20-39% of transfers. 4 = Fair minus. Concerns for patient safety with 40-59% of transfers. 5 = Poor plus. Concerns for patient safety with 60-79% of transfers. 6 = Poor. Concerns for patient safety with 80-99% of transfers. 7 = Poor minus. Concerns for patient safety with 100% of transfers. IMPROVED OUTCOMES IN SNF 52 Section 2: Self-Care 2.1) Toileting The score for this item reflects the patients safety impairment with toileting with or without assistance from a caregiver (if applicable). The score is not affected by the use of assistive device (e.g. toilet tissue aid). If the patient requires a device (e.g. catheter or colostomy bag), the score should reflect patients or caregivers abilities to setup and manage the device. The score for this item does not include the transfer onto or off of the toilet. Circumstances for Scoring Patient has a caregiver, and requires caregiver assistance: Score the patients safety impairment for the activity WITH caregiver assistance. For example, if a patient who requires maximal assistance to perform the activity receives safe and appropriate caregiver assistance, and there are no concerns for safety, the item would be scored as 1. Contrarily, if the therapist has concerns for the patients safety when receiving assistance from the caregiver, the score should reflect the safety impairment percentage accordingly. If the patient does not require caregiver assistance: Score reflects safety concerns for the patient if the activity were to be performed without assistance. If the patient requires assistance, but does not have a caregiver: Score safety concerns for the patient if the activity were to be performed without assistance. This scoring method may commonly be used at initial evaluation if caregiver is not present and additional information cannot be obtained regarding the caregivers ability to sufficiently assist the patient in the activity. However, if additional information can be obtained regarding the caregivers ability to sufficiently assist the patient, the score should reflect this. Clinical judgment is encouraged to score EPRF items as accurately as possible. Scoring Criteria There are three scoring criteria for this item: (1) Clothing management before toileting (2) Perineal hygiene (3) Clothing management after toileting These criteria do not apply to patients who use a medical device. If a medical device is used, score this item based on the patients or caregivers abilities to setup and manage the device safely and appropriately. 1 = Good. No concerns for patient safety 2 = Fair plus. Concerns for patient safety with 1-19% of toileting 3 = Fair. Concerns for patient safety with 20-39% of toileting 4 = Fair minus. Concerns for patient safety with 40-59% of toileting 5 = Poor plus. Concerns for patient safety with 60-79% of toileting 6 = Poor. Concerns for patient safety with 80-99% of toileting 7 = Poor minus. Concerns for patient safety with 100% of toileting IMPROVED OUTCOMES IN SNF 53 2.2) Feeding & Eating The score for this item reflects the patients safety impairment with feeding and eating with or without assistance from a caregiver. The score is not affected by the use of assistive devices (e.g. rocker knife to cut food). If the patient requires a medical feeding device (e.g. tube feeding), the score should reflect the patients or caregivers abilities to manage device. Circumstances for Scoring Patient has a caregiver and requires assistance: Score the patients safety impairment for transfers with caregiver assistance. For example, if a patient who requires moderate assistance to perform the activity receives safe and appropriate caregiver assistance, and there are no concerns for safety, the item would be scored as 1. Contrarily, if the therapist has concerns for the patients safety when receiving assistance from the caregiver, the score should reflect the safety impairment percentage accordingly. If the patient does not require caregiver assistance: Score reflects safety concerns for the patient if the activity were to be performed without assistance. If the patient requires assistance, but does not have a caregiver: Score safety concerns for the patient if the activity were to be performed without assistance. This scoring method may commonly be used at initial evaluation if caregiver is not present and additional information cannot be obtained regarding the caregivers ability to sufficiently assist the patient in the activity. However, if additional information can be obtained regarding the caregivers ability to sufficiently assist the patient, the score should reflect this. Clinical judgment is encouraged to score EPRF items as accurately as possible. Scoring Criteria There are six scoring criteria for this item. These criteria do not apply to patients who use a medical feeding device. (1) Appropriate use of utensils: utensils are handled safely and appropriately (2) Oral transport: food is transferred efficiently into mouth (3) Appropriately-sized bites: bites of food are appropriate to avoid choking (4) Chewing: the patient sufficiently chews and manages food in mouth (5) Does not overfill mouth: bringing food to mouth is well-paced to avoid choking (6) Regular diet: If the patient is not on a regular diet (is on a modified diet), this implies a safety concern (e.g. aspiration) 1 = Good. No concerns for patient safety 2 = Fair plus. Concerns for patient safety with 1-19% of feeding and eating 3 = Fair. Concerns for patient safety with 20-39% of feeding and eating 4 = Fair minus. Concerns for patient safety with 40-59% of feeding and eating 5 = Poor plus. Concerns for patient safety with 60-79% of feeding and eating 6 = Poor. Concerns for patient safety with 80-99% of feeding and eating 7 = Poor minus. Concerns for patient safety with 100% of feeding and eating 54 IMPROVED OUTCOMES IN SNF Section 3: Functional Cognition 3.1) Functional Cognitive Skills The score for this item reflects the patients functional cognitive skills without caregiver assistance. This item is a global assessment of problem solving, self-awareness, goal-directed behavior, self-monitoring of performance, and adjustment of performance as appropriate for task performance. Table 2 displays scoring examples of other tools including: Global Deterioration Scale, Allen Cognitive Levels, and Blessed Dementia Scale. Table 2 Functional Cognitive Skills EPRF Blessed Dementia Scale Global Deterioration Scale Allen Cognitive Levels 1 = Good 2 = Fair plus 3 = Fair 4 = Fair minus 5 = Poor plus 6 = Poor 7 = Poor minus 0 1-2 3-5 6-11 12-13 14-15 16-17 1 2 3 4 5 6 7 6.0 5.6-5.8 5.4 4.6-5.2 4.0-4.4 3.4-3.8 0.8-3.2 Note: Scores on one assessment tool may not directly translate into scores on another assessment tool, but may provide similar insight into the patients functional cognitive skills. For example, interpretation for a score of 5.2 on the Allen Cognitive Level is not the same as interpretation for a score of 4 on the Global Deterioration Scale. Clinical judgment is encouraged to score EPRF items as accurately as possible. Listed below are descriptions of the patients cognitive abilities and supervision needs within the home environment. These are not required scoring criteria, but are listed to assist with scoring. 1 = Good. No concerns for safety. May live alone. Patient predicts potential mistakes or consequences, and self-monitors performance to maintain safety. 2 = Fair plus. Very mild impairment for safe problem solving and judgment. May live alone with occasional check-in reminders to complete household tasks. Patient can perform instrumental activities (medication management, financial management, etc.) with written instructions. Patient typically monitors his or her own safety. 3 = Fair. Mild impairment for safe problem solving and judgment. May live alone with weekly check-in supervision. Patient requires supervision for safety with instrumental activities. Self-monitoring for safety is inconsistent, and the patient may occasionally perform tasks automatically without consideration of potential outcomes of actions. If challenges occur, the patient may abruptly change his or her original plans to complete a task. 4 = Fair minus. Moderate impairment for safe problem solving and judgment. Patient would require daily check-in supervision for personal safety. Living alone is questionable. Patient is oriented to time and age. Able to safely complete self-care tasks in highly structured routine; daily check-in required. Patient requires assistance with instrumental activities. Intermittent impulsive behaviors. IMPROVED OUTCOMES IN SNF 5 = Poor plus. Significant impairment for safe problem solving and judgment. Patient would require 24-hour supervision for safety; cannot live alone. Patient is disoriented to time and age (may believe age is 20-40 years old). Patient needs a lot of assistance for safety with instrumental activities. Patient requires close supervision and consistent cueing for safety for self-care. Generally demonstrates impulsive behaviors, unaware of limitations, and may be easily agitated. 6 = Poor. Severe impairment for safe problem solving and judgment. Patient would require 24-hour physical assistance for safety. Patient is disoriented, and may believe (s)he is a child. Patient requires physical assistance for self-care required to maintain safety. There is an absence of goaldirected behavior, and the patient is unaware of his or her surroundings. 7 = Poor minus. Patient is unable to follow simple commands and/or is unable to recognize safety concerns despite consistent maximal cues. Patient requires 24-hour care, usually nursing or hospice care. 55 IMPROVED OUTCOMES IN SNF 56 Section 4: Home Environment 4.1) Home Assessment This item is scored based on the patients safety impairment with performance and/or accessibility of items listed on the Home Assessment tool. The score reflects performance and/or accessibility with or without a caregiver. Circumstances for Scoring Scoring at Initial Evaluation If the home assessment has not been completed at the time of initial evaluation, use clinical reasoning to score this item; gather as much reliable information about the home as possible via report or medical chart. Discharge Evaluation If the home assessment has not been completed, score this item using information from the patients medical chart and any information gathered via reliable reports from the patient, caregiver(s), or other care team members. Only score this item as an 8 if the patient will remain in a skilled nursing facility. Scoring Criteria Refer to the Lifespan Home Assessment tool to calculate score. Items in this section include (1) patient views, (2) living situation, (3) physical assessment of the home, and (4) recommendations. 1 = Good. No concerns for patient safety for within the home. 2 = Fair plus. Concerns for patient safety with 1-19% of occupations or accessibility within the home. 3 = Fair. Concerns for patient safety with 20-39% of occupations or accessibility within the home. 4 = Fair minus. Concerns for patient safety with 40-59% of occupations or accessibility within the home. 5 = Poor plus. Concerns for patient safety with 60-79% of occupations or accessibility within the home. 6 = Poor. Concerns for patient safety with 80-99% of occupations or accessibility within the home. 7 = Poor minus. Concerns for patient safety with 100% of occupations or accessibility within the home. 8 = Not applicable. Patient will remain in a skilled nursing facility. IMPROVED OUTCOMES IN SNF 57 Section 5: Caregiver Return Demonstration ! If the patient requires a caregiver for tasks included in Sections 1-4, but DOES NOT HAVE a caregiver: score items 5.1 and 5.2 as 7. A score of 8 is only used if the patient does not require a caregiver. 5.1) Functional Mobility Assistance The score for this item is based on a global assessment of the caregivers safety impairment regarding the provision of assistance to the patient for mobility tasks included in Section 1. Circumstances for Scoring Initial evaluation: If caregiver is not present, score this item as 7, as the caregiver is unable to demonstrate the ability to provide safe and appropriate assistance. Discharge evaluation: If caregiver has previously participated in therapy and patient assistance has been observed, score the caregivers safety impairment based on the most recent observation of the caregivers abilities to provide safe and appropriate assistance. Scoring Criteria There are four scoring criteria for this item: (1) Setup: proper setup and use of assistive devices/equipment (if applicable) (2) Body mechanics: caregiver demonstrates proper body mechanics to prevent injury when providing patient assistance (3) Quality of patient assistance: positioning and handling of patient is appropriate, safe, controlled, and secure to prevent patient injury (4) Communication: communication between patient and caregiver is clear and effective. Communication should not be counted against score if patient unable to comprehend verbal instructions. 1 = Good. No concerns for caregiver safety when providing assistance to patient. Caregiver consistently demonstrates safe and appropriate assistance, and shows good awareness of patients needs. 2 = Fair plus. Concerns for caregiver safety with 1-19% of patient assistance. Caregiver rarely need cues for safety; may occasionally forget minor aspects of techniques for safe assistance, but is able to recognize potential issues and adjust accordingly with extra time. 3 = Fair. Concerns for caregiver safety with 20-39% of patient assistance. Caregiver is usually able to verbalize safe assistive techniques, but requires cues for recognition or correction of potential safety issues. Occasional cues may be needed for proper setup of assistive devices/equipment. 4 = Fair minus. Concerns for caregiver safety with 40-59% of patient assistance. Caregiver frequently requires cues for proper setup of assistive devices/equipment. Frequent cues are also need for recognition and correction of potential safety issues. The caregiver requires standby assistance from the therapist to ensure safety. IMPROVED OUTCOMES IN SNF 5 = Poor plus. Concerns for caregiver safety with 60-79% of patient assistance. Caregiver is frequently unable to correct techniques for safety despite cues. Caregiver requires minimal physical assistance from the therapist to ensure safety. 6 = Poor. Concerns for caregiver safety with 80-99% of patient assistance. Caregiver is frequently unable to correct techniques for safety despite cues. The caregiver requires moderate assistance from the therapist to ensure safety. 7 = Poor minus. Caregiver does not demonstrate safety techniques for patient assistance. Or patient requires caregiver, but does not have one. Caregiver is frequently unable to correct techniques for safety despite cues. The caregiver requires maximal to total assistance from the therapist to ensure safety. 8 = Not applicable. Patient does not require a caregiver. 58 IMPROVED OUTCOMES IN SNF 59 5.2) Self-Care Assistance The score for this item is based on a global assessment of the caregivers safety impairment regarding the provision of assistance to the patient for self-care tasks. Circumstances for Scoring Initial evaluation: If caregiver is not present, score this item as 7, as the caregiver is unable to demonstrate the ability to provide safe and appropriate assistance. Discharge evaluation: If caregiver has previously participated in therapy and patient assistance has been observed, score the caregivers safety impairment based on the most recent observation of the caregivers abilities to provide safe and appropriate assistance. Scoring Criteria There are four scoring criteria for this item: (1) Setup: proper setup and use of assistive devices/equipment (if applicable) (2) Body mechanics: caregiver demonstrates proper body mechanics to prevent injury when providing patient assistance (3) Quality of patient assistance: positioning and handling of patient is appropriate, safe, controlled, and secure to prevent patient injury (4) Communication: communication between patient and caregiver is clear and effective. Communication should not be counted against score if patient unable to comprehend verbal instructions. 1 = Good. No concerns for caregiver safety when providing assistance to patient. Caregiver consistently demonstrates safe and appropriate assistance, and shows good awareness of patients needs. 2 = Fair plus. Concerns for caregiver safety with 1-19% of patient assistance. Caregiver rarely need cues for safety; may occasionally forget minor aspects of techniques for safe assistance, but is able to recognize potential issues and adjust accordingly with extra time. 3 = Fair. Concerns for caregiver safety with 20-39% of patient assistance. Caregiver is usually able to verbalize safe assistive techniques, but requires cues for recognition or correction of potential safety issues. Occasional cues may be needed for proper setup of assistive devices/equipment. 4 = Fair minus. Concerns for caregiver safety with 40-59% of patient assistance. Caregiver frequently requires cues for proper setup of assistive devices/equipment. Frequent cues are also need for recognition and correction of potential safety issues. The caregiver requires standby assistance from the therapist to ensure safety. 5 = Poor plus. Concerns for caregiver safety with 60-79% of patient assistance. Caregiver is frequently unable to correct techniques for safety despite cues. Caregiver requires minimal physical assistance from the therapist to ensure safety. 6 = Poor. Concerns for caregiver safety with 80-99% of patient assistance. Caregiver is frequently unable to correct techniques for safety despite cues. The caregiver requires moderate assistance from the therapist to ensure safety. IMPROVED OUTCOMES IN SNF 7 = Poor minus. Caregiver does not demonstrate safety techniques for patient assistance. Or patient requires caregiver, but does not have one. Caregiver is frequently unable to correct techniques for safety despite cues. The caregiver requires maximal to total assistance from the therapist to ensure safety. 8 = Not applicable. Patient does not require a caregiver. 60 61 IMPROVED OUTCOMES IN SNF Total Score Initial Discharge Change Add scores of all items with a score of 1 through 7. Scores of 8 on the tool have a value of 0 and, therefore, do not affect the total score. Potential Hospital Readmission Risk Risk Level EPRF Total Score Range Very Low Low Moderate Low Moderate Moderate High High Very High 7 - 13 14 - 20 21 - 28 29 - 35 36 - 42 43 - 49 50 - 56 Patient Care Critical Checklist This checklist is provided to track the timeline the patients care pathway. Admission Dates (mm/dd/yyyy) Home Evaluation Caregiver Training Discharge OT PT ST Resources Used for the Development of the EPRF Allen, C. K. (1991). Cognitive disability and reimbursement for rehabilitation and psychiatry. Journal of Insurance Medicine, 23(4), 245-247. Allen, C. K. (1985). Occupational therapy for psychiatric diseases: Measurement and management of cognitive disability. Boston: Little, Brown. Berg, K., Wood-Dauphinee, S., Williams, J. I., & Maki, B. (1992). Measuring balance in the elderly: Validation of an instrument. Canadian Journal of Public Health, (Suppl. 2), S7S11. Blessed, G., Tomlinson, B. E., & Roth, M. (1968). The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. British Journal of Psychiatry, 114(512), 797-811. Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139(9), 1136-1139. Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34(2), 119-126.  ...

... Running head: ADDICTION RECOVERY An Occupational Therapy Doctoral Capstone Experience in Addiction Recovery Aubriana Adney University of Indianapolis ADDICTION RECOVERY 2 Abstract The addiction of one individual affects much more than that person; addiction impacts the individuals family, as well as the entire community. Addiction leads to loss of life, social disruption, role disruption, and emotional displacement. A Better Life - Briannas Hope, an addiction support and recovery group, supports all who are impacted by addiction including the community and family. The organization, community, and family were assessed to develop programs and the population served using a SWOT analysis, literature review, personal conversations, or continuous problem-solving model. Utilizing workshops based on life skills, educating large crowds, training leaders, using handouts and resources throughout the community, providing advocacy and prevention to young children, and creating a means to be financially stable occupational therapy graduate student was able to respond to the ever-changing needs of society. During large community resource events, 140 individuals gained information and connections with available resources in the community. 24 individuals completed surveys; 62.5% were completely satisfied and 25% were somewhat satisfied with the event. Overall, ABLBH has spoken to approximately 12,000 students about prevention and the impacts of addiction. All members were invited to attend High Impact Parties creating another aspect of prevention and a positive social experience for the whole family. Attendance ranged from 24 people at the first and 31 at the second party. Continued ongoing quality improvements throughout the project and experience addressed the changing needs of the individuals, families, children, and the community. Keywords: addiction recovery, substance abuse, community, family, impact, doctoral capstone experience, occupational therapy ADDICTION RECOVERY 3 Literature Review/Background Information An epidemic of drugs has been spreading through the United States since the 2000s. The Center for Disease Control (CDC) (2017) states, The United States is in the midst of an opioid overdose epidemic. The rate of drug overdoses has increased at a rate of 137% according to Rudd, Aleshire, Zibbell, and Gladden (2016). As the rate of drug overdoses increases, the rate of sustainable evidence-based programs for individuals who use drugs should increase. According to Substance Abuse and Mental Health Services Administration (SAMHSA) (2017), In 2014 an estimated 22.5 million Americans aged 12 and older self-reported needing treatment for alcohol or illicit drug use, and the CDC (2017) states opioids has killed more than 42,000 people in 2016, more than any year on record. The previous statements suggest a need throughout the United States for a greater understanding of the impact addiction has on the family, as well as the entire community. Overdoses with opioid pharmaceuticals led to almost 17,000 deaths in 2011. Since 1999, opiate overdose deaths have increased 265% among men and 400% among women (SAMHSA, 2017). Overdose deaths create loss of life in the community which leads to the loss of income, social disruption, role disruption, and emotional displacement for the community, families, and children. Martin, Smith, Wallen, and Boisvert (2011) studied the stories of mothers recovering from addiction including the initial cause of addiction and their recovery processes. Eight out of 10 of the participants in the study authored by Martin et al. (p. 154) mentioned they had dysfunctional parents who had substance abuse issues. Lander, Howsare, and Byrne (2013) state, a parent with a substance use disorder is 3 times more likely to physically or sexually abuse their child (p. 200) which increases the likelihood a child will have poorer physical, intellectual, social, and emotional outcomes. The previous statements suggest children living with parents or guardians who have a substance use disorder have a greater risk of developing a ADDICTION RECOVERY 4 substance use disorder themselves. A cycle of substance abuse is shown to be a major factor in addiction studies authored by Martin et al. and Lander et al., suggesting disruption of the cycle would be beneficial to the prevention of addiction in younger generations. McKeganey, Barnard, and McIntosh (2009) studied the impact of parental drug use on children and found that children with parents with a substance use disorder experienced material neglect associated with their parents drug use. The children were exposed to drug use, drug abuse, drug violence, and the consequences of drug use as well as watching their parents overdose at young ages. The children were also at risk of witnessing criminal behavior and experiencing physical, mental, and emotional abuse. Family disruption and break up was also mentioned as an impact of parental drug use (McKeganey et al., 2009). The CDC (2017) states prevention can be achieved by expanding evidence-based treatment options for individuals who use drugs. Prevention of overdoses includes the future generations cycle of addiction. Addiction impacts the whole family unit, as well as the surrounding community (Lander et al., 2013). Addiction can leave extended family with "feelings of abandonment, anxiety, fear, anger, concern, embarrassment, or guilt", and can impact relationships between siblings through "negative role modeling, lack of trust, and diminished concepts of normative behavior" (Center for Substance Abuse Treatment, 2004, p. 22). Relationships with neighbors, friends, and coworkers can be at risk as well. Persons with addiction become unreliable which causing their neighbors, friends, or coworkers to help financially, be forced to compensate for decreased productivity, or increase their share of the workload" (Center for Substance Abuse Treatment, 2004, p. 22). Addiction impacts the individuals performance patterns, performance capacity, as well as their occupational identity (Martin et al., 2011). Helbrig and McKay (2003) stated Addiction is occupational in nature and can lead to occupational disruption (p. 140). Wasmuth, Crabtree, ADDICTION RECOVERY 5 and Scott (2014) extend this thought to describe addiction as an occupation that causes an occupational deficit. Opp (2018) describes occupational deficit as the inability to engage in meaningful activities. Combining these theories produces the suggestion a person in addiction has an occupational deficit and lacks engagement in meaningful activities that leads to disruption in their life and identity. Occupations include things people need to, want to, and are expected to do (American Occupational Therapy Association [AOTA], 2014). If treating addiction is seen as replacing occupations to allow a person to do everything they need to, want to, or are supposed to do by societal or cultural standards, occupational therapists would play a vital role. Occupational therapists focus on occupations and factors impacting the individuals context including their environment, performance skills, and performance patterns. Performance patterns are the routines, habits and roles a person exhibits throughout their daily life and performance skills are the abilities a person is born with and gains over time (AOTA, 2014). Occupational therapists look at the person individually before considering how the diagnosis affects the person. This helps develop and create an individualized treatment plan. For those with addiction, this way of thinking and processing provides a look beyond the addiction and yields steps to redefine themselves in a sober manner. Addressing addiction as an occupation within a group of individuals may assist in increased recovery outcomes while also decreasing the number of relapses as a result. Occupational therapy will facilitate replacement of addiction in positive ways such as creating new occupations and finding purpose and meaning in life. Wasmuth and Pritchard (2016) were able to assist participants of their study by replacing the addiction with new occupations or activities which gave the participants satisfaction in their activities and a sense of freedom from concerns and judgement. Feeling a lack of satisfaction and purpose is suggested to occur in those with addiction. According to Broadbear, Winger, ADDICTION RECOVERY 6 Rivier, Rice, and Woods (2004), the hormones in your body take at least a year to normalize before pleasure is felt without assistance of medication after the use of drugs. This suggests a lack of reinforced success in the first year of participating in recovery and new occupations. The regulation of hormones without the use of medication may play a part in each individuals recovery process. Since the neurophysiological responses are not initially felt, it could suggest that those with an addiction are more likely to relapse within the first year without the use of medication to facilitate hormone regulation. Introduction to new occupations, going to meetings, is the first part of treatment of addiction after working through detox and residential programs at A Better Life - Briannas Hope (ABLBH), an addiction support and recovery group throughout East Central Indiana. The next part of treatment is to have volition or motivation to create performance patterns including habits, routines, roles, and rituals used in the process of engaging in occupations or activities that can support or hinder occupational performance (AOTA, 2014, p. S8). Many individuals going through recovery establish multiple roles such as partner, spouse, worker, student, drug user/ person with addiction, drug dealer, and parent (Martin et al., 2011). ABLBH utilized an occupational therapists way of thinking before the graduate students came and without realization by stating a person who is recovering should change their people, places, and things to be most successful in sobriety. The organization had a way of thinking like an occupational therapist without using the words utilized by occupational therapists. The organization makes it a goal to grow and help as many people as possible who are affected by the drug epidemic sweeping the country. With this goal in mind, an occupational therapist working with the organization could reach more individuals indirectly by working with parents on coping strategies, social interactions, parenting skills, and creating structure for the parents to thrive ADDICTION RECOVERY 7 which impacts the child's living environment. The study by McKeganey et. al, (2009) suggests occupational therapists can advocate for the person with addiction, their children, and the family as a whole in a drug-related situation through education and role identification for each individual involved. Treatment can aid to improve quality of care for the children, while also teaching the parent how to succeed in their role as a parent and the importance of appropriate decision-making. Addiction impacts society on many different levels including the family, children, and community. To map out the different levels, create understanding of a persons or communitys needs, and how each path is different but interconnected the occupational therapy graduate student used the KAWA model. The KAWA model is different than most theories developed for occupational therapy use. It is ever changing and allows for interpretation of the clients needs. It focuses on the interconnectedness of the environment and nature that frames life experiences (Iwama, Thomson, & MacDonald, 2009). According to Iwama et al., (2009), the river is a metaphor for life flow, whereas most models use a mechanical and scientific explanation as a part of the whole model. The authors tried to make the model better address the rehabilitation requirements of diverse clientele (Iwama et al., 2009 p. 1125). This model has been used for patients of an adult community mental health team to describe a persons life story and current circumstances (Kawa cross-section) and help them to share elements with others that they feel are significant (Iwama, 2006; Iwama, 2013). Dellow and Skeels (2017), found the Kawa Model to be an effective tool that helps address the difficulties individuals face and help set goals to overcome the difficulties. Dellow and Skeels (2017) also found this model to encourage communication and identification of common experiences (depression, poor motivation, poor self-esteem etc.) These difficulties are common among people who are recovering. Using the ADDICTION RECOVERY 8 KAWA (River) Model has worked best to organize thinking and focus of the projects and programs being developed at ABLBH. It allows for change and can be split into multiple rivers to help look at specific barriers of smaller projects that might influence the larger projects created. The Doctoral Capstone Experience and projects were an attempt to further what is offered by the nonprofit organization pertaining to addiction, family, and community involvement. Screening and Evaluation To further what is offered at ABLBH, a needs assessment and evaluation were completed on the elements of society impacted by addiction including the nonprofit organization, families and children connected to the individuals with addiction, and community. The assessments were chosen using Bonnel and Smiths (2018) plan for continuous quality improvement (CQI) which includes multiple avenues for analyzing different areas of practice. The evaluation team chose to use a strengths, weaknesses, opportunities, and threats (SWOT) analysis of the organization, a literature review about what ABLBH should provide based on the needs of those with addiction, and the continuous problem-solving model for the community. Each area of society impacted by addiction (families, children, and the community) was analyzed using a SWOT analysis, a literature review, or a continuous problem-solving model from Bonnel and Smith (2018). Organization and addiction ABLBH was assessed by key professionals at the organization including Randy Davis, the executive director, and Gina Raines, the secretary and executive treasurer, as well as two occupational therapy graduate student interns which formulated the evaluation team. This team utilized the SWOT analysis method and discussed the goals and mission of ABLBH to assess the organizations needs. It was important to the executive director to include the mission statement ADDICTION RECOVERY 9 of the organization in the discussions to remind the team of why the organization does what they do. A literature review was performed to establish how ABLBH should best serve the population. The results of the literature review and the needs assessment were placed in the SWOT analysis of the organization. The SWOT analysis is meant to be dynamic, organic, and evolving according to Pickton and Wright (1998). The evaluation team continues to meet weekly to discuss the current week, reflect on the previous week in order to evolve ideas and interventions proposed, and to solve problems for the nonprofit and the population served. A SWOT analysis shows where an organization needs to improve and the areas that are strengths to an organization (Mind Tools Content Team, 2018). Many of the findings of the SWOT are below and a complete list can be found in the Appendix A. An element of strength found in the SWOT analysis included developing leadership and volunteers during the chapter meetings. The chapter meetings are much like AA meetings, but they do not use the 12-step program. Leadership of overcomers are grown through the chapter meetings when the individuals use the tools presented to them and learn to cope. An overcomer is a person who has an addiction but has been clean for more than 3 years. These overcomers then grow to be leadership in ABLBH. Using this approach strengthens the organization by showing a success story in the leadership of the organization. Another strength of ABLBH included providing services based on the needs of the individuals served. The chapter meetings happen once a week on a designated day. At the meetings, the leaders serve hot meals that many individuals in the area do not get without the meetings. Randy Davis, the executive director of ABLBH states these meals are sometimes the only hot food the individuals with addiction have throughout the week. Some of the people only come for the food, but they keep coming back. This tells me to keep the food coming (personal communication, January 2, 2018). Even though the nonprofit is rapidly growing, there are still ADDICTION RECOVERY 10 many different interventions and plans that are required for the organization to continue to expand. These plans include applying for grants for funding that is sustainable, creating curriculum for increased consistency across the chapters, and networking with individuals and school systems across the state. ABLBH has set goals to continue growing throughout the state of Indiana and Ohio. Currently, the organization has grown to 25 chapters in the past 3 years. With such rapid growth of the organization, the structure of the leadership and board of directors does not suit the size. There are many people on the board of directors (3 individuals from each chapter totaling 75 members) with ideas that need to be considered and due to the structure of the organization many ideas do not make it out of a meeting. This creates a weakness during organizational meetings as well as a weakness to the population being served. Another area of weakness has been an absence of training for the leadership team throughout the 3 years. Lack of training causes unhappy leadership, leadership and volunteer burnout, and loss of customers (Amo, 2018). Providing and distributing resources, setting a curriculum, and electronic technology have been a shortcoming according to Randy Davis (personal communication, January 2, 2018). This contributes to the lack of training and resources for the chapters. Finally, ABLBH relies on donations and grants for funding and because of this, there is a clear weakness in the ability to be financially self-sustaining. Before the graduate student interns arrived, funding was limited to donations from the community. The office staff and volunteers are starting to write grants for funding but still rely primarily on donations. The identification of strengths and weaknesses of the organization allows for the creation of a strategy to be a successful and competitive business. By identifying the internal factors (strengths and weaknesses), it creates the ability to capitalize, manage, or eliminate the ADDICTION RECOVERY 11 opportunities and threats, which are external factors, in order to continuously improve the outcomes of the organization (Mind Tools Content Team, 2018). Opportunities such as gaining paid employees, becoming self-sustainable financially, increasing the ability to write grants for future funding, and partnering with other agencies to provide increased services are all areas where ABLBH can expand. The opportunities present must be capitalized on in order to advance and increase programing through the organization. Threats have the potential to destroy an organization (Mind Tools Content Team, 2018). The leadership of each chapter is asked to volunteer their time to mentor and help those with addiction. Asking too much of the leadership can lead to burnout and eventually the closing of a chapter. The relapse of an individual in leadership could place a bad stigma on the organization. A relapse from leadership could also decrease volunteer, community, or financial support leading to increased cost for the organization or decrease in ability to help individuals. Another threat to ABLBH is the loss of funding. Loss of funding would decrease the number of people with addiction the organization could send to detox and residential treatment. Treatment costs a burdensome amount for these individuals and most of the time the family has to find the money to compensate for services at the facilities. ABLBH helps those families decrease the financial burden placed on them by their loved ones who have an addiction. Without the funding created by donations from the community and individuals many people with addiction served by ABLBH would not get the treatment needed. The top priorities of this Doctoral Capstone Experience (DCE) include acquiring funding through grants for sustainability and treatment, training of the leadership team, and supporting the community including families of individuals with addiction through the addition of programs. Impact of addiction on children and family ADDICTION RECOVERY 12 A literature review using the search terms addiction, support groups, occupational therapy, impact of addiction, substance use disorder, substance use, and substance abuse through the University of Indianapolis, Krannert Memorial Library, worldcat.org database was performed to find what an organization should provide with regards to addiction. During this review, many articles stated family and children were impacted by addiction and lacked the support necessary to cope (Barnard & McKeganey, 2004; Chassin, Pitts, DeLucia, & Todd, 1999; Gideon, 2007; Lander et. al, 2013; McKeganey et. al, 2009; Solis, Shadur, Burns, & Hussong, 2012; WaldmanLevi & Weintraub, 2014). A literature review was then completed on the needs of the family and children using the search terms occupational therapy, family, parent, child, addiction, children, impact of addiction, substance use disorder, substance use, and substance abuse through the same database. The list of demands was shortened into attainable possibilities for the occupational therapy graduate student to achieve in the 16 weeks she is present at the organization. After the literature review was finalized, informal discussions occurred with people who currently have an active addiction, persons who are recovering from addiction, grown children of parents with addiction, and other family members who give care to individuals with addiction. The final demands of the family and children include a support group for families, improvement of relationships with the family, education for parents who have an addiction including parenting skills and developmental milestones for their children, and education about the role family plays in recovery and addiction. Impact of addiction on the community A literature review and multiple conversations with the leaders and members of ABLBH and other organizations such as the Jay County Drug Prevention Coalition were completed to assess the needs of the community. Demands of the community consisted of: education for ADDICTION RECOVERY 13 children in schools about prevention to interrupt the cycle of addiction; education about the struggles people face trying to get and stay sober; education about how addiction can be seen as an occupation because the individual with addiction replaces everything else meaningful in their life with the addiction; and education about local and state resources. The evaluation team continuously reassesses the outcomes, interventions, and plans based on the feedback of the participants and leaders of the chapters. How can occupational therapy help? Occupational therapy started with roots in mental health and is trying to return with policies and education (Scheinholtz, 2010). Since addiction is a mental health issue, occupational therapy is an important part of recovery (Champagne & Gray, 2016). This DCE project was in an unusual mental health area of practice for an occupational therapist. Occupational therapy is typically found in acute care, long-term care, community-based mental health facilities, skilled nursing facilities, military facilities, hospitals, justice centers, residential and day programs, and outpatient facilities (Champagne & Gray, 2016). Occupational therapists are not typically seen leading support and recovery groups due to this setting being an emerging area of practice and the lack of reimbursement from insurance agencies. Because occupational therapy facilitates participation and is client-centered, it plays an important role in the success of those recovering in the community (AOTA, 2010; Scheinholtz, 2010) (Castandea, Olson, & Radley, 2013). An occupational therapist in a community setting can address the stigma of the community, evaluate and adapt the environment, provide training to individuals and staff members, and facilitate supportive environments (Castandea, Olson, & Radley, 2013). Screening and evaluations in this setting were different than most due to the nature of being an emerging practice area and the number of elements that were being assessed. The ADDICTION RECOVERY 14 SWOT analysis used for the organizational assessment is typically used for organizations during strategic planning phases but can also be used for personal reflection. The SWOT can also be used during an occupational therapy consultation to increase the organizations sustainability (Jacobs, & McCormack, 2011). This type of assessment allowed the occupational therapy graduate student to look at the internal and external factors of the organization and determine the best way to proceed depending on the needs of ABLBH. The family and children were assessed using a literature review and personal conversations. This type of assessment could be compared to occupational profiles and needs assessments completed on individuals during the intake evaluation process of an inpatient and outpatient facility (AOTA, 2014). However the population was assessed, the goals and opportunities formulated and found by the evaluation team were focused to improve the services presented by ABLBH. Implementation With ABLBH being new to occupational therapy, there were many ideas discussed that could be possible during the DCE in addiction recovery. The implementation phase included the following: advocating for the profession of occupational therapy (OT) creation of handouts and website information about resources and education for the community implementation of programs for individuals with addiction and their families including children to have positive social interaction training of leadership discussing during chapter meetings to the members the roles and routines of parenting and how to be a positive family member ADDICTION RECOVERY 15 creating a community outreach event where resources can be distributed providing education to children in schools about addiction and what they can do about it now while still in school Advocacy about the profession of OT at ABLBH occurred during meetings, through social media, and discussions throughout the communities served. A video was made, which can be found at https://www.ablbh.org/meet-the-staff, discussing the profession and how OT can be used in addiction recovery. At every new chapter meeting attended by the OT graduate student interns, the leaders make it a point to hold a discussion about who we are and what we do as interns for the organization. During that time, the members of the meetings can ask questions which may not have been addressed during other discussions. Handouts and lists of resources have been created and can be found under the resources tab on the website. The handouts were based on how to better an individuals roles and routines (sober living facilities, treatment centers, homeless shelters). Handouts of resources include food pantries, thrift stores, and other helpful tips which can be found in Appendix B. Some other handouts discuss child occupations, parental assistance in childhood mental health, child development, and how addiction affects children. These handouts can be found in Appendix C. Having resources at hand can create ease in time of need. The chapter leaders were trained over the life skills curriculum created for ABLBH during the DCE project. The curriculum was created based off of evidence found in literature searches. Each skill placed in the curriculum guide was suggest by literature to be a skill lacking in the generalized population of those with addiction. Training chapter leaders in the curriculum provided the education, resources, language, and skills needed to further the skills of those with addiction. The training also provided the ability for competence and understanding to be gained by leadership decreasing the risk of burnout and other threats identified in the ADDICTION RECOVERY 16 SWOT analysis. Part of the curriculum focused on roles and routines of those with addiction. Many individuals need to create or recreate positive roles, routines, and relationships with their family members. The OT graduate student completed a workshop with the members of ABLBH at the Redkey and Hartford City locations focused on creating/recreating positive roles and routines throughout life. Another attempt with creating positive relationships, roles, and routines through social interaction included the High Impact Parties. The High Impact Party was designed to be a time where families can join together and not have to discuss the addictions being faced but be in a supportive environment where they can create positive roles and routines through games, food, fellowship, and social interaction. A large community outreach and resource event called Connecting the Links was held March 10th in Delaware County. The goal of the event was to provide resources, education, and awareness on local business and organizations that help individuals in the community be successful as well as hear some perspectives of individuals living with addiction or who help those with addiction. ABLBH speaks to school corporations, after school clubs, churches, and community events about prevention, struggles of recovery, personal stories, stigma, and hope. This provided the opportunity to educate children on the effects of addiction and advocate for prevention of addiction and choices leading to addiction. Leadership The implementation of these projects required immense planning and organization to be completed successfully and timely. A large calendar, schedule, and sticky notes were used to keep track of all events, trainings, workshops, social engagements, and due dates of items. The large community outreach events required the most involved leadership skills by contacting multiple vendors and creating relationships for the organization. The large events require marketing to businesses, deciding which audience to target, discovering how to market to that ADDICTION RECOVERY 17 audience, and coordinating dates and times to meet to discuss how to market the needs of ABLBH and other organizations to improve the resources gained by the individuals attending the events. This type of work required quick thinking in the moment. During one of the weekly group meetings, where a program had been planned about budgeting and management of money, an individual had a topic that needed to be discussed, needed support from the group members, and the ability to express her grief. She did not understand how to cope with the death of a loved one and was at risk for choosing relapse. Instead of continuing the program about finances, the meeting took another path to rediscover what life looked and felt like in that moment. Listening to the wants and needs of the participants of the group was an integral part of being a leader of a group. It is important to train and educate the chapter leaders to capitalize on these types of moments. Capitalizing on those moments creates trust, inclusion, engagement, and respect. Many of the services delivered including workshops, leadership training, implementation of programs, and education to children in school required direct care to individuals with addiction. Other services ABLBH provides are delivered indirectly through emails, website postings, social media postings, and through facilitation of the leadership of other chapters for both group and individual. Outcomes At Connecting the Links, outcomes were assessed by both the attendance of individuals and a feedback/satisfaction survey. The surveys were placed near the exit for individuals to fill out as they left and presented to vendors at their booths. The survey was anonymous and provided feedback to determine the effectiveness of the event. The attendance and survey give feedback on the impact of the marketing options used. An example of the survey can be found in Appendix D. A total of 140 people attended the event; 34 vendors/volunteers and 106 guests (64 ADDICTION RECOVERY 18 adults and 42 children). Out of the 140 people who attended 24 completed a feedback survey. The survey requested feedback about the marketing options used to spread the word about the event. The results are as follows: 25% of people who attended discovered the event from a newspaper, 29% were invited through their employer, 21% were invited from a family or friend, 17% were invited from Facebook, 29% heard from word of mouth, and 21% were invited by another source (8% ABLBH, 4% the facility, 8% email). The next section of the survey requested feedback about what interested the individuals in attending. The results are as follows: 12.5% came for the speakers, 12.5% came for the vendors, 50% came for both the speakers and the vendors, 4% came for the food, 4% came for the food, vendors, and speakers, and 21% came for other (8% community awareness and 12.5% networking). Out of the attendees who took the survey 62.5% were completely satisfied, 25% were somewhat satisfied, and 4% were completely dissatisfied. Many of the answers to the open-ended questions provided feedback on how to better the event. Suggested changes included increased advertisement and publicity, increase the number of vendors, increase the foot traffic, increase the size of the signs used, and decrease the amount of time the event is offered. Other suggestions included adding more peer support groups such as Narcotics Anonymous, Alcoholics Anonymous, Celebrate Recovery, and Reformers Unanimous. Having the vendors and speakers in the same room, inviting churches, schools, and local radio stations, as well as having someone outside waving for people to come in were suggestions to better the event. The outcomes from the survey will be used in the future to make changes to the next large event that ABLBH plans to complete. Prevention was assessed by counting the number of children spoken to throughout the elementary schools, middle schools, high schools, and clubs. The High Impact Parties were assessed through attendance, conversations with the leadership, and feedback from the ADDICTION RECOVERY 19 participants. Attendance at the first High Impact Party was counted at 24 attendees, with 7 of those attendees being family of the occupational therapy students working with the organization. The second High Impact Party totaled 31 attendees with 3 of the attendees being leaders/hosts of the event. Changes were made to increase the quality of the program including the time of the event and how/when the party is marketed to the community. The changes were necessary for continuation of the programs and increased attendance. Quality of services and sustainability To ensure the quality of the services and the sustainability of the programs provided by ABLBH, the leadership teams (or chapter leaders) were offered training over roles, routines, budgeting, resume building, interview skills, coping skills, time management, and positive occupations led by the occupational therapy students. The training provided consistency throughout each chapter utilizing the workshops. Changes to the curriculum were made, updated, and presented to the leadership teams to continue growth, knowledge, and use of evidence-based practice for the population served. The use of evidence-based thinking and practice has also increased the quality of the services provided at ABLBH. Scaffa and Reitz described sustainability as an ongoing process that is often times not achieved (2014). As the discontinuation phase of the DCE occurs, changes will occur more often as the staff at ABLBH takes over. Each chapter leader will place their own spin on some of the information provided while maintaining the programs evidence-based nature. Another part of becoming a sustainable organization includes the ability to be financially stable. A grant to Executive Director of Drug Prevention, Treatment, and Enforcement, Jim McClelland, was written to ask for funding to sustain the programs being implemented by ABLBH. Another grant was written to the Jay County Drug Prevention Coalition for funding for the continuation of the large community ADDICTION RECOVERY 20 events like Connecting the Links. Funding has been typically in the form of donations from the community and wealthy individuals who believe in the cause. By writing grants, the organization will have increased financial stability and provide a peace of mind for the executive director as well as the board members. Another aspect of stability includes updating the website. The website has been updated to improve the ability of participants and leadership to have direct access to information presented by ABLBH. Resources on the website were created for individuals who are seeking help in the form of treatment facilities, food banks, sober living facilities, homeless shelters, and businesses. The chapter leaders were provided resources to assist in locating organizations in the area that provide services for affordable housing, childcare assistance, and discounted items such as food or clothing. Many of the resources on the website were requested by either leadership or individuals. Meeting the needs of society Findings from literature and from personal conversation enabled the occupational therapy graduate student to utilize occupational therapy to respond to the needs of society. Flexibility and the willingness to change based on feedback from the participants and the leadership teams allowed ABLBH to responds to the needs of the population served and the community surrounding and supporting the population. This ensured that the needs of individuals, community, and families were met; it further ensured the quality of the programs. ABLBH continued ongoing quality improvements throughout the DCE projects to address the changing needs of the individuals, families, children, and the community. Overall Learning Throughout my DCE, I have maintained professional communication through email, phone conversations, and face to face contact. Many hours were spent on the phone or in front ADDICTION RECOVERY 21 of groups discussing occupational therapy and how occupational therapy can assist an individual achieve recovery. Discussions occurred about the use of occupational therapy outside of the medical model multiple times. In school, we learned and discussed the many different avenues an occupational therapist could take to help an individual thrive in his/her environment. Many times, the community would not understand the use of occupation as a means of recovery, this led to many conversations and educational opportunities to build the skills and confidence I needed to effectively interact and advocate for the profession. The DCE project has prepared me to advocate for the services I will provide in my future practice. I have communicated through writing multiple documents and emails for the purposes of ABLBH and my schooling. Each of the documents written maintained professionalism throughout. From this experience, I have learned a considerable amount about how environment, education, support systems, peers, and experiences that impact ones life. Many individuals experience hardships and adverse experiences that begin to create a lack of an ability to cope in a positive way may lead to the use of drugs or relapse. The knowledge gained will be carried over into my future practice, used to educate those who may be at risk, and used to understand the people served on a different level. Each person has a story. The more information and knowledge I can gather from the individual, the more I can help my client, or understand how they got to where they are and how I can help them get back to where they need to be. That client may be struggling to maintain recovery, stay in school due to behavioral issues, struggling due to mental health, social health, or physical health issues. This experience has taught me to think on my feet, use knowledge and evidence to base my thinking, provide a discussion rather than direction, use myself in a therapeutic way that benefits the clients I am working with. It has also taught me to never stop learning and inventing ways that will help a person navigate his/her ADDICTION RECOVERY 22 struggles. Each individual is unique and sometimes after trying the evidence-based practice without success, an occupational therapist must take a different route to help an individual succeed. I have also learned to think beyond the evidence. Each individual brings their own experiences to the equation and at some points generalized evidence-based practice studies do not cover the unique nuances detailed in an individuals experience. Also, during this experience, I have learned that when an individual is struggling there are at least a few others that are struggling alongside whether it be a person in the community, a family member, a child, or all of the above. For the future, I will investigate those around the client I am treating to see if there is someone else impacted by what the client is going through including caregivers, parents, guardians. Sometimes my job will encompass giving the person who is a caregiver to my client a number to a respite facility, a support group meeting time, or a number to an organization that has more knowledge about what the caregiver are going through. That could be the best way for me to impact my client, by giving their caregiver information about how to take care of themselves while caring for my client. ADDICTION RECOVERY 23 Reference American Occupational Therapy Association. (2010). Specialized knowledge and skills in mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 64(Suppl.1), S30S43. doi:10.5014/ajot.2010.64S30 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl.1), S1 S48 http://dx.doi.org/10.5014/ajot.2014.682006 Amo, T. (2018). The negative effects of a lack of training in the workplace. Smallbusiness.chron.com. Retrieved from http://smallbusiness.chron.com/negativeeffects-lack-training-workplace-45171.html Barnard, M., & McKeganey, N. (2004). The impact of parental problem drug use on children: What is the problem and what can be done to help?. Addiction, 99(5), 552-559. http://dx.doi.org/10.1111/j.1360-0443.2003.00664.x Bonnel, W., & Smith, K.V. (2018). Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company. Broadbear, J., Winger, G., Rivier, J., Rice, K., & Woods, J. (2004). Corticotropin-Releasing hormone antagonists, Astressin b and Antaramian: Differing profiles of activity in rhesus monkeys. Neuropsychopharmacology, 29(6), 1112-1121. doi:10.1038/sj.npp.1300410 Castandea, R., Olson, L., & Radley, L. C. (2013). Occupational therapys role in community mental health. Bethesda: American Occupational Therapy Association. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/MH/Fa cts/Community-mental-health.pdf ADDICTION RECOVERY 24 Center for Disease Control. (2017). Understanding the epidemic. Cdc.gov. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html Center for Substance Abuse Treatment. (2004). Substance abuse treatment and family therapy. Treatment Improvement Protocol (TIP) Series, No. 39. HHS Publication No. (SMA) 154219. Rockville, MD: Substance Abuse and Mental Health Services Administration. Chassin, L., Pitts, S., DeLucia, C., & Todd, M. (1999). A longitudinal study of children of alcoholics: Predicting young adult substance use disorders, anxiety, and depression. Journal of Abnormal Psychology, 108(1), 106-119. http://dx.doi.org/10.1037/0021843x.108.1.106 Champagne, T., & Gray, K. (2016). Occupational therapys role in mental health recovery. Bethesda: American Occupational Therapy Association. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/MH/Fa cts/Mental%20Health%20Recovery.pdf Dellow, B. & Skeels, H. (2017). Development of a KAWA model workshop for patients of an adult community mental health team. Dorset HealthCare University NHS Foundation Trust. Seminar presented by Christchurch & Southbourne Community Mental Health Team, Dorset, UK. Retrieved from: http://www.kawamodel.com/v1/index.php/2017/01/12/development-of-a-kawa-modelworkshop-for-patients-of-an-adult-community-mental-health-team/ Gideon, L. (2007). Family role in the reintegration process of recovering drug addicts: A qualitative review of Israeli offenders. International Journal Of Offender Therapy And Comparative Criminology, 51(2), 212-226. http://dx.doi.org/10.1177/0306624x06287104 ADDICTION RECOVERY 25 Helbig, K., & McKay, E. (2003). An exploration of addictive behaviors from an occupational perspective. Journal of Occupational Science, 10(3), 140-145. doi:10.1080/14427591.2003.9686521 Iwama, M. (2006). The KAWA model: Culturally relevant occupational therapy. Edinburgh: Churchill Livingstone Elsevier. Iwama, M. (2013). Future-proofing OT for a multicultural world. Occupational Therapy News, 21(3), 35. Iwama, M., Thomson, N., & Macdonald, R. (2009). The KAWA model: The power of culturally responsive occupational therapy. Disability & Rehabilitation, 31(14), 1125-1135. doi:10.1080/09638280902773711 Jacobs, K., & McCormack, G. L. (2011). The Occupational Therapy Manager. Bethesda, MD: AOTA Press. Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: From theory to practice. Social Work in Public Health, 28(0), 194205. http://doi.org/10.1080/19371918.2013.759005 Martin, L. M., Smith, M., Rogers, J., Wallen, T., & Boisvert, R. (2011). Mothers in recovery: An occupational perspective. Occupational Therapy International, 18(3), 152-61. McKeganey, N., Barnard, M., & McIntosh, J. (2009). Paying the price for their parents' addiction: Meeting the needs of the children of drug-using parents. Drugs: Education, Prevention and Policy, 9(3), 233-246. Mind Tools Content Team. (2018). SWOT analysis: Discover new opportunities, manage and eliminate threats. Mindtools.com. Retrieved from https://www.mindtools.com/pages/article/newTMC_05.htm ADDICTION RECOVERY 26 Opp, A. (2018). Recovery with purpose: Occupational therapy and drug and alcohol abuse. aota.org. Retrieved from https://www.aota.org/About-OccupationalTherapy/Professionals/MH/Articles/RecoveryWithPurpose.aspx Pickton, D. W. and Wright, S. (1998), What's SWOT in strategic analysis?. Strategic Change, 7: 101109. doi:10.1002/(SICI)1099-1697(199803/04)7:2<101::AID-JSC332>3.0.CO;2-6 Rudd, R., Aleshire, N., Zibbell, J., & Matthew Gladden, R. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. American Journal of Transplantation, 16(4), 1323-1327. http://dx.doi.org/10.1111/ajt.13776 SAMHSA - Substance Abuse and Mental Health Services Administration. (2017). Prevention of substance abuse and mental illness. Samhsa.gov. Retrieved from https://www.samhsa.gov/prevention Scaffa, M. E. & Reitz, S.M. (2014). Occupational therapy in community based practice settings (2nd ed.). Philadelphia: F.A.Davis. Scheinholtz, M. (2010). Occupational therapy in mental health: Considerations for advanced practice. Bethesda, MD: AOTA Press. Solis, J., M. Shadur, J. M., Burns, A. R., & Hussong, A. M. (2012). Understanding the diverse needs of children whose parents abuse substances. Current Drug Abuse Reviews, 5(2), 135-147. http://dx.doi.org/10.2174/1874473711205020135 Waldman-Levi, A., & Weintraub, N. (2014). Efficacy of a crisis intervention in improving motherchild interaction and childrens play functioning. American Journal of Occupational Therapy, 69(1). http://dx.doi.org/10.5014/ajot.2015.013375 ADDICTION RECOVERY 27 Wasmuth, S., Crabtree, J. L., & Scott, P. J. (2014). Exploring addiction-as-occupation. The British Journal of Occupational Therapy, 77(12), 605- 613. doi:10.4276/030802214X14176260335264 Wasmuth, S., & Pritchard, K. (2016). Theater-based community engagement project for veterans recovering from substance use disorders. American Journal of Occupational Therapy,70(4), 7004250020p1-7004250020p11. doi: 10.5014/ajot.2016.018333. ADDICTION RECOVERY 28 Appendix A STRENGTHS WEAKNESSES What advantages does your organization have? What do you do better than anyone else? What unique or lowest-cost resources can you draw upon that others can't? What do people in your market see as your strengths? What factors mean that you "get the sale"? What is unique about your organization? What could you improve? What should you avoid? What are people in your market likely to see as weaknesses? What factors lose you sales? o passion from chapter to chapter for growth- 25 chapters as of January 8, 2018 o they are originally, timely, and where the action is o able to provide meals at each meeting o nonjudgmental, accepting, o previous addicts as leaderships allow for ability to relate o financially transparent o director is able to train leadership in each chapter o designed on the need of the individual participant driven no set curriculum o community support and availability o Structuring need structure to meet all needs Company grew beyond vision o Budgeting o trainings per quarter o ability to provide resources o no set curriculum o financially self-sustaining o support for family o relapse of individuals placing bad name on brand OPPORTUNITIES What good opportunities can you spot? What interesting trends are you aware of? Useful opportunities can come from such things as: Changes in technology and markets on both a broad and narrow scale. Changes in government policy related to your field. Changes in social patterns, population profiles, lifestyle changes, and so on. Local events. o grants 3 paid employees trainings for benefits funds for detox/treatment placement o sustainability o partnering with other agencies to provide more services o interns o continuously growing due to dire need THREATS What obstacles do you face? What are your competitors doing? Are quality standards or specifications for your job, products or services changing? Is changing technology threatening your position? Do you have bad debt or cash-flow problems? Could any of your weaknesses seriously threaten your business? o o o o o o loss of funding leadership relapse financial transparency burnout in leadership decrease in volunteer support decreased community support ADDICTION RECOVERY 29 Appendix B ADDICTION RECOVERY 30 ADDICTION RECOVERY 31 ADDICTION RECOVERY 32 ADDICTION RECOVERY 33 Appendix C ADDICTION RECOVERY 34 ADDICTION RECOVERY 35 ADDICTION RECOVERY 36 ADDICTION RECOVERY 37 Appendix D Thank you for attending Connecting the Links! We hope the event met your reason for coming. Please take a second to complete this survey to help us better understand what we did right and how we could improve. How did you hear about this event? Radio Newspaper Employer Family/friend Facebook Word of mouth Other: _______________ What interested you in attending? Speakers Vendors Both Food Other: _______________ How satisfied were you with the overall event? (Circle one) Completely Satisfied Somewhat Satisfied Somewhat Dissatisfied Completely Dissatisfied What was your favorite part of the event? Was there anything about the event you think we could have done better? Additional Comments/Suggestions:  ...

... Running head: PROGRAM DEVELOPMENT WITHIN MENTAL HEALTH 1 An Occupation-Based Approach for Program Development within an Acute Mental Health Setting Ashley Scheidler May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Sally Wasmuth, PHD, OTR MENTAL HEALTH 2 A Capstone Project Entitled An Occupation-Based Approach for Program Development within an Acute Mental Health Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Ashley Scheidler, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date MENTAL HEALTH 3 Abstract Acute psychiatric facilities serve individuals with serious mental illnesses in hopes of providing adequate care to promote a successful community reintegration, although many facilities lack having an occupational therapist on staff to help in the recovery process. In this doctoral capstone experience (DCE), an occupational therapy (OT) student from the University of Indianapolis advocated for the OT profession by creating and implementing a seven-week occupation-based program with adult patients at LaRue D. Carter Memorial Hospital, as there was no OT practitioner on staff. The participants were chosen through a convenience sample and to measure outcomes, the OT student utilized structured and unstructured assessments. The program focused on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) that were deemed meaningful during the completion of the needs assessment. Through the results of a pre-post survey and participant feedback, there was an increase in knowledge of the OT scope of practice. The Goal Attainment Scale (GAS) was an outcome tool used to measure the effectiveness of the program, which met the expected level of outcome. The results of the program showed the need of an OT practitioner at this specific site, as OT provides holistic, occupation-based therapy. For future practice, the need for more OT practitioners within the mental health setting, especially acute care facilities, is evident and vital during these individuals recovery process. MENTAL HEALTH 4 Introduction Serious Mental Illnesses Individuals with serious mental illnesses are viewed differently in society, yet there is little light shed on the underlying physiological aspects that are affecting these individuals. In a report from 2015, The National Institute of Mental Health reported 10 million Americans over the age of 18 are living with a serious mental illness, but many do not receive treatment (2018). A serious mental illness is defined as individuals 18 and older either living with or diagnosed within the past year with a mental, behavioral, or emotional disorder that results in serious functional impairment (APA, 1994; SAMHSA, 2013). According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2013), common serious mental illnesses include, but are not limited to, schizophrenia, bipolar disorder, borderline personality disorder, major depressive disorder, and psychotic disorder. The exact cause of a serious mental illness is unknown; however, environmental, biological, and psychological factors play a role. Individuals may have altered brain chemistry due to substance abuse, family history of mental illness, and/or difficult upbringings involving trauma. These factors increase the chances of having a serious mental illness (SAMHSA, 2013). Individuals with serious mental illnesses have decreased motivation, poor self-care, limited social skills, and the biggest burden is unemployment (Dewa, McDaid, & Ettner, 2007; Harvey, Green, Keefe, & Velligan, 2004). The goal is for the individuals to learn to lead a productive life while managing symptoms to promote successful community reintegration. A Gap in Healthcare MENTAL HEALTH 5 According to Mental Health America, Indiana is ranked 48 out of 51 states overall, indicating higher prevalence rates and lower access to care for those with a mental illness (2017). Across America, 56% of American adults with a mental illness do not receive treatment and there is up to a 6:1 ratio of individuals with a mental illness to mental health professionals (MHA, 2017). There is an obvious shortage of professionals available to help individuals with these diagnoses, however many do not take the necessary steps for treatment, as showcased above. There are an estimated 26% of homeless adults that are living with a serious mental illness (U.S. Department of Housing and Urban Development, Office of Community Planning and Development, 2011). Within the department of corrections, 20% of state prisoners and 21% of county jail prisoners have a mental health condition with 2 million that are incarcerated each year (Glaze & James, 2006; NAMI, n.d). At least 83% of individuals do not receive the appropriate help and care within the jail system causing their symptoms to worsen (NAMI, n.d.). There is an evident gap in healthcare between various populations within the United States. Individuals with a serious mental illness have an increased risk of having a chronic medical condition and these individuals on average die 25 years earlier than others (Colton & Manderscheid, 2006). This unimaginable statistic is related to the access to healthcare. All of these statistics produce staggering numbers that indicate serious concerns and issues relating to healthcare and quality of life for individuals with mental illness. The National Institute of Health (n.d.) discussed the 21st Century Cures Act passed in 2016 is monumental in the recovery of individuals with mental illnesses. It allows more opportunity for research to have clinical trials in hopes of new therapies for these individuals (NIH, n.d.). This advance in healthcare may be eliminated due to political changes; however it is still important to advocate for changes in the mental health setting to advance opportunities. MENTAL HEALTH 6 Recovery Model SAMHSA has defined recovery as the process of change which individuals improve their health and wellness, live a self-directed life, and strive to reach their highest potential (SAMSHA, 2017, para 2). The recovery model is utilized to assist individuals with leading a successful daily life while managing symptoms. The four dimensions included in this model are health, home, purpose, and community (Duckworth, 2015). The recovery process is clientcentered and is supported through various treatment services, community-based programs, peers, and family (SAMSHA, 2017). Ten components are discussed within the model to support individuals during the recovery model, such as, hope, respect, relational, culture, peer support, holistic, many pathways, person-driven, strengths/responsibilities, and trauma (SAMSHA, 2013). The fundamental aspects of the recovery model coincide with the philosophy of occupational therapy (OT). Many principles of the model are reflected in the Model of Human Occupation (MOHO), a model utilized in OT practice to integrate volition into the individual recovery process (Cole & Tufano, 2008). Model of Human Occupation According to Cole & Tufano (2008), the MOHO is an open system that focuses on a holistic and systemic approach for individuals of all ages with various needs. The open system consists of multiple factors that work together, which all effects an individuals motivation, behavior, and performance. This model emphasizes both internal and external aspects of an individuals life and how they are connected. The MOHO divides the person into three subcategories, which are volition, habituation, and performance capacity. Volition includes values, interests, and personal causation. Habituation is habits and roles that become routines for the MENTAL HEALTH 7 client. Lastly, performance capacity is the ability to act with the appropriate skills needed. The MOHO is a client-centered model; however, the environment can play a role in the outcome of the performance (Cole & Tufano, 2008). Wimpenny, Forsyth, Jones, Matheson, and Colley found that when theory is used and health professionals collaborate with one another, the implementation of the theory, specifically the MOHO, will advance practice and the intervention process (2010). The MOHO is commonly used within the mental health setting because it is client-centered. Individuals with mental illnesses have decreased self-esteem and a loss of selfworth, so putting the person at the center of the OT process will potentially increase the individuals volition and overall quality of life. Occupational Therapy in Mental Health According to the American Occupational Therapy Association (AOTA), OT practitioners work collaboratively with individuals with mental illnesses to increase motivation, empowerment, and to foster hope, in order to increase participation and satisfaction in meaningful occupations. OT practitioners also hope to help individuals be as independent as possible in their daily lives through evaluation and intervention tools. Interventions include identifying healthy habits and routines, learning coping strategies, identifying personal values, needs, and goals, and even making a recovery action plan (AOTA, 2016). Intervention sessions take place individually or in groups. The OT Practice Framework suggests individuals must have appropriate client factors, performance patterns, and performance skills in order to be successful in completing the occupation (2014). In mental health settings, OT practitioners need to be client-centered to allow the individual to make goals and individualized choices during the OT process in order to increase participation and have positive outcomes (Arbesman & Logsdon, 2011). OT can serve individuals through community-based programs, inpatient facilities, MENTAL HEALTH 8 schools, forensic centers, outpatient facilities, and skilled nursing facilities (AOTA, 2016). According to the Occupational Therapy Compensation Workforce Study, only 2.9% of OT practitioners work in a mental health setting (AOTA, 2010). There is an obvious shortage in the mental health setting of OT practitioners and there are many reasons as to why this is. According to Buchmueller, Cooper, Jacobson, and Zuvekas, the shortage is due to a larger crisis where services may not be reimbursed within the mental health setting (2007). With this shortage, OT practitioners need to become members of state and national organizations, conduct research to show evidence of how important OT is within the mental health setting, and practitioners need to advocate to administrators on the important role of OT (Gutman, 2011). Inpatient Mental Health Facilities According to Mental Health America (MHA), hospitalization becomes necessary for an individual with a mental illness when their illness becomes serious enough that they are at risk for harming themselves and/or others (2016). LaRue D. Carter Memorial Hospital is a state psychiatric hospital that has been serving individuals with serious illnesses since 1948 (IN.gov, 2018). These patients are treated through an interdisciplinary approach that focuses on a holistic, client-centered basis. The hospital has a three-fold mission of providing research, education, and treatment to patients. There are two service divisions within the hospital that provide treatment to adults age 18 and over such as, journey to recovery and channel for change (IN.gov, 2018). The pathway to healing is the division for children and adolescents with severe emotional disturbances (IN.gov, 2018). There are various professions on the treatment teams, such as physicians, psychologists, social work, dietitians, and recreational therapists; however there is no OT. The role of OT within the mental health setting, especially on the inpatient level, is vital to the individuals recovery and reintegration into the community in order to lead a productive life. MENTAL HEALTH 9 This experience will look into the effectiveness of the OT process through group treatment sessions within the acute mental health setting. Methods Participants The occupation-based program took place on an adult unit at LaRue D. Carter Memorial Hospital in a nutrition room. All participants had a serious mental illness diagnosis that had impacted their daily life to the extent of having a court order to be patients at this hospital. The participants ages ranged from 19-60 years old. The program was conducted in person between the leader (OT student) and patients throughout the entire process. The individual portion was held during the screening and evaluation process, while the group portion was held during the intervention phase. Group therapy in the acute mental health setting is a core part of OT, which is the reason the program at LaRue Carter had multiple participants (Cole, 2008). Study Design Screening. A mixed methods approach was utilized throughout the screening and evaluation process, which was reflected by tools that included quantitative and qualitative data. The screening process determines individual strengths and limitations through existing data, observations, and tools to determine the need for additional assessments (Hinojosa & Kramer, 2014). The screening process is an essential part to determine what evaluations are needed; therefore, leading to a productive intervention phase. Without the supervision of a registered occupational therapist (OTR), there could not be any OT specific standardized screening and/or evaluation MENTAL HEALTH 10 tools used. The Mini Mental State Examination (MMSE) is a generalized screening tool used throughout healthcare. It was created for adults who have psychiatric, neurological, and other conditions (Folstein & Folstein, 2010). The MMSE screening tool is used to determine the individuals cognitive function (Ong et al., 2016). This screening tool is important in the mental health setting to not only plan for productive treatment sessions, but also to promote cognizance of the participants cognition. Ong et al. (2016) reported cognition is a key impairment in individuals with schizophrenia. Decreased levels of cognition can affect an individuals functional ability, such as completing self-care tasks, independence, social skills, and work skills (Lepage, Bodan, & Bowie, 2014). AOTA encourages OT practitioners to focus on the relationship between the individuals cognition, functional performance, and environmental context (AOTA, 2017). Therefore, it was essential to address these areas in the screening and evaluation process. Evaluation. According to Cole & Tufano (2008), the evaluation process should be client-centered and thoroughly done. Utilizing data to learn more about the individual from an outsider looking in and understanding how individuals perceive themselves are two steps in the evaluation process that ensure adequate information is obtained (Cole & Tufano, 2008). Since there were no OT standardized assessments used, it was imperative to include various levels of structured and unstructured assessments in order to consider all aspects of OT that were meaningful to the individual. Clinical observations were conducted on the unit and during various groups to observe individuals actions and behaviors in different situations. Areas focused on during the observation period included appearance, mood, eye contact, orientation, etc. Structured interviews and patient checklists were also a part of the evaluation process. Interview questions MENTAL HEALTH 11 included occupational profile questions to build rapport with the participants. Questions highlighted sensory processing, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and triggers that bought on certain behaviors. Since the MOHO guided this experience, it was imperative to base the program off the clients needs and wants. The participant completed a short checklist to allow some control during the evaluation process. These questions determined meaningful occupations for each participant. Scanlan and Novak (2015) found that sensory approaches are essential in mental health because it can help individuals regulate behaviors through self-direction and empowerment. Through this process, there has been a reduction in restraints and seclusion (Scanlan & Novak, 2015). Therefore, it was important to include sensory-based questions. Edelow and Krupa suggested individuals with serious mental illness have limited participation in meaningful occupations, personal growth, and social participation, indicating the importance of addressing these issues during the evaluation process (2011). The data collected determined the structure for the intervention process. Compare/Contrast Areas of Occupational Therapy Throughout the scope of OT, the goal for the screening and evaluation process is to gain valuable information about the individual in hopes of creating a client-centered intervention process. The difference is the various screening and evaluation tools, specific to a population or setting, that gather this information. OT is unique in its own way because practitioners address an individuals mental health needs in all practice settings (AOTA, 2016). Specifically in mental health, the goal is for the client to live a productive life while managing his/her symptoms through meaningful interventions. Simpson, Bowers, Alexander, Ridley, and Warren (2005), conducted research on an acute mental health floor and found OT practitioners assessed patients MENTAL HEALTH 12 and provided group therapy, which was similar to the occupation-based program at LaRue Carter. However, the OT practitioners focused more on ADLs, whereas the program completed in this study focused on IADLs (Simpson et al., 2005). Spence, Schwarzschild, and Synovec (2015) reported OT practitioners at John Hopkins Hospital on the psychiatric floors conducted various therapeutic groups that focused on IADLs. The groups specifically focused on one IADL throughout the program, which was based on cognition and community reintegration goals for each patient. The practitioners had eight or less participants in each group, which is similar to the program at LaRue Carter (Spence et al., 2015). The program at Johns Hopkins focused on one IADL at a time, whereas the program at LaRue Carter focused on both ADLs and IADLs. In acute mental health settings, it is common to have group therapy that focuses on IADLs, such as money, time, and medication management, and activities that motivate the clients to have a healthy life to promote purposeful and meaningful skills. Needs Assessment Results A convenience sample was utilized during the screening and evaluation process, which resulted in eight participants. Based on the results from the MMSE, one participant scored in the moderate cognitive impairment range, three in the mild cognitive impairment range, and four in questionably significant impairment range. Some participants did require assistance with reading and writing. During the interview, all participants reported their biggest problem was being a patient at LaRue Carter and their goal was to be discharged. All participants reported the desire to hold a job. Seven participants reported the need to increase self-esteem and skills for money management. Four participants reported difficulty in completing daily self-care tasks. Three participants reported loud sounds and certain clothing bother them. The participants were observed on the unit during recreational therapy groups. Seven participants had appropriate MENTAL HEALTH 13 behavior, however; one participant did voice negative comments at times. All participants needed reminders to stay on task at least once and most had flat affect. All participants were oriented appropriately and some participants were observed wearing the same clothing on consecutive days. Six participants were chosen to be a part of the program through a treatment team decision after compiling results. The treatment team included a physician, pharmacist, social worker, registered nurse, and a recreational therapist. Outcome Measures Participants completed a pre and post-test survey during the first and last session to determine the effectiveness of the program through their lens. The survey was five questions that included multiple choice, true and false, and short answer questions. The questions were based off of information presented to the participants throughout the duration of the program. The goal was for the participants to gain knowledge in these various areas by the time the posttest survey was administered. The Goal Attainment Scale (GAS) was utilized as an outcome tool to determine the effectiveness of the program through goal writing. The level of attainment was laid out through numbers and expectations. The present level was scored as a -2, meaning it was much less than expected. There was no OTR on staff, so there were no occupation-based programs before the OT student arrived and the staff had not been educated on the role of OT at LaRue Carter. The next level was -1, which meant the goal was somewhat less than expected. This goal was met during the progression of the doctoral capstone experience (DCE). Zero was the expected level of outcome, meaning it was the annual goal. The expected goal of the program was to plan and implement a seven-week occupation-based program on an adult unit that focused on various MENTAL HEALTH 14 ADLs and IADLs. The second goal was to educate staff and patients on the role of OT at this site through in-services or handouts. The next level was +1, which meant it was somewhat more than expected and it exceeded the annual goal. The highest level of attainment was +2, which meant much more than expected and it far exceeded the annual goal. The OT student strived to meet the expected level of outcome, but was satisfied with any score higher. The leader of the group determined if the goal was met at the end of the program. Procedure Implementation The program at LaRue Carter, led by an OT student, took place one day a week for 45 minutes for seven weeks. Throughout the entire program, the title and goals of the program were reviewed weekly. Each session included a purpose, educational concepts, instructions, a sharing component, and questions for discussion. All sessions were led by the OT student; however, there were times when the participants were encouraged to lead the group. During the first session, each participant filled out a pre-test survey. The same survey was completed again during the last session to determine the effectiveness of the program. The first session highlighted self-esteem and confidence through an activity and openly sharing with the other participants. The activity focused on the participants and how they viewed themselves in society. The participants were asked to pick words from a pile that described them, and at the end of the session, participants went around and discussed the reason for the words chosen. The goal for this session was to build rapport with the participants and increase their comfortability levels within the group dynamic. MENTAL HEALTH 15 The second session focused on social participation and interaction. On the unit, many participants tended to sit alone and did not interact with others often. Participants completed a worksheet that highlighted meaningful occupations and items. Once completed, the participants were asked to openly share. Participants then role played social scenarios with one another on how they would react if they were in certain situations. The goal was for the participants to branch out of their comfort zone and interact with one another. The third session focused on money management. Participants filled out a money log to track their spending and also discussed wanted versus needed items. Participants were educated on the difference between the two terms. Participants then were divided into groups based on where they were sitting to complete a next dollar up activity that included fake money and printed off items with prices on them. The participants worked together on how much money was needed to purchase the item. Based on the results from the needs assessment, participants tended to spend money on unnecessary items, so the goal was for the participants to keep track of their money and what they buy. The fourth session addressed self-care routines and the participants created their own daily checklist. The checklist not only focused on hygiene, but self-care for the body, mind, and soul. Participants were shown examples of other individuals self-care checklist and then were asked to create their own. The participants were able to fill out their checklist with important items that they wanted to complete on a daily basis regarding this topic. There was also a reward system with the checklist to add a motivating factor for the participants. The goal was for the participants to be aware and responsible for completing self-care tasks on a daily basis. MENTAL HEALTH 16 The fifth session focused on creating a sensory diet for the participants in order for them to have optimal arousal levels. The participants were given examples of calming and energizing activities and even examples of various sensory diets. Participants created their sensory diet for different parts of the day and examples included, washing face with cold water, pacing, listening to music, wrapping up in a blanket, and eating crunchy foods. After interviewing staff, many participants did not know how to control their behaviors in an appropriate manner, so this was an opportunity for them to address self-control and emotional regulation. The goal for this session was to increase the participants self-control and emotional regulation on a daily basis. The sixth session addressed cognitive remediation through purposeful activities that addressed selective and working memory. The participants filled out word searches, comprehension worksheets, and sequencing worksheets in order to stimulate their brain. The participants had a discussion on the importance of completing these activities and why it was important within their daily life. The results from the MMSE indicated cognitive impairments for multiple participants, so completing this activity activated and hopefully increased various parts of the participants memory. The goal for this session was to address any cognitive deficits and learn how to adapt to any challenges that arise on a daily basis. The last session included the post-test survey and addressed the participants successes in life. The post-test survey included the same questions and format as the pre-test survey. The participants then completed a success worksheet about their life. The purpose of the worksheet was to end the program on a high note where the participants felt an increased sense of worth. At the end of the session, the OT student and participants reflected on the program. The goal of the last session was to wrap up the program and complete the post-test survey in hopes that the participants gained more knowledge throughout the program. MENTAL HEALTH 17 All session topics were determined through the results of the needs assessment and input from the treatment team. The overarching goals for the program were to improve and address self-esteem, self-care, social participation and interaction, money management, sensory-based concerns, and cognitive remediation in order for the participant to have a productive daily life. All activities chosen were designed to help the participants reach the program goals. Leadership Skills and Staff Education Since there were no OT practitioners at this site, it was essential to demonstrate effective leadership skills to advocate for the profession and the importance of creating the program. Many professionals do not fully understand OTs scope of practice, so educating these individuals is key to the growth of OT in mental health. The OT student demonstrated effective communication skills, responsibility, and confidence when advocating for the importance of the program. Meetings with the rehabilitation director, treatment team professionals, and various staff led to the creation of the program. Discussions with multiple recreational therapists about the overlap with OT and the distinct value of OT took place to determine potential session topics. Throughout this experience, strategies that were identified were the vision and mission of LaRue Carter. Advocating and educating staff on the OT program was rooted from these distinct statements. During the implementation phase of the program, the OT student demonstrated various leadership skills in order to lead an effective program. The OT student was confident, yet personable during sessions. The OT student maintained ethical standards throughout sessions, as there were many contraband items and discouraged verbiage when interacting with participants. Contraband items were prohibited due to safety concerns for the participants, which included scissors, sharp objects, strings, etc. To promote OT, handouts were distributed to staff and patients on the role of OT at this site and the overview of the completed program during MENTAL HEALTH 18 April for OT month. During monthly rehab meetings, progress of the program was presented and feedback with potential ideas from other professionals were accepted to promote interprofessional care. Any additional strategies and skills were introduced as the program progressed. Discontinuation Outcomes As the program progressed, changes arose that were addressed by the OT student. During the first week, participants were shy and did not openly share unless called on. Even with explanation, some participants were confused on the purpose of the program. Although, all participants did fill out the pre test and did complete the assigned activity. The OT students approach changed in order to continue building rapport and ensure participants success throughout the program. During week two, social participation and interaction were addressed. The activities chosen were meant to move participants out of their comfort zone, as many did not interact with one another regularly. It was evident some participants did not feel comfortable, so the OT student allowed for a more open session and did not require any participant to answer something they did not want to. Participants seemed to like this idea through communication and facial expressions. Some participants then shared with one another and volunteered throughout the session with prompting. During week three, the session focused on money management. Participants practiced the next dollar strategy with fake money and printed out items with prices on it. One participant became agitated, stating I already know how to count money, and had to be verbally redirected MENTAL HEALTH 19 by the OT student. Other participants voiced how beneficial this session was. After week three, one participant dropped out of the program due to treatment plan changes, leaving five participants in the program. During week four, self-care was addressed utilizing a checklist. Participants were asked to write down self-tasks they completed on a daily basis. A reward was given to four participants, who brought back the checklist the following week with it filled out. Many participants enjoyed this idea and were successful in sharing ideas with others and completing the activity. The same self-care checklist was given to the participants who wished to continue this weekly after this session. Week five focused on creating a sensory diet. Participants were confused at times, but with additional direction, were able to fill out the chart. The OT student had to help most participants on an individual basis in order for them to correctly fill it out. The challenges were mainly due to the participants not understanding the purpose of this session, even with some verbal redirection. The OT student did want to challenge the participants since many do not have a grasp on their self-control. At the end of the session, most participants liked this chart and said they would use it on a daily basis. During week six, the session focused on cognitive remediation, also known as cognitive rehabilitation. The session was cut short due to a routine fire drill. The participants enjoyed completing the various sequencing and crossword activities. The participants voiced that they would enjoy doing these activities on a daily basis to stimulate their brain. The sequencing worksheet was comprised of 16 steps for having a dinner party. The participants took more time than expected to get started, but they were all able to complete it independently. It was MENTAL HEALTH 20 interesting how the participants freely completed these types of activities, when others have been a struggle for them to participate in. The last session focused on the five remaining participants filling out the post-test survey. One participant needed help reading the questions, while the other four participants were independent when completing the survey. The participants were also asked to complete a success worksheet, in order to end the session and program on a high note. One participant was disruptive during the session by saying inappropriate things and had to be verbally redirected several times by the OT student. Four participants were willing to share at the end of the session. When asked about the program as a whole, one participant voiced how positive this group was. Four participants said they would be in this group again if it was offered and they liked how the group was small. Challenges arose throughout the sessions due to participants' underlying diagnoses and behavioral difficulties. The OT student was mindful when these times occurred and worked with the participants to address the situation. Participants required more direction and time than anticipated in order to complete activities, so session outlines were modified to meet the participants needs. The goals of each session did not change; however there were fewer discussion questions and activities provided during sessions to ensure productive sessions for the participants. Being mindful of feedback from the participants was important to ensure quality improvement. Providing holistic care is an approach used throughout the scope of OT, so changing the program as needed was essential to meet the participants needs, especially within the mental health setting. At the conclusion of each session, questions and feedback were welcomed by the participants. MENTAL HEALTH 21 To measure the outcome of the program, the GAS was utilized. Refer to Appendix A for detailed goals and objectives. All goals started off at the present level, which was -2. As the DCE progressed, the goals kept increasing in the level of attainment, which will be discussed below. Goal 1 was for the occupation-based program, which was to plan and implement a sevenweek program on an adult unit. The expected level of outcome (0) was met at the cession of the DCE, which can be seen in Appendix A. Goal 2 discussed advocating for the role of OT at this site through either an in-service or handouts. The outcomes of this goal were somewhat more than expected (+1), as there was an in-service and handouts given to staff. Both goals were outcomes that provided positive support with the idea of having an OT practitioner on staff at this site. Goal 3 was completed during a different part of the DCE, which was not discussed in this paper. The pre-test survey was given to the participants to gain information on their knowledge of OT during the first session. All participants identified at least one correct ADL; however, only one participant knew what OT was. All participants were able to at least identify one correct coping strategy. No participants were able to correctly identify an IADL from a list of options. Three participants needed assistance with spelling. The post-test surveys were administered during the last session to see if the participants had gained any knowledge throughout the entire program. Four participants were able to correctly identify at least one IADL. All participants were able to identify at least one ADL. Only one participant was able to correctly write out what OT meant. Three participants were able to identify more than one coping strategy. The OT student reviewed the surveys and determined that the program was successful and the participants did know more information on the post-test survey, even with behavioral difficulties during the last session. MENTAL HEALTH 22 Sustainability/Societal Needs Sustainability was difficult to address since there were no OT practitioners on staff at LaRue Carter. The OT student compiled information into a binder that included session protocols, session worksheets, and a curriculum for sustainability of the program when there is an OT practitioner on staff. The OT student was a self-advocate, as well as an advocate for the role of OT at the site. The OT student provided education to staff on ways to provide an optimal environment for specific participants and other patients in the hospital in order to have a productive daily life. As the program evolved, staff voiced the need for an OT practitioner at this site. The rehabilitation director advocated to other staff members at various meetings to create an OTR position at LaRue Carter. Individuals throughout the hospital witnessed the benefits of OT within this population and setting. Even though mental health is the root of OT, there are few OT practitioners actually working in this field, as discussed in the introduction. With no OT practitioner on staff, the OT student took on a leadership role during this experience in order to make necessary changes without overstepping any boundaries of other staff. According to MHA, individuals with mental health diagnoses have unmet health needs (2017). In order to assist in a successful community reintegration, individuals in an acute mental health setting would benefit from OT services in order to lead a productive daily life. The occupation-based program at LaRue Carter helped advocate for the role of OT and educated staff and patients on the benefits of occupation-based programs. Discussion Overall Learning MENTAL HEALTH 23 LaRue D. Carter Memorial Hospital is one of many acute psychiatric facilities in the state of Indiana that do not have an OT practitioner on site. This exploratory DCE looked into the benefits of having an OT practitioner on site and what occupation-based programs would look like. There were positive outcomes from the occupation-based program and advocating for the profession of OT that took place. The participants voiced improved knowledge through the prepost surveys of what OT is and noted increased participation and success rates through daily activities, which in turn led to a more productive daily life. Staff was educated on the role of OT at this site and how beneficial it was to have an OT practitioner on staff. Overall, this experience captured what the OT student wanted to accomplish and an OT position at LaRue Carter will soon be open for applicants. Many limitations were present during the experience, with no OT practitioner on staff as the biggest one. The OT student was limited in the way the OT process was completed during the DCE. Standardized assessments could have been utilized during the needs assessment to help individualize the program better. The number of participants was limited due to other groups going on at the same time and many patients not wanting to participate. The intervention process activities were limited due to patient population and risks for the participants, themselves, and staff. The program was still beneficial; however, it was limited due to multiple reasons. Throughout this exploratory DCE, all routes of communication were kept professional by the OT student, participants, staff at LaRue Carter, and professors from the University of Indianapolis. Communication varied from face to face, emails, and phone conversations. The beneficial outcomes of this experience have been influenced from the effective communication between every individual involved. MENTAL HEALTH 24 Implications After witnessing the positive effects from the occupation-based program, the OT student has more respect for mental health facilities because of the patient population. The OT student has a better understanding and knowledge of how to interact with individuals with serious mental illnesses in order to provide meaningful, effective therapy. The OT student has seen the evident need for an OT practitioner at this site through leading the program. Going forward, it is imperative to have OT practitioners on staff at acute psychiatric facilities. These facilities have various reasons as to why they do not hire an OT practitioner; however, it is our responsibility to advocate for the profession. OT practitioners are trained and licensed professionals who have the ability to provide therapy to individuals with serious mental illness to learn to cope and lead a productive daily life through the use of meaningful occupations. After this experience, the hope is for other professions and sites to see the benefits of hiring an OT practitioner and will do so in order to help in individuals with serious mental illness in their recovery process. MENTAL HEALTH 25 References Arbesman, M., & Logsdon, D. W. (2011). Occupational therapy interventions for employment and education for adults with serious mental illness: A systemic review. American Journal of Occupational Therapy, 65, 238246. doi: 10.5014/ajot.2011.001289 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Occupational Therapy Association. (2017). Occupational therapys role in adults with cognitive disorders. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Fac ts/Cognitive-Disorders-Fact-Sheet.pdf American Occupational Therapy Association. (2016). Occupational therapys role in mental health recovery. Retrieved from https://www.aota.org/About-OccupationalTherapy/Professionals/MH/mental-health-recovery.aspx American Occupational Therapy Association. (2010). Workforce trends in occupational therapy. Retrieved from https://www.aota.org//media/corporate/files/educationcareers/prospective/workforce-trends-in-ot.pdf American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Buchmueller, T. C., Cooper, P. F., Jacobson, M., & Zuvekas, S. H. (2007). Parity for whom? Exemptions and the extent of state mental health parity legislation. Health Affairs, 26, w483w487. MENTAL HEALTH 26 Cole, M. B. (2008). Client-centered groups. Occupational Therapy and Mental Health. Churchill Livingstone, Elsevier, Edinburgh: 31531 Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Colton, C. W., & Manderscheid, R. W. (2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing chronic disease: Public health research, practice and policy, 3(2), 1 14. Dewa, S. C., McDaid, D., & Ettner, S. L. (2007). An international perspective on worker mental health problems: Who bears the burden and how are costs addressed? Canadian Journal of Psychiatry, 52, 346356. Duckworth, K. (2015). Science meets the human experience: Integrating the medical and recovery model. National Alliance on Mental Health (NAMI). Retrieved from https://www.nami.org/Blogs/NAMI-Blog/April-2015/Science-Meets-the-HumanExperience-Integrating-th Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational timeuse intervention for people with serious mental illness. American Journal of Occupational Therapy, 65, 267276. doi: 10.5014/ajot.2011.001313 Folstein, M. F., & Folstein, S. E. (2010). Mini-Mental State Examination, 2nd Edition (MMSE-2). Lutz, FL: PAR. Glaze, L. E. & James, D. J. (2006). Mental health problems of prison and jail inmates. Bureau of justice statistics special report. U.S. department of justice, office of justice programs Washington, D.C. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf MENTAL HEALTH 27 Gutman, S. A. (2011). Special issue: Effectiveness of occupational therapy services in mental health practice. American Journal of Occupational Therapy, 65, 235-237. Harvey, P. D., Green, M. F., Keefe, R. S. E., & Velligan, D. I. (2004). Cognitive functioning in schizophrenia: A consensus statement on its role in the definition and evaluation of effective treatments for the illness. Journal of Clinical Psychiatry, 65(3), 361-372. doi:10.5014/ajot.2011.001339 Hinojosa, J., & Kramer, P. (2014). Evaluation in occupational therapy: Obtaining and interpreting data, 4th edition. Bethesda, MD: AOTA IN.gov (2018). Family and social services administration. Retrieved from http://www.in.gov/fssa/dmha/6801.htm Lepage, M., Bodnar, M., & Bowie, C. R. (2014). Neurocognition: Clinical and functional outcomes in schizophrenia. Can. J. Psychiatry Rev. Can. Psychiatr. 59(1),5. Mental Health America. (2016). In patient care. Retrieved from http://www.mentalhealthamerica.net/patient-care Mental Health America. (2017). The state of mental health in America. Retrieved from http://www.mentalhealthamerica.net/issues/state-mental-health-america National Alliance on Mental Illness. (n.d.). Jailing people with mental illness. Retrieved from https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness National Association of State Mental Health Program Directors Council. (2006). Morbidity and mortality in people with serious mental illness. Retrieved from http://www.nasmhpd.org/docs/publications/MDCdocs/Mortality%20and%20Morbidity% 20Final%20Report%208.18.08.pdf MENTAL HEALTH 28 National Institute of Health. (n.d.) The 21st century cures act. Retrieved from https://www.nih.gov/research-training/medical-research-initiatives/cures National Institute of Mental Health. (2018). Statistics. Retrieved from https://www.nimh.nih.gov/health/statistics/index.shtml Ong, H. L., Subramaniam, M., Abdin, E., Wang, P., Vaingabkar, J. A., Lee, S. P., et al. (2016). Performance of Mini-Mental State Examination (MMSE) in long-stay patients with schizophrenia or schizoaffective disorders in a psychiatric institute. Psychiatry Research 241, 256262. Scanlan, J. N., & Novak, T. (2015). Sensory approaches in mental health: A scoping review. Australian Occupational Therapy Journal, 62(5), 277-285. Simpson, A., Bowers, L., Alexander, J., Ridley, C., & Warren, J. (2005). Occupational therapy and multidisciplinary working on acute psychiatric wards: The Tompkins acute ward study. The British Journal of Occupational Therapy, 68(12), 545-552. Spence, T. L., Schwarzschild, J., & Synovec, C. (2015). Integrating everyday functional skills into acute mental health settings. OT Practice, 20(12), 13-17. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Recovery and recovery support. Retrieved from https://www.samhsa.gov/recovery Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Results from the 2012 national survey on drug use and health: Mental health findings (NSDUH series H-47, HHS Publication No. [SMA] 13-4805). Rockville, MD: Author. U.S. Department of Housing and Urban Development, Office of Community Planning and Development. (2011). The 2010 Annual homeless assessment report to congress. MENTAL HEALTH 29 Retrieved from https://www.hudexchange.info/resources/documents/2010HomelessAssessmentReport Wimpenny, K., Forsyth, K., Jones, C., Matheson, L., & Colley, J. (2010). Implementing the model of human occupation across a mental health occupational therapy service: Communities of practice and a participatory change process. British Journal of Occupational Therapy, 73(11), 507-516. MENTAL HEALTH 30 Appendix A GOAL ATTAINMENT SCALE FORM Level Of Attainment -2 Much less than expected (Present Level) -1 Somewhat less than expected (Progress) 0 Expected level of outcome (Annual Goal) +1 Somewhat more than expected (Exceeds annual goal) +2 Much more than expected (Far exceeds annual goal) Goal 1: Goal 2: Goal 3: Did not plan or implement an occupation-based program on an adult unit Did not educate staff or patients on role of Occupational Therapy Did not educate or give staff a handout on a potential sensory room for the youth unit Plan an occupationbased program, but do not implement the program Educate the RT staff on role of Occupational Therapy through handouts Give staff a handout on a potential sensory for the youth unity, but do not educate staff Plan and implement a 7 week occupation-based program on an adult unit that focuses on ADLs and IADLs Educate staff and patients on role of Occupational Therapy through in-services or handouts Educate and give staff a handout on a potential sensory room for the youth units Plan and implement a 7 week occupation-based program on 2 adult units Educate all staff and patients on adult units on role of Occupational Therapy through in-services and handouts Educate and give staff multiple resources and create a handout on a potential sensory room for the youth unit Plan and implement a 7 week occupation-based program on 3 adult units Educate 75% of hospital staff and patients on role of Occupational Therapy through various inservices and multiple handouts Design, educate, and give staff multiple resources and create a handout on a potential sensory room for the youth unit  ...

... Administration and Leadership Development within Skilled Nursing Facilities Darian Burchfield May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Julie Bednarski, MHS, OTD, OTR A Capstone Project Entitled Administration and Leadership Development within Skilled Nursing Facilities Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Darian Burchfield Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: ADMINISTRATION AND LEADERSHIP 3 Abstract The purpose of this doctoral capstone experience was to develop administration and leadership skills in regards to occupational therapy practices in the skilled nursing facility environment through literature review, mentorship, interdisciplinary collaboration and practical application. Through evaluation, concerns with skilled therapy documentation and group therapy utilization in the skilled nursing facility environment were revealed. Weaknesses in skilled therapy documentation were found to affect patient length of stay, reimbursement, and quality services provided. In response, a documentation manual, was created in order to increase proficiency and efficiency, as well as to promote veracity. Effectiveness will be measured via quarterly documentation review audits. A group therapy educational program was created and presented to increase competency and promote ethical client centered therapy practice. Outcomes of this program will be analyzed for efficacy and to identify areas of continuous program improvement. Group therapy percentage tracking will be used to screen for changes in utilization. Learning occurred via development and execution of educational programs and resources deemed necessary through program evaluation. Effective and professional communication was demonstrated and improved upon throughout this capstone experience. Advanced reasoning was employed to analyze, synthesize, and evaluate concerns related to occupational performance, participation, reimbursement and appropriate therapeutic service provision. Keywords: Occupational therapy, skilled nursing facility, documentation, group therapy ADMINISTRATION AND LEADERSHIP 4 Administration and Leadership Development within Skilled Nursing Facilities Doctoral Capstone Experience Background Skilled Nursing Facilities Skilled nursing facilities provide short term 24-hour skilled care to qualifying recipients, which primarily consist of older adults (Sollitto, 2017). Skilled services provided in this environment typically include nursing, social services, dietary, occupational therapy, physical therapy and speech therapy (Your Medicare Coverage, n.d.). Diagnoses frequently addressed in skilled nursing facilities consist of joint replacement, septicemia, pneumonia, congestive heart failure exacerbation, urinary tract infections, and acute renal failure (About Occupational Therapy, n.d.; Sollitto, 2017). Occupational therapy. Occupational therapy is a key skilled service that is proven to increase functional independence with the common diagnoses treated in the skilled nursing facility environment (Jette, Warren & Wirtalla, 2005). Occupational therapists address factors necessary to complete activities that the clients may need, have and/or want to participate in (About Occupational Therapy, n.d.). Within the skilled nursing facility environment, occupations commonly addressed by occupational therapists include activities of daily living (ADLs), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation (American Occupational Therapy Association, 2014). Client factors, performance skills, performance patterns, context and environment are taken into consideration to address the activities above (AOTA, 2014). Occupational therapists collaborate with other key disciplines of skilled services providers such as nursing, speech and physical therapy in an effort to reach optimal patient outcomes (Sollitto, 2017). Increased spending on occupational therapy ADMINISTRATION AND LEADERSHIP 5 has proven to reduce 30-day patient hospital readmissions, potentially due to occupational therapys unique client centered focus with regards to functional and social needs (Rogers, Bai, Lavin & Anderson, 2017). Reimbursement. There are several sources of reimbursement for skilled services provided to patients within the skilled nursing facility environment, such as occupational therapy. Medicare is the largest and most commonly billed reimbursement source for rehabilitative stays in a skilled nursing facilities. Currently, Medicare Part A covers a stay in a skilled nursing facility following a qualifying hospitalization and a referral for skilled rehabilitation (Your Medicare Coverage, n.d.). Other common payer sources include Medicaid, Medicare Part B, private insurance, and Medicare replacement plans. Each reimbursement source varies in the way that they disperse payment (levels, per diem reimbursement rate, resource utilization group based), qualifying days of therapy, admittance regulations, and skilled services documentation requirements. These sources can also determine the minutes, units, and/or current procedural terminology (CPT) codes that they deem reimbursable, which in turn affects therapeutic service provision. Changes in reimbursement. There are several new reimbursement programs that have already been put in place for cost saving and increased continuity of care initiatives. These programs include Bundled Payments for Care Improvement (BPCI), Accountable Care Organizations (ACO), Next Generation Accountable Care Organizations (NGACO), Health Maintenance Organizations (HMO), and managed care (Innovation Models, 2017). These programs have affected reimbursement for skilled nursing facility stays as well as changed service provision. Among several commonalities between these programs, decreasing patient length of stay seems to be at the forefront of their initiatives. ADMINISTRATION AND LEADERSHIP 6 Future changes in reimbursement. Drastic changes to Medicare reimbursement systems have been proposed to be implemented following October, 2018 at a currently undisclosed time (Centers for Medicare and Medicaid Services, 2018). Although the feasibility of the program has been brought into question, Resident Classification System, Version 1 (RCS-1) is the suggested program to be implemented. This program will shift skilled nursing facility reimbursement from a fee-for-service, resources utilization group based model, to value-based reimbursement model. In theory, this means that hospitals and skilled nursing facilities will be compensated based on the quality of the services provided instead of the merely the amount. The goal is for patients to receive better quality of care by rewarding effective interdisciplinary collaboration between hospitals and skilled nursing facilities. For therapists providing services to beneficiaries in skilled nursing facilities, it is proposed that patients will be clinically categorized, based on their primary diagnosis, into sections including major joint replacement or spinal surgery, other orthopedic, non-orthopedic surgery, medication management, and acute neurologic. The proposed program would reimburse skilled nursing facilities for 100% of the services provided for days 1-14 of the stay and then is reduced every 3 days by 1% (CMS, 2018). This program will potentially incentivize shorter length of stays, increased quality of services leading to better outcomes, and decreased hospital readmissions (Optima Health Solutions, 2018). RCS-1 will have major effects on therapeutic service provision in the hospital and skilled nursing facility setting (Optima Health Solutions, 2018). Documentation. One factor that can affect reimbursement for skilled therapy in the skilled nursing facility setting, regardless of the payer source, is documentation of the skilled services provided. Clinical records are required to be maintained within professional standards and practices that are complete, accurately documented, readily accessible, and systematically ADMINISTRATION AND LEADERSHIP 7 organized (Lewis, 2015). Occupational therapy practitioners have a duty to uphold veracity in their documentation practices by providing comprehensive, accurate, and objective patient information (AOTA, 2015). Required therapy documentation includes evaluations (plan of care), daily treatment notes addressing each CPT code billed, progress notes, updated plans of care and discharge summaries for each treatment episode (CMS, 2017). For proper reimbursement, therapist documentation must advocate that the unique skills of a therapist including but not limited to knowledge, clinical judgment, decision making skills, and expertise were absolutely required to conduct the therapeutic treatment (CMS, 2017). The necessity of the therapeutic services provided must be justified within the documentation as well (CMS, 2017). Group Therapy. Group therapy is a therapeutic service provision method used to provide patient education and increase patient skills through group dynamics and social interaction (AOTA, 2014). The most used definition for group therapy is the treatment of two or more patients simultaneously, who may or may not be performing the same/similar activity. One unit of group therapy per patient is appropriate if the therapist is dividing attention, providing only intermittent personal contact, or giving instructions to two or more patients (RAI, 2017; LCD, 2015). This definition is used for Medicare Part B, accountable care organization, Medicaid, and managed care beneficiaries. Medicare Part A defines group therapy as, the treatment of four patients who are performing the same or similar activities, and are supervised by a therapist or an assistant (RAI, 2017). This definition maintains that the group must be planned in advance for exactly 4 patients and can only be 25% of patients total therapy (RAI, 2017). Currently group and concurrent therapy are less than 1% of all modes of therapy reimbursed in skilled nursing facilities (Pickus, 2017). The evolving reimbursement systems, such as RCS-1, are projected to create an increase in group therapy provision within skilled ADMINISTRATION AND LEADERSHIP 8 nursing facility therapy setting to offset the proposed compensation reduction for skilled services (Optima Health Solutions, 2018). Group therapy may also be a strategy used to increase productivity for therapists (Optima Health Solutions, 2018). Theory Theoretical paradigms and principles were used to guide this doctoral capstone experience, in an effort to ensure that core occupational therapy values were utilized to progress the profession, while meeting identified societal needs. The overall paradigm used for this doctoral capstone experience is the American Occupational Therapy Association (AOTA) 2015 Code of Ethics, which includes core values that direct the occupational therapy profession such as altruism, equality, freedom, justice, dignity, truth, and prudence (AOTA, 2015). Continuous quality improvement was also utilized as a leading principle for the actions completed throughout this doctoral capstone experience, as it aims to address practice with a focus on improving efficiency, patient care, or clinical outcomes (Basics of Quality improvement, 2014). The five pillars commonly addressed in quality improvement include establishing a culture of quality, identifying and prioritizing improvement, collect and analyze data, communicate results, and commit ongoing evaluations (Basics of Quality Improvement, 2014). While examining service provision through the code of ethics lens, societal needs were identified and prioritized for potential areas of improvement. The specific framework of continuous quality improvement was used to prioritize, develop and execute programs in an effort to perpetuate a culture of quality in this environment. Purpose The overall purpose of this doctoral capstone experience was to develop administration and leadership skills, with regards to occupational therapy in the skilled nursing facility ADMINISTRATION AND LEADERSHIP 9 environment, through self-directed learning, review of evidence, supervised application, mentorship and interdisciplinary collaboration. Examination of reimbursement sources and their requirements will be completed to create a working knowledge base. Documentation will be assessed and guidelines will be developed to reach optimal reimbursement with increased time for quality patient care and to create continuity of care. Ethical client-centered group therapy practices will be examined with regards to provision of this service, optimal patient care and outcomes, value based reimbursement systems. Professional development within the context of the ever-changing insurance reimbursement systems in skilled nursing facilities will be completed. Screening and Evaluation Continuous Quality Improvement Continuous quality improvement can provide direction in the enhancement of quality and safe patient care (Bonnel & Smith, 2018). The continuous quality improvement process can be used to sustain practical, ethical, appropriate, and evidence based interventions used in patient care (Lorch & Pollack, 2014). Skilled nursing facilities are regulated by several bodies that advocate for continuous service enhancement including Medicare, state agencies, accrediting bodies, accountable care organization partnerships, bundled payment systems, managed care programs, hospital partnerships, facility and company requirements. State operated skilled nursing facilities are surveyed by state and regional offices to determine if the facilities are eligible to participate in Medicare or Medicaid (Nursing homes, 2018). Measures are in place to assess performance such as the bundled payment systems that are responsible for patients 90 days postoperatively (Bonnel & Smith, 2018). Joint excellent certification through the joint commission assesses quality of care, continuous improvement outcomes, and good use of ADMINISTRATION AND LEADERSHIP 10 resources (Bonnel & Smith, 2018). Five-star quality rating system which includes health inspections, staffing, and quality measures (Five-star quality rating system, 2018). CARF attempts to maintain quality standards for patients within the providers (CARF, 2018). OSHA strives to create safe working conditions for all workers by enforcing standards and providing training, outreach, education and assistance (Occupational Safety and Health Administration, n.d.). Within the company that the doctoral capstone experience was completed, in-house continuous quality improvement strategies include interdisciplinary continuous quality review (CQR) meetings. These meetings are completed by the regional building managers, in an effort to ensure that quality standards and processes are being upheld as required by regulations in the best interest of the patients they serve. The meetings require administrators and a representative from each department including nursing, therapy, dietary, activities, the business office, admissions, and minimal data set (MDS) coordinators to attend at each individual facility. Patient care over the past quarter is examined extensively for areas of improvement. Patient data is compared to national, state, and similar facility data to screen for possible areas of concern as well. If there are concerns noted, collaborative action plans are developed to correct the issue. This is the step in the process that evidence based practices are incorporated into patient care to remediate issues and to continuously better patient care practices. A timeline to complete these changes as well as follow-up action plans to ensure changes have been made are developed and employed. All of these processes are used to monitor continuous quality improvement with regards to patient care or operations within skilled nursing facilities. Needs Assessment ADMINISTRATION AND LEADERSHIP 11 A needs assessment was performed in an effort to uncover further potential areas of continuous quality improvement. A SWOT analysis was then completed as a part of the needs assessment which focuses on the strengths, weaknesses, opportunities, and threats of the organization (Bonnel & Smith, 2018). Strengths of the internal organization included ethical practice, growing number of facility acquisitions, occupational therapist led company, several established skilled nursing facility therapy departments and usage of continuous quality improvement. Implementation of new programs before they are mandatory is a strength that allows therapists, facilities, and patients to adjust to the changes and address challenges earlier, as they arise. Established weaknesses included therapist resistance to providing group therapy, productivity demands, and documentation time. Identified opportunities from outside the organization included decreased readmission rates, length of stay, increased documentation skills, and increased group therapy for therapeutic benefit. With managed care and accountable care organization reimbursement programs on the rise, there is an opportunity to increase continuity of care from post-operation or hospital stay to discharge from skilled nursing facility for patients enrolled in these programs. A major threat included the proposed Medicare reformation, RCS-1, which presents opportunities to transforms service delivery models to continually strive for quality of care. Literature review and collaboration with knowledgeable mentors was completed to screen for areas of further potential continuous quality improvement needs specific to therapy within the skilled nursing facility. Documentation guide. Site mentors identified skilled therapy documentation as a source of weakness for therapists, which can affect patient length of stay, reimbursement, and quality services provided. Backman, Kwe, and Bjorklund (2008), showed that only 21% of occupational therapy documentation included in patient records is actually complete. Discussion ADMINISTRATION AND LEADERSHIP 12 and observation with therapists revealed that they were feeling frustrated with documentation requirements taking up patient care time and were often unsure of how to adequately document skilled services to justify reimbursement. Review of current patient therapy documentation revealed several concerns, such as inability to discriminate between occupational and physical therapy documentation. Another concern identified in the documentation was that there was no mention of activities of daily living (ADL), occupational performance, or cognition in a troubling amount of patient documentation. It is good practice to analyze occupational performance, which includes client strengths and areas for improvement, and to document the results as a portion of the patient evaluation (AOTA, 2014). A lack of standardized and/or nonstandardized tests to measure and demonstrate progress was identified in the documentation reviewed. According to AOTA (2014), standardized assessments are preferred, when appropriate and available, to provide objective data about factors that may affect engagement and performance in occupation. The culmination of these identified weaknesses determined the need for a skilled documentation guide and educational for therapists. Group therapy. Group therapy was also identified as a factor that has affected therapy service provision in the skilled nursing facility setting. Group therapy has been projected to be the future of therapy in the skilled nursing facility environment and will also be used to increase and supplement productivity standards for therapists with changing reimbursement systems such as RCS-1 (Optima Health Solutions, 2018). Site mentors agreed with this statement, communicating that group therapy is becoming more prevalent as a mode of therapy and a way to increase profit. Therapy supervisors were emailed and asked to provide common questions, comments, and/or concerns they receive regarding the provision of group therapy. It was concluded that group therapy can be difficult to perform within the skilled nursing facility ADMINISTRATION AND LEADERSHIP 13 environment through conversation and observation of therapists. Reasons such as, managing several patients at once and scheduling groups around several patient schedules were found to hinder the provision of group therapy. It was also identified that the definition of group therapy for certain payers and the confines of how group therapy can be performed and billed were widely misunderstood. Although frustrations regarding group therapy have been expressed, literature supports the use of group therapy for certain diagnoses often treated within the skilled nursing facility environment including hip or knee replacement, Parkinsons disease, cerebrovascular accident, knee osteoarthritis, post-cerebrovascular accident aphasia, back pain and urinary incontinence (Coulter, Weber, Scarvell, 2009; Gauthier, Dalziel, and Gauthier, 1987; Mehdizadehm, Mehraban, Zahediyannasab, 2017; Allen, et al., 2016, Layfield, Ballard, Robin 2013; Robertson & Harding, 2014). The push for increasing the provision of group therapy as a mode of therapy, and the frustrations conveyed by therapists and experts in the field, identified a need for the implementation of a group therapy educational program as well as helpful resources. Practice Area Skilled nursing facilities are a traditional and existing practice area for occupational therapists. Although it is a traditional area, practice is constantly evolving, creating the need for continuous needs assessments and quality practice improvements. An occupation based treatment approach is being promoted to increase quality of care, like many other existing and emerging areas of occupational therapy. Value based reimbursement systems are affecting and will continue to affect occupational therapy services provided within the skilled nursing facility setting, but also other traditional areas of OT, such as acute care. Accountable care organizations are facilitated by the participating hospital, making it their responsibility to follow the patient and attempt to create ADMINISTRATION AND LEADERSHIP 14 continuity of care (AOTA, 2012). D'Aunno, Broffman, Sparer, Kumar, and D'Aunno (2018) found that interdisciplinary and collaborative relationships between healthcare providers, including therapists, can distinguish high from low performing accountable care organizations. This puts more responsibility on doctors, nurses, therapists, and social workers to increase collaboration for patient care in the acute care setting as well as the skilled nursing facility setting. Resulting from the push to decreased length of stay from programs such as accountable care organizations, acute care occupational therapists will be asked to use their unique client centered holistic methods to increase patient independence faster, which is also the case in skilled nursing facilities (AOTA, 2012). Therapists in both settings are expected to be guided by altruism, equality, freedom, justice, dignity, truth, and prudence (AOTA, 2015). Although skilled nursing facilities and acute care occupational therapy differs in many ways, the common principles of practice such as the core values from AOTA 2015 Code of Ethics are the same. Implementation Administration and leadership skills were developed through research, planning, development and implementation of therapy staff education regarding group therapy and skilled documentation skills. Staff development regarding therapy documentation was implemented including plans of care, progress notes, daily notes, insurance updates and discharge summaries via dissemination of resource guides and virtual education. Group therapy education was disseminated via verbal presentation as well. These were implemented to increase effective quality service provision for identified societal needs. These educational programs and resources were executed in an effort to promote increased patient outcomes while simultaneously maximizing financial opportunity. ADMINISTRATION AND LEADERSHIP 15 Documentation Manual A comprehensive documentation manual, refer to Appendix A, was created to be utilized by occupational, physical, and speech therapy practitioners to increase proficiency and efficiency with patient documentation. This guide was developed in an effort to ensure veracity within therapy documentation practices. It can be referenced for guidance when documenting skilled therapy services within the skilled nursing facility environment and consequently increase the chances of proper reimbursement. Resources including Medicare guidelines, local determination coverage norms, insurance documentation guidelines, relevant literature, and the company documentation programs were used to modify the previous Lifespan Documentation Guide to meet the current needs of therapists. These practices led to the first draft of the documentation guide that was then used to audit occupational, physical, and speech therapy documentation company-wide. This audit was completed to uncover further potential areas of improvement. Plans of care, daily notes, progress notes, and discharge summaries for patients throughout the company were included in this review process. Several repetitive discrepancies between the established guidelines and actual patient documentation were identified. An example of a variance was the inclusion of group therapy indicators. According to Accelerated Care Corporation (2015), a rationale for utilizing group therapy as a treatment modality must be indicated in the plan of care. This was not consistently identified in the plans of care for patients that participated in group therapy. Common discrepancies were investigated through staff and management collaboration, electronic medical record reporting via Casamba, and literature review. Information to remediate these inconsistencies was then included or clarified in the documentation guide. ADMINISTRATION AND LEADERSHIP 16 Following these procedures, the guide was in its completed form and was reviewed for accuracy and flow by another occupational therapy doctoral capstone student with an abundant knowledge of the material. Final guidelines were presented to management and edited collaboratively for content. Once this was completed, a master documentation manual was produced. Resources referenced within the guidelines, such as Wisconsin Physicians Service (WPS) Local Coverage Determination (LCD) Modalities in Depth, were added as appendices to create a comprehensive documentation manual for therapists to utilize. Resources included in the manual included specific examples of how to document specific scenarios and current procedural terminology codes. A documentation education session was provided to therapists via mandatory Skype meeting. Lead therapists were notified of the appointment, via company email, four days before the meeting. The session was scheduled for less than ten minutes. Attendance was taken at the beginning of the Skype session to ensure participation company-wide. The day before the educational session, the documentation manual was emailed to each therapy supervisor within the company to initiate implementation to staff. Due to the previous Lifespan Documentation Guide being widely known and accepted within the company, the presentation included mainly the highlights of the changes made to the documentation manual as well as the reasoning behind the change. This was to maintain the efficient use of therapist time throughout the day. Topics covered included precautions vs. contraindications, documentation of the Evaluation of Potential Readmission Factors outcome measure, inclusion of standardized tests, documentation of group therapy practices, consent to treat for Part B patients, documentation of modalities, skilled verbs for daily notes, red flag words, how to include function into documentation, and how to show functional progress or lack thereof with standardized tests. Examples of how to implement the ADMINISTRATION AND LEADERSHIP 17 changes were also included in the education. Questions were taken and answered throughout the presentation to ensure understanding. Following the education, supervisors were instructed to distribute the manual to therapists and to convey the importance of its implementation and compliance. The manual has been placed in the Cyber Attack Plan Manual located at each facility and also was placed in plain sight in the therapy office for therapists to reference. It was incorporated into the new hire packet and mandatory orientation session in an attempt to increase documentation competency from the beginning of the orientation process. Further questions regarding the manual were directed to assigned regional managers. Group Therapy Education As another form of internal staff development to meet identified societal needs, group therapy education was created and presented to staff. This educational program was presented to staff including occupational, physical, and speech therapy practitioners to increase competency and promote ethical provision of this mode of therapy. The evidence-based staff education was developed after a thorough literature review as well as Medicare guidelines, local determination norms, and advice from therapists as well as management. Current prevalence, reimbursement, diagnoses, effectiveness, ethical considerations and outcomes were the focus of the literature review in preparation for this educational program. Health sciences databases were used to scour the evidence regarding group therapy information including; OT search tool, MEDline Plus with Full Text and CINAHL Plus with Full Text. MeSH (Medical subject headings) and CINAHL Plus with Full Text tutorials were utilized to maximize identification of evidence. This information was synthesized and used to create the educational PowerPoint presentation, refer to Appendix B. ADMINISTRATION AND LEADERSHIP 18 Staff education was implemented via mandatory Skype sessions with all the lead therapists within the company. Lead therapists were notified of the appointment, via company email, one week before the session. This email also contains a handout, PDF of the PowerPoint presentation slides, to follow along with the session and to act as a resource for the future. The handout was emailed in advance to allow lead therapists time to review the material before the presentation and formulate questions, if appropriate. Sessions were scheduled based on availability and took no longer than ten minutes. Attendance was taken at the beginning of the Skype session to ensure participation company-wide. The education began with an introduction of the presenter and a brief explanation of the occupational therapy doctoral capstone experience. The educator then presented the information, following the sequence of the provided PowerPoint presentation. The definition of group therapy was presented followed by a validation of identified challenges and an explanation of the increased need for group therapy as an intervention. Rationale for the infrequent use of group therapy used in the recent past within the skilled nursing facility setting was presented based on past laws and policies. Throughout the presentation, these former laws and guidelines were compared and contrasted with current laws and regulations to encourage understanding ethical usage of this mode of therapy. Staff education then transitioned to the presentation of appropriate purposes of group therapy, populations, goals, diagnoses, and effective evidence based treatments. The effects of group therapy on reimbursement were included in the presentation to create a deeper understanding of the requested increase in group therapy. The education session concluded with the presentation of examples of appropriate group therapy usage and documentation of those services. Questions were taken via live messaging with regional managers. ADMINISTRATION AND LEADERSHIP 19 Lead therapists were asked to educate their therapy team at mandatory weekly team meetings on group therapy based on the resources and presentation provided. All therapy practitioners within the company are unable to attend to the Skype call due to productivity standards and general feasibility. Lead therapists were encouraged to contact the presenter or assigned regional managers for any questions in the future. Leadership Professional leadership skills were developed through creation and dissemination of these educational resources and programs. To determine programmatic needs, appropriate communication and clinical reasoning were employed to investigate the professional abilities of therapy practitioners. Marketing skills were used to implement the education programs effectively and to create therapist buy-in. A leadership skill that was strengthened through the implementation of the group therapy educational program was advocacy for evidence-based patient care. Advocacy for patients and therapy practitioners is also evident in the development and implementation of these programs. Discontinuation and Outcomes The preceding section described strategies utilized for quality improvement throughout the developmental and implementation stages of the documentation manual and group therapy education. After implementation, continuous quality improvement remains essential to ensure that practices executed throughout this doctoral capstone experience remain best practice. For group therapy education and the documentation manual to remain sustainable; usefulness, ease of use, and improved participation need to be measured to identify effectiveness and to ensure that they continue to meet societal needs. The following is an explanation of ongoing strategies ADMINISTRATION AND LEADERSHIP 20 for continuous improvement of the educational programs and resources, in an effort to advance patient outcomes while simultaneously maximizing financial opportunity. Documentation Manual Improvements of the documentation manual were made throughout the duration of the developmental process based on the needs of the therapists, relevant literature, and input from management. Following reveal of the documentation manual, staff comprehension and compliance will be measured via quarterly documentation review audits and then these will be compared to previous results. The company Documentation Audit Form will be used to complete this measure. These quarterly audits are completed at each building for all disciplines at the facility level by assigned regional managers. This documentation compliance audit will be compared to the first quarterly audit completed in 2018. The outcomes of these reports will be used to adapt the documentation manual for increased effectiveness and accuracy, if appropriate. Any concerns voiced by therapists following the reveal of the documentation manual will be addressed by clarification or modification of the document with regards to current laws and required procedures. For continuation of quality improvement, these audits will continue to be compared for the next two audit cycles of 2018. In October 2018, after the commencement of a new Medicare reimbursement system, this manual will need to be revised based on the societal needs. In January of 2019, documentation compliance will be reassessed, which may reveal the need for another occupational therapy doctoral capstone student to update this guide. Group Therapy Education After the group therapy education has been disseminated, outcomes of the educational program will be analyzed for efficacy. These outcomes will be used to identify areas of possible ADMINISTRATION AND LEADERSHIP 21 program improvement. Data to be analyzed will be collected three weeks after the education is presented by the doctoral student. It will be collected in this timeframe due to the weekly reporting schedule, in an effort to capture authentic and accurate results. This will also give lead therapists time to educate their staff appropriately and allow time for proper implementation. Group therapy percentages for each facility are measured by a Casamba group therapy report each week. This report is based on the amount of group therapy that was provided compared to the amount of eligible group therapy minutes. Following the education, this report will be completed and percentages will be compared to the previous four weeks percentages, to measure change. In January 2019, after the new Medicare reimbursement system has been in place for three months, group therapy protocols will be revisited by management. This may be proposed to a different occupational therapy doctoral capstone student as a potential project. Continuous quality improvement measures must be sustained to ensure that the programs and resources put into place throughout this doctoral capstone experience, remain best practice. Furthermore, any questions, comments, and/or concerns identified following the implementation of the programs, will be addressed in a timely manner to ensure responsiveness. Regional management has been assigned these continuous quality improvement tasks, but the 2019 occupational therapy doctoral capstone experience student will also act as an an asset in this process. Overall Learning The purpose of this doctoral capstone experience was to cultivate advanced practice occupational therapy skills with regards to therapy administration and leadership in the skilled nursing facility environment. Learning occurred via development and execution of educational programs and resources deemed necessary through program evaluation. Programmatic needs ADMINISTRATION AND LEADERSHIP 22 were identified through effective communication with therapists, analylization of societal needs, and interdisciplinary collaboration. Program evaluation and continuous quality improvement took place throughout the entire experience, which allowed for development of the skills required to complete these actions. Ethical client-centered practices, guided by professional standards, were promoted through the creation and implementation of the program and educational resources. After extensive evaluation of the site, the needs of therapists, and the needs of the patients, group therapy education and skilled documentation education emerged as potential areas of improvement to increase ethical provision of therapeutic services with regards to reimbursement. Evaluation Advanced professional reasoning was employed to analyze, synthesize, and evaluate concerns related to occupational performance, participation, reimbursement and appropriate therapeutic service provision in the skilled nursing facility environment. Literature review and collaboration with site mentors were completed to screen for areas of potential continuous quality improvement needs. Communication and clinical reasoning were required to determine programmatic needs through the investigation of professional abilities of the therapy practitioners. The evaluation process required further development of research skills to identify the most relevant evidence-based information. Documentation manual. Site mentors identified skilled therapy documentation as a source of weakness for therapists, which can affect patient length of stay, reimbursement, and quality services provided. Therapists revealed that they were experiencing frustration with documentation requirements through effective communication. Skilled therapy documentation audit revealed several concerns, such as inability to discriminate between occupational and ADMINISTRATION AND LEADERSHIP 23 physical therapy documentation. Abilities to effectively audit documentation required growth in that skill. The culmination of these identified weaknesses determined the need for a documentation guide for therapists. Group therapy. Throughout extensive evaluation of relevant literature, appropriate provision of group therapy services was identified as a factor that is effecting therapy services in the skilled nursing facility setting. Communication with site mentors, as well as evaluation of evidence, revealed that group therapy is becoming more prevalent as a mode of therapy due to increased accountable care organization reimbursement sources and a way to increase profit. Ability to analyze financial impact of assorted therapeutic modes of therapy was employed to understand the full impact on total reimbursement. The push for increasing use of group therapy and the frustrations conveyed by therapists identified a need for group therapy education. Implementation Following the evaluation and identification of these concerns, the information was synthesized and an implementation plan to target these problems through continuous quality improvement was developed. After these plans were developed to meet the societal needs identified, they were implemented. Documentation guide. A documentation guide was created to meet the need identified in the evaluation stage. It was created for therapists and students to increase proficiency and efficiency with documentation skills. The guide strives to ensure veracity within occupational therapy practices, which was found to be lacking in the evaluation phase. Literature review, effective communication with therapists and administrators, and skilled observation skills were all exercised throughout the development of the documentation guide. Skills to synthesize the needs identified in the evaluation stage and to develop long lasting strategies to address these ADMINISTRATION AND LEADERSHIP 24 needs were used throughout this stage. After the guide was created, collaboration with therapists, site mentors, and another doctoral capstone experience student took place to allow for continuous quality improvements. Group therapy. Group therapy education was developed to address the need for increased knowledge for appropriate service provision. This was in an effort to increase competency and promote ethical client centered occupational therapy service delivery. Evidenced based research skills were used to identify critical knowledge and factors required for effective and ethical group therapy practices. This information was synthesized and a comprehensive educational presentation was developed based off of these identified factors. Education on group documentation requirements, covered and non-covered group therapy modes, reimbursement and evidence based procedures were included to assist in increasing group therapy percentages. Ideas for conducting occupation based, diagnosis or functional impairment specific groups, were provided as well. Education was implemented through a skype session presented to therapy supervisors using effective marketing and communication methods. Information delivery was modified throughout the implementation of this program, based off of trials, increasing ability to successfully impact therapists as a leader. Presentation of this educational program developed the ability to advocate for evidence-based patient care. Conclusion Throughout this doctoral capstone experience the AOTA 2015 Code of Ethics, as well as continuous quality improvement, were used as guiding principles in program development to meet identified societal needs within the skilled nursing facility environment. These societal needs were identified by program evaluation and program develop was utilized to increase quality processes. Programs were implemented in an effort to increase ethical and evidenced ADMINISTRATION AND LEADERSHIP 25 based patient care with regards to financial gain. A comprehensive documentation manual was created for occupational, physical, and speech therapy practitioners when documenting skilled therapy services. A group therapy educational program was created and presented to therapists to increase understanding and ethical implementation of this mode of therapy. Effective and professional communication was completed throughout this capstone experience. Advanced reasoning was employed to analyze, synthesize, and evaluate concerns related to occupational performance, participation, reimbursement and appropriate therapeutic service provision. Advanced occupational therapy knowledge was developed through exploration and utilization of administration and leadership skills throughout this innovative research application process. ADMINISTRATION AND LEADERSHIP 26 References About CARF. (2018). CARF International. Retrieved February 10, 2018, from http://www.carf.org/About/ About Occupational Therapy. (n.d.). Retrieved January 25, 2018, from https://www.aota.org/About-Occupational-Therapy.aspx Accelerated Care Corporation (2015). Group therapy: An accelerated clinical practice. Reno, NV. Allen, K. D., Bongiorni, D., Bosworth, H. B., Coffman, C. J., Datta, S. K., Edelman, D., & ... Hoenig, H. (2016). Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial. Physical Therapy, 96(5), 597-608. doi:10.2522/ptj.20150194 American Occupational Therapy Association. (in press). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69(Suppl. 3). American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3 rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Occupational Therapy Association. (2014). The American occupational therapy association advisory opinion for the ethics commission: Ethical considerations for productivity, billing, and reimbursement. Retrieved from http://www.aota.org/practice/ethics/advisory.aspx American Occupational Therapy Association. (in press). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69(Suppl. 3). ADMINISTRATION AND LEADERSHIP 27 American Occupational Therapy Association. (2015). Standards for continuing competence. American Journal of Occupational Therapy, 69(Suppl. 3), 6913410055. http://dx.doi.org/10.5014/ajot.2015.696s16 Backman, A., Kwe, K., & Bjorklund, A. (2008). Relevance and focal view point in occupational therapists' documentation in patient case records. Scandinavian Journal of Occupational Therapy, 15(4), 212-220. doi:10.1080/11038120802087626 Basics of Quality Improvement. (2014, September 12). Retrieved January 24, 2018, from https://www.aafp.org/practice-management/improvement/basics.html Bonnel, W. & Smith, K.V. (2018). Clinical projects and quality improvement: Thinking big picture. Proposal writing for clinical nursing and DNP projects, Second edition. (pp. 4457). New York, NY: Springer Publishing Company. Coulter, C., Weber, J., Scarvell, J. (2009). Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: A sequential cohort study. Arch Phys Med Rehabil, 90:17271733. Centers for Medicare & Medicaid Services (October, 2017). Long-term care facility resident assessment instrument 3.0 user's manual. Department of health & human services. Retrieved from https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October1-2017-R.pdf Centers for Medicare & Medicaid Services (2018). SNF PPS Payment Model Research - Centers for Medicare & Medicaid Services. [online] Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/therapyresearch.html [Accessed 25 Jan. 2018]. ADMINISTRATION AND LEADERSHIP 28 D'Aunno, T., Broffman, L., Sparer, M., Kumar, S. R., & D'Aunno, T. (2018). Factors that distinguish high-performing accountable care organizations in the medicare shared savings program. Health Services Research, 53(1), 120-137. doi:10.1111/14756773.12642 Five-Star Quality Rating System. (2018, January 24). Centers for Medicare & Medicaid Services. Retrieved January 31, 2018, from https://www.cms.gov/medicare/providerenrollment-and-certification/certificationandcomplianc/fsqrs.html Fransen, M., Crosbie, J., Edmonds, J. (2001). Physical therapy is effective for patients with osteoarthritis a randomized controlled clinical trial. The Journal of Rheumatology, 28(1) 156-164. Gauthier, L., Dalziel, S., Gauthier, S. (1987). The benefits of group occupational therapy for patients with parkinsons disease. The American Journal of Occupational Therapy, 41(6) 360-365. Innovation Models. (2017, July 31). Retrieved January 26, 2018, from https://innovation.cms.gov/initiatives/index.html#views=models Janssen, C., Largo-Janssen, A., Felling, A. (2000). The effects of physiotherapy for female urinary incontinence: Individual compared to group treatment. British Journal of Urology International, 43: 458-64 Jette, D. U., Warren, R. L., & Wirtalla, C. (2005). The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86, 373379 Layfield, C., Ballard, K., Robin, D. (2013). Evaluating group therapy for aphasia: What is the evidence? Psych Corp, 7(5) ADMINISTRATION AND LEADERSHIP 29 Lewis, L. (2015). Documentation Guidelines for Skilled Care. [PowerPoint slides]. Retrieved from http://www.pacahpa.org/Education/DocumentationGuidelinesforSkilledCarePACAH.pdf Lorch, J. A., & Pollak, V. E. (2014). Continuous Quality Improvement in Daily Clinical Practice: A Proof of Concept Study. Plos ONE, 9(5), 1-11. doi:10.1371/journal.pone.0097066 Mehdizadehm M., Mehraban, A., Zahediyannasab, R. (2017). The effect of group-based occupational therapy on performance and satisfaction of stroke survivors: Pilot rial, neuro-occupational view. Basic Clin Neurosci, 8(1): 69-76. doi:10.15412/J.BCN.03080109 Nursing Homes. (2018, January 18). Centers for Medicare & Medicaid Services. Retrieved January 31, 2018, from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/NHs.html Occupational Safety and Health Administration. (n.d.). United States Department of Labor. Retrieved January 31, 2018, from https://www.osha.gov/about.html Optima Health Solutions. (2018). RCS-1 FAQ: Strategies for success under RCS-1. Pickus, J. (2017, September 05). RCS-1 is a complete rewrite of therapy reimbursement rules. Retrieved January 27, 2018, from https://www.mcknights.com/marketplace/rcs-1-is-acomplete-rewrite-of-therapy-reimbursement-rules/article/686264/ Robertson, B., Harding, K., E. (2014). Outcomes with individual versus group physical therapy for treating urinary incontinence and low back pain: A systematic review and metaanalysis of randomized controlled trials. Arch Phys Med Rehabil, 95(11): 2187-2198. doi:10.1016/j.apmr.2014.07.005 ADMINISTRATION AND LEADERSHIP 30 Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research & Review, 74(6), 668-686. doi:10.1177/1077558716666981 Sollitto, M. (2017, June 12). What's the Difference Between Skilled Nursing and a Nursing Home? Retrieved January 25, 2018, from https://www.agingcare.com/articles/differenceskilled-nursing-and-nursing-home-153035.htm Wertz, R.T., Collins, M.J., Weiss, D.G., Kurtke, j.F., Freiden, T., Brookshire, R.H., Pierce, J., Holzapple, P., Matovitch, V., Mortey, G.K., Resurreccion, E. (1981). Veterans administration cooperative study on aphasia; A comparison of individual and group treatment. Journal of Speech Hearing Res. 24, 580-594. Your Medicare Coverage. (n.d.). Retrieved January 25, 2018, from https://www.medicare.gov/coverage/skilled-nursing-facility-care.html Appendix A Lifespan Documentation Guidelines Plan of Care: 1. Demographic Information: Guarantee all demographic information is entered in Casamba so it transfers to the POC. Ensure if Jr., SR. or middle initial is listed in Matrix under Name on the facesheet, it is also included in Casamba. If the name does not match exactly, the claim can be denied. 2. Onset Date: Must reflect the most recent documented incident, decline, and/or acute onset of a functional deficit or an acute impairment that warranted the current initiation of therapy services. The onset date is NOT the date that the resident was diagnosed with a disease or condition. The onset date is chosen for the primary and secondary diagnoses. 3. Qualifying Hospital Stay: These dates should match the dates listed in Matrix under Qualifying Hospital Stay. If the hospital stay pulls over to the POC from a prior therapy episode and is not pertinent to the current therapy episode, remove it. 4. Reason for Referral: Be specific regarding who referred the resident for treatment, what occurred that prompted the need for therapy, the date that the referral was documented, and what functional deficit areas and/or underlying impairments were noted that created the need for the referral. 5. Therapy Necessity: Document necessity of skilled therapy services and examples of negative outcomes that may occur if the therapy services were not provided. 6. Medications: Do NOT write see Matrix. Instead, list the current medications that the resident has been prescribed. Medications can have a huge impact on function and can cause extrapyramidal symptoms. Also, if the resident has recently had an increased dose of pain medications, anti-anxiety medications, psychotropic medications, or hypnotic medications ordered, it would be excellent to mention this. These types of medication changes can lead to falls, declines in function, changes in status, or increased behaviors. 7. Precautions: Precautions reflect situations in which a patient is at a risk of experiencing adverse effects (Bellew, Michlovitz & Nolan, 2016, p. 16). Include all physician ordered precautions. a. Examples include weight bearing restrictions, fall risk, special precautions (hip, spinal, sternal/cardiac, isolation), swallowing, hard of hearing, legally blind, brace/orthosis, thickened liquids, blood thinners, wounds, O2 requirements, SOB, endurance, diet restrictions, behaviors, required assistive devices, stats, and the stage of cognitive impairment should be listed. 8. History/ Medical Complexities/ Patient Factors: List all pertinent diagnoses that could be causing the acute symptoms or decline in function. 9. Prior Residence and Living Arrangement: This section should be very thorough. It is an opportunity to write a narrative prior level of function and should include: living environment (# of stairs, rails, grab bars, which level bed/bath is on), amount of assistance required and who provided the assistance, assistive devices and adaptive equipment utilized, and functional skills related to mobility, communication, ADLs, IADLs, community mobility, swallow, and/or cognitive status. Updated 2018 10. Discharge Environmental Factors/Social Support: Discuss the residents support system (family, a hired caregiver, restorative nursing, home health, etc.) and the amount of assistance that the resident will receive after therapy services are discontinued. 11. Contraindications: Specific situation which makes treatments (specifically modalities) potentially harmful to patients (Bellew, Michlovitz & Nolan, 2016). Including but not limited to DVT, infection, pacemaker, aortic aneurysm, orthostatic hypotension, shortness of breath, abnormal potassium levels. a. Example: Heat modalities contraindicated on hands secondary to reduced sensation 12. Previous Therapy: The dates of the most recent episode of therapy at this facility should be listed. Goals, residents response to intervention and the outcome of the prior episode of therapy should be documented. 13. Discharge Plans: List goals and outcomes the resident and/or caregiver is expecting from skilled therapy intervention. 14. Informed Consent: For the LTC residents, consent to treat must be documented in the daily note, on the day of the evaluation, under the evaluation CPT code. The information included in the daily note should contain 1) name of the person contacted, 2) relationship of the resident to the patient, 3) if the contact was made in person or over the phone, and 4) that consent to treat was given. This process is billable if completed when the therapist is with the resident. If the person is unable to be contacted after several attempts, document the attempts and if a message was left. 15. Functional Deficits: Identify the current functional deficits and enter the prior, current, and anticipated level of function. Do NOT enter UNKNOWN! a. Section GG b. Pain Impacting c. Hospital Readmission Factors: Scores indicate levels of safety impairment and are based on criteria for each item that measure how safely tasks are performed with or without a caregiver (reference EPRF Users Manual). Sections are listed below. PT: Readmit Risk: (Pre)Ambulatory Fall Risk (Section 1.1a: Functional Mobility) OR Wheelchair Mobility Fall Risk (Section 1.1b, Functional Mobility) o Only score ONE of the ambulation scores; (pre)ambulatory -OR- w/c mobility; whichever item is most appropriate for the patient. The other item that is not the most appropriate should be scored as '8' for all three scoring sections. o This is patients safety impairment without caregiver Safety in Transfers (Section 1.2: Functional Mobility) o This is patients safety impairment without caregiver Caregiver-Mobility (Section 5.1: Caregiver Return Demonstration) o Do not use '8' to score caregiver assistance at initial evaluation if the patient has a caregiver who is able to assist the patient. o A score of '8' should only be used if the patient does NOT require caregiver assistance. o If the patient requires assistance, but does not have a caregiver score the item as a 7. Updated 2018 o If the patient DOES have a caregiver, the score should be acquired through information on the patient's medical chart; if no information can be acquired to score this item, score as a '7'. OT: Readmit Risk: Toileting Safety (Section 2.1: Self Care) o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Feeding & Eating (Section 2.2: Self Care) o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Fxnl Cognition (Section 3.1: Functional Cognition) Home Evaluation (Section 4.1: Home Environment) o Do not use '8' to score the home assessment if the patient will return to a home environment. A score of '8' should only be used if the patient will remain in SNF or is homeless. o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Caregiver-Self Care (Section 5.2: Caregiver Return Demonstration) o Do not use '8' to score caregiver assistance at initial evaluation if the patient has a caregiver who is able to assist the patient. o A score of '8' is only used if the patient does NOT require caregiver assistance. o If the patient requires assistance, but does not have a caregiver score the item as a 7. o If the patient DOES have a caregiver, the score should be acquired through information on the patient's medical chart; if no information can be acquired to score this item, score as a '7'. *If the therapist is unable to determine if the patient has a caregiver who can provide safe and appropriate assistance, score the item(s) without caregiver assistance. *Scores are not affected by the time it takes to complete tasks or by the use of adaptive equipment/devices, unless specified otherwise. All test items must be scored. * Items are scored on a scale of 1 to 7. Higher scores indicate greater safety impairment; a score of 1 indicates no safety concerns and a score of 7 indicates safety concerns for 100% of the activity. An additional score option of 8 is available for items that are not applicable to the patient. *If more information on any of these factors would be beneficial, add a narrative section and include further clarification. Reference the Evaluation of Potential Readmission Factors (EPRF) Manual for further instruction. 16. Underlying Impairments: Identify all underlying impairments and add the level of current impairment. In the narrative box, please include, goniometric measurements, functional skills impacted by pain, safety awareness deficits, activity tolerance, cognitive impairments, ROM deficits, etc. Only impairments that are addressed by a goal need to be included, it is not necessary to indicate intact or normal. a. PHQ9 Psychosocial Well being Updated 2018 b. Standardized Tests: It is best practice to have at least 1, if not more, standardized tests on all evaluations. Make sure to include what the standardized test results indicate in this section or in the goals. 17. Goals: Please make sure that goals make sense and are as specific as possible. Goals must be patient centered, measurable and pertaining to identified functional impairments. Use percentages of cues (verbal, tactile, written) to show progress. Must be written with adequate baseline of functional documentation so change can be measured. The best practice is to make STGs Performance Skills / Underlying Deficits specific and make the LTGs Occupation / Functional Skills based. This helps to show progress. 18. Rehab Potential: This should always be good if the goals are written appropriately. 19. CPT Codes- Requires skilled services to focus on: Include CPT codes that will be billed and provided during intervention. Do not use cognitive retraining, this is very difficult to get reimbursed and is only appropriate in rare instances. a. PAM: If including a physical agent modality, only choose 1 and follow the ACP protocol. The chosen modality needs to be included in a short-term goal as well. The clarification order for a modality must include: specific modality, body location, physiological impairment, function impacted, frequency, and duration. b. Group Therapeutic Procedures CPT 97150/92508: If appropriate, group therapy should be included as a CPT intervention code. The rationale for utilizing group therapy should be documented in the POC. Some ability to self-initiate the tasks/activities in the group such that they dont need 1-on-1 assistance 100% of the time (ACP). 20. Treatment Diagnosis: Refer to Appendix C, ICD-10 Therapy TREATMENT Codes that Support Medical Necessity (are reimbursable), for more information. 21. Frequency/Duration/Amount: Duration is the number of days the patient will be seen, this can be no greater than 90 days. Frequency is the amount of times the patient will be seen per week. Amount is times per day (BID/QD). Daily Note: 1. Purpose: Record skilled interventions and treatments provided to justify the billed codes on the claim. It must be conveyed that the unique skills of a therapist were absolutely necessary to provide the treatment. Refer to the Appendix A, WPS CPT Documentation Tips Guide, for specific examples per CPT code. a. Modalities: Only charge for the skilled part of modalities including choosing parameters electrode placement, skin checks, determining proper pulse frequency and duration, and simulation mode, etc. Do NOT charge for patients sitting and receiving a modality when the therapist is not actively engaged. Refer to Appendix B, WPS LCD Modalities in Depth, for more information and specific examples. Skilled documentation of modalities must include: The specific modality, device used (what size US transducer, type of electrodes), body location treated, parameters (waveform for e-stim, frequency, intensity and measure i.e, 24 volts or 1.0 Watts/cm2), treatment duration, physiological effect resident response to treatment (descriptors such as muscle twitch), patients tolerance to treatment, patients Updated 2018 cooperation, patient comments regarding the modality, skin integrity prior to and after intervention, physiological impairment treated and functional improvements, rationale for continued use or discontinuing the modality. b. Group Therapeutic Procedures CPT 97150/92508: Include the purpose of the group and the number of participants. Group activities must address at least 1 of each participating patients treatment goals. Group attendees should have similar levels of acuity/severity (ACP). Therapeutic benefit from group dynamics and socialization should be documented. Skilled nature of group therapy needs to be described. For example, upgrading the difficulty of the activity for an individual could be included. For more information reference Appendix D, Group Therapy. 2. Consent to treat upon evaluation: For the LTC residents, consent to treat must be documented in the daily note, on the day of the evaluation, under the evaluation CPT code. The information included in the daily note should contain 1) name of the person contacted, 2) relationship of the resident to the patient, 3) if the contact was made in person or over the phone, and 4) that consent to treat was given. This process is billable if completed when the therapist is with the resident. If the person is unable to be contacted after several attempts, document the attempts and if a message was left. 3. Skilled Verbs: Evaluated, fabricated, analyzed, guided, corrected, adapted, instructed, modified, assessed, coordinated, facilitated, tailored, graded, developed, designed, optimized, stabilized, educated. 4. Red flags: Slight improvement, routine, monitor, maintain, making slow progress, no progress made, reviewed, unable to learn, overall generalized weakness, poor/fair rehab potential, poor participation, low motivation, poor prognosis 5. Daily note on day of discharge: Do not just write see d/c. Include the skilled interventions that took place on the day of discharge. Progress Note: 1. Goals: Enter the current level of the STGs. If the goal is achieved, upgrade or discharge the goal to show movement in the documentation. If no progress has been made for 2 progress notes in a row with a specific goal(s), downgrade or discharge the goal, then add new goals pertaining to long term goals. Remember, that the goal date is the date the therapist expects the goal will be met. This date should be no longer than 2 weeks from day set. 2. Analysis of functional Outcome/Clinical Impression: Discuss the residents response to intervention and modifications made to approaches when necessary. Also, discuss improvements in underlying impairments and functional skills. List barriers to progress, and why the skills of the therapist are required to provide the skilled intervention. Update standardized test scores and include narrative interpretations. This section should specifically describe the contributing factor(s) to the functional deficits, and the impact on their health/well-being. 3. Remaining Functional Deficits/ Underlying Impairment: Include deficits that are still present or newly identified and what the focus of intervention will be for the next 2 weeks, keeping long term goals in mind. 4. Precautions 5. Updated Standardized Tests Updated 2018 6. Skilled Services Provided since Last Report: Do not simply list the codes that were billed such as ther ex, neuro, ADL etc. Discuss the skilled services that were provided for each code billed since the last progress note or evaluation. This section should describe what therapy is doing with or teaching the patient that no one else has the skill to provide. Explain modifications to tasks, grading of tasks, compensatory and adaptive strategy education, skilled assessment of task performance, techniques used to improve functional performance, etc. a. Skilled Services: Therapeutic exercise is NOT a skilled service. CNAs, RNAs, rehab aides, and caregivers can all give a patient a 2 lb weight. However, graded resistance exercise with assessment of muscle fatigue is skilled. The Omnicycle is not skilled, however, it becomes skilled when the therapist provides continued assessment of the patients cardiopulmonary function or vital signs. Refer to Appendix A, WPS CPT Documentation Tips, for more information. b. Physical Agent Modality: If a PAM was billed, discuss the physiological impairment treated, body location, parameters, skin integrity prior to and following the modality and functional improvements. Also include patients tolerance, cooperation, and comments regarding the modality. Include the rationale for continued use of the modality. Refer to Appendix B, WPS LCD Modalities in Depth, for more information. All of the following components should be addressed for each PN when a modality has been utilized in the progress reporting period including the specific modality, waveform for e-stim, frequency, intensity and measure (i.e, 24 volts or 1.0 Watts/cm2), descriptors such as muscle twitch, treatment duration, body location treated, device used (what size US transducer, type of electrodes), physiological effect, resident response to treatment, rationale for continued use or discontinuing the modality 7. Updates to Treatment approach: List changes in intensity of services, added treatment modalities, or changes in goals or discharge plans. 8. Reason for Missed Treatments 9. Patient / Caregiver Training: Therapists are teachers. This section should contain information on every note. Therapists educate and train not only the patient, but also CNAs, family members, caregivers, RNAs, and other interdisciplinary team members. Make sure that the answers to the questions listed below are all included in patient/caregiver education documentation. a. Who did I education? (patient, caregiver, restorative aide) b. What did I educate? Technique, strategy or exercise: (hip precautions, cardiac precautions, swallow strategies, adaptive equipment use, positioning device use) c. How did I educate? (verbal instructions, written instruction, demonstration of technique) d. Did the patient/caregiver understand? e. Did the patient/caregiver return demonstrate, and how accurate was the return demonstration? 10. Impact on Burden of Care/ Daily Life: The amount of assistance the resident requires and who will be or is providing the assistance. Burden of care is related to the resources (man power) it will take to help the resident in the current environment as well as the anticipated discharge environment. 11. Prognosis for Further Progress: Should be good if goals are appropriate. If it is not good, then goals should be adjusted, as well as treatment approaches. Updated 2018 Discharge Summary: 1. Goals: Enter the current level of the STGs and LTGs. 2. Analysis of Functional Outcome/Clinical Impression: Discuss the residents response to intervention and how approaches were modified if the resident responded negatively. Also, discuss improvements in underlying impairments and improvements in functional skills. List barriers to progress, and why the skills of the therapist are required to provide intervention. 3. Impact on Burden of Care/Daily Life: The amount of assistance the resident requires and who will be or is providing the assistance. Burden of care is related to the resources (man power) it will take to help the resident in the current environment and in the discharge environment. 4. Skilled Services Provided since Last report: Do not simply list the codes that were billed such as ther ex, neuro, ADL etc. Discuss skilled services that were provided for each code billed since the last progress note. The skilled services provided section should describe what therapy did with or taught the patient that no one else had the skill to provide. This section should explain modifications to tasks, grading of tasks, teaching of compensatory and adaptive strategies, skilled assessment of task performance, techniques used to improve functional perform, etc. a. Skilled Services: Therapeutic exercise is NOT a skilled service. CNAs, RNAs, rehab aides, and caregivers can all give a patient a 2 lb weight. However, graded resistance exercise with assessment of muscle fatigue is skilled. The Omnicycle is not skilled, however, It becomes skilled when the therapist provides continued assessment of the patients cardiopulmonary function or vital signs. Refer to Appendix A, WPS CPT Documentation Tips, for more information. b. Physical Agent Modality: If a PAM was billed, discuss the physiological impairment treated, body location, parameters, skin integrity prior to and following the modality and functional improvements. Also include patients tolerance, cooperation, and comments regarding the modality. Include the rationale for continued use of the modality. Refer to Appendix B, WPS LCD Modalities in Depth, for more information. The specific modality, waveform for e-stim, frequency, intensity and measure (i.e, 24 volts or 1.0 Watts/cm2), descriptors such as muscle twitch, treatment duration, body location treated, device used (what size US transducer, type of electrodes), physiological effect, resident response to treatment, rationale for continued use or discontinuing the modality 5. Summary of Skilled Services Provided since SOC: Do not simply list the codes that were billed such as therapeutic exercise, neuro, ADL etc. Discuss what skilled service was provided for each code billed for the entire duration of treatment. Also, discuss the functional gains achieved by providing each billed code. The skilled services provided section should describe what therapy did with or taught the patient that no one else has the skill to provide. This section should explain modifications to tasks, grading of tasks, teaching of compensatory and adaptive strategies, skilled assessment of task performance, techniques used to improve functional perform, etc. 6. Patient/ Caregiver Training since Last Report: Therapists are teachers. This section should contain information on every note. Therapists educate and train not only the patient, but also CNAs, family members, caregivers, RNAs, and other interdisciplinary team members. Make sure that the answers to the questions listed below are all included in patient/caregiver education documentation. a. Who did I education? (patient, caregiver, restorative aide) Updated 2018 b. What did I educate? Technique, strategy or exercise: (hip precautions, cardiac precautions, swallow strategies, adaptive equipment use, positioning device use) c. How did I educate? (verbal instructions, written instruction, demonstration of technique) d. Did the patient/caregiver understand? e. Did the patient/caregiver return demonstrate, and how accurate was the return demonstration? 7. Precautions 8. Reason for Missed Treatments 9. Discharge Plans & Instructions: List the discharge environment, caregiver instruction provided, home exercise program, restorative nursing program, and any follow up services that will be provided such as home health or outpatient services. Also, discuss equipment ordered or needed upon discharge. Patient and/or caregiver have acknowledged understanding of post-discharge plan from therapy. 10. Updated Standardized Tests: Complete standardized tests completed in the plan of care. Add a narrative of what the change in scores indicates. 11. Contraindications 12. Patient/Caregiver is aware and reports understanding of the diagnosis and prognosis 13. Functional Deficits: Enter the current level of the functional deficits listed. Do NOT enter UNKNOWN. a. Section GG b. Pain Impacting c. Hospital Readmission Factors: Scores indicate levels of safety impairment. Scores are based on criteria for each item that measure how safely tasks are performed with or without a caregiver upon evaluation and discharge (reference EPRF Users Manual). PT: Readmit Risk: (Pre)Ambulatory Fall Risk (Section 1.1 a: Functional Mobility) OR Wheelchair Mobility Fall Risk (Section 1.1b: Functional Mobility) o Only score ONE of the ambulation scores; (pre)ambulatory -OR- w/c mobility; whichever item is most appropriate for the patient. The other item that is not the most appropriate should be scored as '8' for all three scoring sections. o This is patients safety impairment without caregiver Safety in Transfers (Section 1.2: Functional Mobility) o This is patients safety impairment without caregiver Caregiver-Mobility (Section 5.1: Caregiver Return Demonstration) o Do not use '8' to score caregiver assistance at initial evaluation if the patient has a caregiver who is able to assist the patient. o A score of '8' should only be used if the patient does NOT require caregiver assistance. o If the patient requires assistance, but does not have a caregiver score the item as a 7. o If the patient DOES have a caregiver, the score should be acquired through information on the patient's medical chart; if no information can be acquired to score this item, score as a '7'. OT: Readmit Risk: Updated 2018 Toileting Safety (Section 2.1: Self Care) o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Feeding & Eating (Section 2.2: Self Care) o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Fxnl Cognition (Section 3.1: Functional Cognition) Home Evaluation (Section 4.1: Home Environment) o Do not use '8' to score the home assessment if the patient will return to a home environment. A score of '8' should only be used if the patient will remain in SNF or is homeless. o Items scored based on the patients safety impairment with or without caregiver assistance (if applicable) Caregiver-Self Care (Section 5.2: Caregiver Return Demonstration) o Do not use '8' to score caregiver assistance at initial evaluation if the patient has a caregiver who is able to assist the patient. o A score of '8' should only be used if the patient does NOT require caregiver assistance. o If the patient requires assistance, but does not have a caregiver score the item as a 7. o If the patient DOES have a caregiver, the score should be acquired through information on the patient's medical chart; if no information can be acquired to score this item, score as a '7'. d. If the therapist is unable to determine if the patient has a caregiver who can provide safe and appropriate assistance, score the item(s) without caregiver assistance. e. Scores are not affected by the time it takes to complete tasks or by the use of adaptive equipment/devices, unless specified otherwise. All test items must be scored. f. Items are scored on a scale of 1 to 7. Higher scores indicate greater safety impairment; a score of 1 indicates no safety concerns and a score of 7 indicates safety concerns for 100% of the activity. An additional score option of 8 is available for items that are not applicable to the patient. g. If more information on any of these factors would be beneficial, add a narrative section and include further clarification. Reference the Evaluation of Potential Readmission Factors (EPRF) Manual for further instruction. Updated 2018 References Accelerated Care Plus Corporation (2015). Group therapy: An accelerated clinical practice series. Reno, NV Bellew, J., Michlovitz, S., & Nolan, T. (2016). Introduction to therapeutic modalities. Modalities for therapeutic intervention. (6th ed.). (pp. 16). Philadelphia: F.A. Davis. Centers for Medicare & Medicaid Services (October, 2017). Long-term care facility resident assessment instrument 3.0 user's manual. Department of health & human services. Retrieved from https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October-1-2017-R.pdf Updated 2018 Appendix B Objectives Group Therapy in a Skilled Nursing Facility Presented by: Darian Burchfield Definition of Group Therapy Non-RUG Based The treatment of 2 or more patients simultaneously, who may or may not be performing the same/similar activity. If the therapist is dividing attention, providing only intermittent personal contact, or giving instructions to 2 or more patients, one unit is appropriate per patient. (RAI,2017; LCD, 2015) To increase knowledge regarding service provision guidelines of group therapy To increase understanding of ethical billing and effective documentation of group therapy To increase knowledge regarding the benefits of ethical group therapy as evidenced by peer reviewed literature Definition of Concurrent therapy RUG Based The treatment of 2 patients, who are not performing the same or similar activities, at the same time, regardless of payer source, both of whom must be in the line-of-sight of the treating therapy practitioners Only exists for RUG-based payers Definition of Group Therapy RUG Based Treatment of 4 patients who are performing the same or similar activities, and are supervised by a therapist or an assistant. Must be planned in advance for exactly 4 patients Only 25% of total therapy (RAI, 2017) CPT Billing Codes CPT 97150- Therapeutic Procedure (s), group (2 or more individuals) Occupational and Physical Therapy Speech therapy- Dysphagia only CPT 92508- Group, two or more individuals Speech therapy (RAI, 2017; LCD, 2015) Question? Question? You have two patients that come down to the therapy gym and participate in therapy, at the same time, for 30 minutes. One is Medicare Part A and one is Medicare Part B. How does the therapist bill those minutes? All patients below have non-RUG based payers. The therapist treats 3 patients from 1:00pm-2:00pm providing brief intermittent instruction while monitoring all 3. How does the therapist bill these minutes? Patient A= 1:00 pm - 2:00 pm (60 minutes) Patient B= 1:00 pm- 1:30 pm (30 minutes) Patient C= 1:30 pm- 2:00 pm (30 minutes) Non-Covered Group Therapy Provided by students (without supervision), therapy aides, rehab techs, nursing aides, recreational therapists, exercise physiologists, or athletic trainers Previously taught exercise programs, independent exercise, or exercise on machines/equipment in the absence of skilled care Routine (i.e., supportive) groups such as maintenance programs, nursing rehabilitation programs, or recreational therapy programs (LCD, 2015) Relevant Literature THA/TKA Back pain Parkinsons Disease CVA Knee OA Post stroke aphasia Session Participation Patients do not have to be at the same functional level to participate in group therapy Reminder: Does NOT have to be the same or similar activity Inappropriate Patients Isolation, extreme behaviors, requires constant 1-on-1 attention, patient preference Unique Benefits of Group Therapy Motivating Carry-over Independence Change-of-pace (ACP, 2015) Peer support Efficiency Unique treatment Fun!!!!!!!!! Positive Impact on Productivity If a therapist spends 60 minutes with a singular client and 45 minutes of that time is billable then the therapist is 75% productive for that hour. If a therapist spends 60 minutes doing group for 2 patients then the therapist is 200% productive for that hour. Gathering Patients Use this time as an opportunity for treatment Address functional transfers, functional mobility, provide education, provide cueing for safety, etc. These minutes count towards Individual patient minutes Therapist productivity Question? A therapist treats 3 patients from 1:00pm-2:00pm providing brief intermittent personal contact while monitoring all 3. What is the therapists productivity for this hour? Patient A= 1:00 pm - 2:00 pm (60 minutes) Patient B= 1:00 pm- 1:30 pm (30 minutes) Patient C= 1:30 pm- 2:00 pm (30 minutes) Productivity & Scheduling When possible, communicate therapy times Patients, other therapists, nursing, family, etc. Flexible Scheduling Group Therapy Expectation Number is skewed Ethical Considerations Is group therapy an ethical mode of therapy? Proper implementation Using appropriate definition for payer Proven benefits Proper billing Group Therapy CPT code, if appropriate Therapy Students Group therapy can be coded when The student provides group treatment and the supervising therapist/assistant is present throughout the session and is not engaged in any other activity or treatment Supervising therapist/assistant is provides group treatment and the therapy student is not providing any other treatment (RAI, 2017) Documentation Requirements CPT code on the POC Description in the daily treatment note Purpose of group Number of participants Individualized patient performance Skilled service- Lifespan Documentation Manual (ACP, 2015) Thank you! Further questions regarding group therapy should be directed to regional managers  ...

... A Theatre-Based Occupational Therapy Intervention for Substance Use Disorders: A NonRandomized Comparison Jordan Jennings Carmen Rosales Elissa Pothast Alex Kessens Neva Graper December, 2017 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Sally Wasmuth, OTR A Research Project Entitled A Theatre-Based Occupational Therapy Intervention for Substance Use Disorders: A NonRandomized Comparison Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Jordan Jennings, Carmen Rosales, Elissa Pothast, Alex Kessens, Neva Graper & Sally Wasmuth, PhD, OTR Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date THEATRE AND ADDICTIONS 2 Abstract The purpose of this study was to examine the effectiveness of theatre-based intervention for recovery from addictions. High relapse rates associated with drug use significantly affect ones ability to perform daily occupations, demonstrating the need for increased research regarding this topic. The design for this study was a nonrandomized comparison. Participants were recruited via convenience sample substance use disorder (SUD) treatment facilities, as well as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings. Participant availability determined placement in intervention or comparison group. The Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS), the General Self-Efficacy Scale (GSE), and the Timeline Followback (TLFB) were used to collect data at baseline, postintervention, and 6-month follow-up. The intervention was a 6-week theatre group where participants rehearsed to publicly perform a play. A statistically significant difference was found between the baseline and 6-month intervention group GSE and OCAIRS scores. This finding suggests that theatre could be an effective intervention for OT to use in the future to facilitate addiction recovery. THEATRE AND ADDICTIONS 3 A Theatre-Based Occupational Therapy Intervention for Substance Use Disorders: A NonRandomized Comparison Addiction is a significant and growing public health concern that has been particularly difficult to treat. According to the National Institute on Drug Abuse (NIDA), 40-60 percent of individuals treated for SUD will relapse (2014). In addition, nearly 80 percent of individuals recovering from SUD have been reported as relapsing within the first year (Bart, 2012), illustrating the need for change in treatment programs. The purpose of this study is to examine the effectiveness of an occupational therapy (OT) theatre intervention as supplementary to treatment as usual (TAU) in reducing relapse rates and improving quality of life in people with addictions. A number of factors have been suggested to facilitate addiction recovery, including positive social interactions (Vallejo, 2011), cognitive challenge (Houston et al., 2014), pharmacological interventions to ameliorate cravings (Park & Friedmann, 2014; Bickel, Koffarnus, Moody, & Wilson, 2014) and participation in meaningful activities, (Hoxmark, Wynn, & Wynn, 2012). Although many treatment programs are deemed successful, the high and unwavering relapse rates in those with addictions remains a concern. According to Wasmuth and Pritchard (2016), theatre interventions would benefit those recovering from addictions for several reasons. Participation in theatre productions can facilitate positive social interactions, help with cognitive deficits through memory training, and provide opportunities for occupational participation as people abstain from drug use. Theatre also provides temporal structure and requires participants to manage their time as they are expected to regularly attend rehearsals and final performances. An intervention involving theatre can offer THEATRE AND ADDICTIONS 4 those with addictions the opportunity to have a sense of purpose and identity while participating in positive habits, roles, and routines. A number of empirical studies reflect these claims. For instance, a mixed methods study by Fenech (2009) describes positive effects such as enjoyment and treatment engagement resulting from an interactive drama performance in participants with impaired neurological functioning. A multimodal study involving a drama intervention for veterans with PTSD also provides evidence to support decreased symptoms of the disorder, while simultaneously improving self-esteem (Rademaker, Vermetten, & Kleber, 2009). Results also indicated increased self-efficacy, a key factor in successful rehabilitation in individuals with SUD (Konopik & Cheung, 2012). A pilot study by Wasmuth and Pritchard (2016) indicated a theatre-based OT intervention to be a feasible and acceptable intervention to facilitate addiction recovery. Wasmuth and Pritchards study provided preliminary positive outcomes; however, the study was limited in that there was no comparison group, and the sample consisted solely of veterans (2016). In order to adequately examine the effectiveness of Wasmuth and Pritchards (2016) intervention program, researchers in this study will investigate whether a 6-month theatre intervention including TAU is more effective than only TAU in reducing both short and long term substance use, and increasing quality of life in persons with SUD. Variables related to client self-efficacy, values, roles, personal causation, interests, habits, and environment will be used to measure quality of life. (Haglund & Forsyth, 2013). A wider scope of participants will also be included to explore effectiveness beyond the veteran population. Background THEATRE AND ADDICTIONS 5 The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines addiction as involving both substance-related and addictive disorders. Substance-related disorders are a combination of the DSM-IV categories of substance abuse and substance dependence. In order to have a substance-related disorder, the DSM-5 requires that the individual present at least two to three symptoms from a list of eleven symptoms that characterize the disorder. For the purpose of this study, both substance-related disorders and addictive disorders will be referred to as addictions. The background information summarized in this study describes areas of focus that directly impact individuals with addictions. These impacted areas have also been shown to support the use of a theatre intervention as an effective form of treatment. Occupation According to the American Occupational Therapy Association (AOTA), occupation is defined as daily life activities in which people engage; they occur over time, have purpose, meaning and perceived utility to the individual, and can be observed by others (American Occupational Therapy Association, 2014, p. 6). Occupations include activities of daily living (ADL), instrumental activities of daily living (IADL), education, work, play, leisure, and social participation (AOTA, 2014). Addiction and Occupation According to Hoxmark et al. (2012), individuals with SUD reported that they participated in fewer of activities (occupations) after the onset of abusing substances compared to before the abuse began. Activities were examined through a questionnaire developed specifically for use in this study. The questionnaire was administered when the individuals were admitted to an inpatient substance abuse rehabilitation program. Decreased participation in occupations also THEATRE AND ADDICTIONS 6 correlated to a decline in patients overall wellbeing, which was assessed using a 5-item version of the Wellbeing Index (WHO-5). Patients also indicated that they desired a greater number of activities in the future compared to their current state. In summary, this study indicated that helping individuals with SUD regain positive activities could not only decrease their substance use, but also improve their overall wellbeing (Hoxmark et al., 2012). Peloquin & Ciro (2013) incorporated the concept of regaining positive activities as part of a population-centered life skills group for women in recovery from SUD in a residential facility. The life skills group met for 60 minutes and focused on themes deemed important in substance dependence literature. The group meeting consisted of preparatory methods, purposeful activities, and discussion of topics. Using a survey designed specifically for the study, high levels of perception of satisfaction and personal engagement in the life skills group were determined. Executive Function Executive function is a broad term that is associated with a variety of cognitive processes occurring within the prefrontal lobes of the brain (Goldstein, Naglieri, Princiotta, & Otero, 2014). Three executive functions are prevalent in addiction literature: response inhibition, decision-making, and cognitive flexibility. Response inhibition represents a persons ability or motivation to refrain from engaging in a particular behaviorthat is, a person is able to inhibit a behavioral response to an internal or environmental cue such as drug-seeking in response to physiological craving (Jentsch & Pennington, 2014). According to these authors, whether or not a person demonstrates response inhibition depends the level of motivation to engage in the behavior as well as the level of motivation to refrain from it. However, deficits in response inhibition, possibly related to THEATRE AND ADDICTIONS 7 neurophysiological changes resulting from addictive behavior, are often present in persons with addictions. Longitudinal research indicates these deficits precede addictive behaviors more often than not (Jentsch & Pennington, 2014). People with addictions often make the decision to engage in immediately rewarding behaviors and accept the consequences, rather than abstain (Dong & Potenza, 2014), and are also more likely to choose immediate over delayed rewards (Bickel et al., 2014). In addition to response inhibition deficits, studies have shown that people who generally engage in high-risk decision making are at a higher risk for alcohol and/or gambling dependency (Harvanko, Schreiber, & Grant, 2013). Cognitive flexibility is the ability to efficiently transition from one situation to another (Dong, Lin, Zhou, & Lu, 2014). According to Dong et al. (2014), this efficiency includes the ability to transition and adapt to different situations as well as the speed with which one can make these transitions. One study that focused on the addictive behavior of heavy drinking indicated that the more alcohol that was consumed, the more negatively cognitive flexibility was impacted (Houston et al., 2014). Self-Efficacy Self-efficacy is another prevalent concept within addiction literature. A study published by Kouimtsidis, Reynolds, Coulton & Drummond (2012) investigated therapeutic outcomes in two groups of people with opioid addictions in relation to self-efficacy before and after treatment. The first group received methadone maintenance treatment (MMT) plus cognitive behavioral therapy (CBT); the second group received only MMT. Self-efficacy to resist the urge to use drugs (Kouimtsidis et al., 2012, p. 255) was measured using the Drug Taking Confidence Questionnaire (DTCQ) which consists of eight self-report questions; results THEATRE AND ADDICTIONS 8 indicated highest scores from the group receiving MMT and CBT. Kelly and Greene (2013) also investigated the relationship between abstinence self-efficacy and motivation in treatment outcomes through a longitudinal study. To measure abstinence self-efficacy, participants were asked to rate the following question on a scale from 1 (not confident) to 10 (very confident): How confident are you that you will be able to remain clean and sober for the next 90 days, or three months? (Kelly & Greene, 2013, p. 930). This single item measure of self-efficacy has been validated as a strong predictor of relapse rates in those with addictions (Kelly & Greene, 2013). Measure for recovery was administered using The Commitment to Sobriety Scale (CSS); this scale includes 5 items to measure motivation of sobriety from drug or alcohol use, and items are measured from 1 (strongly disagree) to 6 (strongly agree) (Kelly & Greene, 2013). These items were then analyzed to see how they relate to treatment outcomes. Results showed that percent days abstinent (PDA) was greatest when both scores of self-efficacy and motivation were high; conversely, PDA was lowest when both were low (Kelly & Greene, 2013). Results from these studies have repeatedly indicated that self-efficacy is a reliable predictor of treatment outcome. Social Participation Vallejo (2011) defines social participation as the extent of an individuals involvement in social activities of groups or organizations (p. 92). This can also include social interaction with friends or other peers outside of an organized group. Research has shown that social networks may have an influence on the substance abuse, but results have been inconsistent (Vallejo, 2011). Some studies have shown that high levels of social participation are linked to a reduction of dependence on substances such as drugs or alcohol, but others have indicated that high levels of social participation are linked to an increase in dependence on substances such as THEATRE AND ADDICTIONS 9 tobacco (Vallejo, 2011). Despite inconsistencies, Vallejo emphasizes that high levels of social participation are linked to a lower incidence of drug use (Vallejo, 2011). It is possible that the nature of social participation may influence its relationship to substance use. For example, in Vallejos study, individuals who were more involved socially in religious associations were 19 percent less likely to use drugs in their lifetime (2011). Research has also shown that the type of individuals within a social network may have an influence on the substance dependence of its members (McDonald Griffin, Kolodziej, Fitzmaurice, & Weiss, 2011). For example, a study completed by McDonald et al. found that a social network that includes two or more drug users significantly influenced the drug use of its other members (2011). This information is important when developing treatment options; programs may inform individuals that spending time around those who use drugs or other substances may trigger a relapse and also emphasize that having a large number of abstinent friends in ones social network may promote recovery (McDonald et al., 2011). Social participation has also been found to decrease risky behavior overall, which may include drug use, unsafe sex and other illegal activity (Leslie, Ahern, Chinaglia, Kerrigan, & Lippman, 2013). Treatment Cognitive Behavioral Therapy (CBT) is an evidence-based intervention used to treat addictions. It is often performed in a group setting, and various forms of group therapy have been suggested to result in promising recovery-related outcomes in persons with SUD. A study by Pagey, Deering, and Sellman (2010) showed that group therapy was important in strengthening interpersonal relationships and could improve treatment retention (Pagey et al., THEATRE AND ADDICTIONS 10 2010). Demonstrating CBTs effectiveness in group therapy, Carroll et al. (2012) compared three types of treatments for marijuana use disorder: CBT alone, CBT with contingency management, and contingency management alone. Results showed the CBT group had greater reduction of overall marijuana use, as well as lower relapse rates one year later (Carroll et al., 2012). Contingency management (CM) and medication addiction treatment (MAT) are other evidence-based treatment methods often utilized in group settings. CM involves positive reinforcement as a motivator for abstinence, whereas MAT works to reduce cravings associated with substance abuse. One CM study included participants trained in CM as well as patients who were part of a methadone treatment facility (Petry, Alessi, & Ledgerwood, 2012). Participants were randomized into either a CM group or a standard care (SC) group. The SC group received daily methadone treatment and therapy meetings; the CM group received contingency management as well as standard care (Petry et al., 2012). Results indicated that participants in the CM group remained in the study significantly longer and achieved significantly longer durations of abstinence from cocaine and alcohol (Petry et al., 2012, p. 292) than those in the SC group. MAT can reduce withdrawal symptoms associated with abstinence and create adverse symptoms when the drug of choice is used, resulting in positive treatment outcomes in those with opioid and alcohol addictions (Park & Friedmann, 2014). Common medications for use with alcohol use disorder include: oral naltrexone, naltrexone depot injections, acramprostate, and disulfuram; methadone and buprenophine are typically utilized with opioid use disorder (Park & Friedmann, 2014). MAT is not only beneficial in reducing substance use, but also in reducing the high mortality rate in those with opioid and alcohol use disorders (Park & Friedmann, 2014). THEATRE AND ADDICTIONS 11 Motivational interviewing (MI) is another type of treatment associated with SUD. This treatment type has been identified as an effective method for behavioral change in adults with SUD by combining characteristics of client-centered therapy with cognitive behavioral strategies designed to elicit behavior change (Jensen et al., 2011, p. 433). One study focused on the effects of motivational interviewing in adolescents with SUD (Jensen et al., 2011). Metaanalysis revealed that MI interventions for adolescent substance use produced significant improvements in treatment outcomes (Jensen et al., 2011). Theatre Role-playing has been used in therapy to help people with progressive and nonprogressive diseases develop social skills through experimenting with various roles. This has resulted in reduced aggression and increased compliance with treatment (Fenech, 2009). Participants included people with Friedreichs ataxia, Parkinsons disease, Huntingtons disease, multiple sclerosis, traumatic brain injury, and/or stroke. Participants who participated in theatrical role playing also reported a sense of achievement after the conclusion of the program, and 35 percent of these individuals were already expressing interest in doing another theatre activity. It was reported that staff and residents had a positive change in community spirit (p. 122), which led to residents feeling more peaceful during the project. Theatre has also been studied as a successful modality in a group setting among those with post-traumatic stress disorder (PTSD). In conjunction with other forms of therapy, psychodrama was part of an outpatient group program which provided these treatments on a weekly basis to veterans with PTSD over the course of 21 weeks. Treatment goals were similar to what they would be in individuals with addictions, with emphasis on targeting chronic symptoms, increasing overall quality of life, and preventing relapse. The results of this program THEATRE AND ADDICTIONS 12 illustrated a decrease in psychopathology, depression, and anxiety in relation to participants PTSD symptoms. Coping strategies and self-esteem improvements were also noted as an effective outcome from pre-to post-treatment (Rademaker et al., 2009). Although this study was deemed successful, effects of psychodrama were reportedly difficult to interpret due to the studys multimodal design. Konopik & Cheung (2012) researched the therapeutic effects psychodrama exclusively in 13 patients in a mental health and chemical dependency program. Sessions were conducted biweekly for two hours, with group participation varying each session. Results from this study indicated increased self-efficacy and hope for the future (Konopik & Cheung, 2012). Current studies of theatre interventions are limited in their design. Studies indicated changes in pre/post outcomes but did not compare outcomes to those of comparison groups; it is therefore unclear if results were due to the theatre intervention alone. To address this gap in the literature, this studys design included a comparison group. Methods Design The design of this study a non-randomized comparison design. Participants in the intervention group participated in a 6-week theatre project. Participants in the comparison group received TAU, which consisted of 12-step recovery and/or outpatient addiction recovery services. Researchers collected baseline, post-intervention and six-month follow-up data from the intervention and the comparison groups. Mean scores at each point in time were compared within and between intervention and comparison groups. Participants THEATRE AND ADDICTIONS 13 To be included participants must meet the following criteria: eighteen or older and involved in SUD outpatient treatment or had to have attended a 12-step meeting within a week of enrollment (however, were not required to remain in treatment throughout the course of the study). Due to the high rate of dual diagnosis (Fernndez-Mondragn, & Adan, 2015), participants with coexisting severe mental illness (SMI) were included. Therefore, our sample consisted of participants with a number of covariates based on other diagnoses/symptoms. Their exclusion would have created a highly unnatural sample that would have limited external validity. Instruments Primary outcome measures included the OCAIRS, GSE, and TLFB. The OCAIRS is a 30-60 minute interview that measures client values, roles, personal causation, interests, habits, and environment; it generates a quantitative score that indicates a participant's level of occupational participation (Forsyth et al., 2005). Limited research is available regarding the English version of the OCAIRS, however OCAIRS-Sweden has been found to have moderate inter-rater reliability (0.75), concurrent validity (r = 0.86), and content validity ranging from 4788 percent. Other studies have used the OCAIRS to assess occupational participation among the homeless population (Bradley, Hersch, Reistetter, & Reed, 2011) and among individuals with SUD (Wasmuth & Pritchard, 2016). The GSE is a 10 item self-report measure used to measure general self-efficacy (Casida, Wu, Harden, Chern, & Carie, 2015). General self-efficacy includes various domains of functioning in which people judge how efficacious they are, and is of specific interest when targeting well-being and health behaviors in patients (Nilsson, Hagell, & Iwarsson, 2015). The GSE has good validity and good test-retest reliability that ranges from .69 to .80 (Nilsson, THEATRE AND ADDICTIONS 14 Hagell, & Iwarsson, 2015). This outcome measure has been used to assess general self-efficacy among individuals with SUD (Wasmuth & Pritchard, 2016) and individuals with Parkinson's disease (Nilsson, Hagell, & Iwarsson, 2015). The TLFB is a 10-30 minute self-report measure that assesses alcohol use, cigarette use, and illicit substance use (Robinson, Sobell, Sobell, & Leo, 2014). The TLFB has high test-retest reliability that ranges from .92 to 1.0 (Lam, Fals-Steward, & Kelley, 2009), as well as convergent and discriminant validity for use with alcohol and other drug addictions (FalsStewart, OFarrell, Freitas, McFarlin, & Rutigliano, 2000). Procedures Recruitment and Enrollment. Researchers recruited a convenience sample from two SUD treatment facilities in a large midwestern city as well as from open 12-step meetings including AA and NA. Participants were not given any payment or compensation for participation. Researchers informed potential participants about this study via a recruitment announcement at recruitment sites during a regularly scheduled meeting. In addition, clinicians informed their clients about the opportunity to participate in this study. Interested clients had the opportunity to talk with the principal investigator following the regularly scheduled meeting where the study was announced. The principal investigator provided more information, reviewed informed consent documents, and if clients were still interested, informed consent documents were signed. All participants were assigned a number, which was logged electronically. A rehearsal schedule was determined based on the greatest availability time of participants; participants were allocated to the intervention group or a comparison group based on whether their schedules allowed them to attend. THEATRE AND ADDICTIONS 15 Twelve participants were allocated to the intervention group and three to the comparison group based on availability (this allocation process is detailed below). Four participants of the intervention group dropped out. Reasons for dropping out included recent employment, participation in recreational therapy, relapse and loss of contact, or choosing not to participate. Of those individuals in the comparison group, one dropped out. The reasoning was undetermined due to inability to reach this participant. Training. Prior to implementation of the OCAIRS, researchers were educated and trained to perform the assessment interview and score the results. Researchers practiced use of this tool amongst each other, while trading roles as interviewer and interviewee. Researchers were deemed competent in administering this assessment tool by a university professor. Data Collection. Three researchers performed interviews and assessments with participants at baseline (the week prior to the intervention), post-intervention (within a week of the final performance), and six months after the intervention. Interviews were recorded, transcribed, and de-identified. Data collection was performed at recruitment sites. OT graduate students performed all interviews and assessments. The OCAIRS, GSE, and TLFB were initially scored by the researcher that performed the interviews/assessments. To ensure reliability of data, a second researcher who was blind to the participants identity, date and time of the interview (e.g. baseline or follow-up) then performed a second rating on each OCAIRs assessment by listening to de-identified interviews. Data Analyses. Regarding OCAIRS and GSE scores, independent samples t-tests were performed to analyze any between-group differences at baseline, post-intervention, and sixmonth follow-up points. Homogeneity of variance was assessed by Levenes Test to ensure THEATRE AND ADDICTIONS 16 Equality of Variances. One-way ANOVA was used to analyze change over time in each group, with post-hoc Bonferroni corrections and cohens d effect size calculations. Intervention. The intervention group rehearsed and performed a play, written specifically for this project. Rehearsals took place three times a week for six weeks. Each rehearsal session lasted 3 hours. Rehearsals consisted of a gentle physical warm-up, teambuilding exercises, reading the script with varying role assignments, discussion of characters and scenes, and a wrap-up during which participants could reflect upon the day's work and express any concerns. At each rehearsal, a professional director, professional actor, and OT were present. The director was in charge of leading discussions, assigning roles for the script readthrough, designing and teaching blocking to the participants (where to enter, where to stand, etc.), and deciding upon costumes, lighting and stage design. The professional actor served as a peer mentor to the other actors. The professional actor also memorized all parts and was able to fill in for any roles if a participant dropped out or was unable to perform for any reason. The actor helped to carry the scenes and promote a successful experience to both the other actors and the audience. OT helped individuals with techniques for memorizing lines and blocking, provided stress and anxiety management techniques, and helped to modify and adapt individual roles to promote a successful experience. Comparison Group. Variance found within the comparison group resulted from the recruitment of participants from both outpatient facilities and 12-step programs within the community at large. Participants were not required to maintain participation in outpatient treatment or 12-step programs; therefore, some participants may not have received TAU. This research study was approved by the University Institutional Review Board. Results THEATRE AND ADDICTIONS 17 The sample of participants included 15 individuals involved in SUD treatment at the time of enrollment. Participant demographics are depicted in Figure 1, and participant drug of choice is depicted in Figure 2. Three participants were using substances throughout the duration of the intervention; one participant had been clean and sober for one month at the start of the intervention, one for two months, two for five months, two for six months, and one for nine months. In addition, two participants had been clean and sober for more than nine years. Three participants that dropped out did not report on their substance use. Due to inconsistency in participants reports of drug use at different points in time, data from the TLFB was not statistically analyzed. Participants were asked about their mental health history, but only five responded. Of the five, one reported having no history of mental health comorbidities while the remaining four specified co-morbidities including ADHD, depression, anxiety, and bipolar disorder. As depicted in Table 1, paired samples t-tests indicated no significant differences between intervention and comparison group mean OCAIRS or GSE scores at baseline, postintervention, or six-month follow-up. Levenes test indicated equality of variance. Table 2 illustrates change over time on OCAIRS and GSE scores in the intervention and comparison groups. One way analysis of variance (ANOVA) indicated a significant change from baseline to longest follow-up in the intervention group on OCAIRS and GSE mean scores. A Bonferroni correction indicated that OCAIRS mean scores significantly increased from postintervention to 6-month follow-up and from baseline to 6-month follow-up with a large effect size. A Bonferroni correction on GSE scores indicated a significant change from baseline to 6month follow-up with a large effect size. Levenes test indicated equality of variance among all THEATRE AND ADDICTIONS 18 groups being compared. Changes in mean OCAIRS and GSE scores over time in the comparison group were not statistically significant. Discussion A study by Wasmuth and Pritchard (2016) examined if theatre was a feasible intervention for veterans with SUD. However, this study did not have a comparison group and the sample consisted solely of veterans. The current study adds to this literature by comparing the theatre intervention with TAU to a comparison group that only received TAU. At the various points in time (baseline, post-intervention, and six-month follow-up) no between group differences were found. Although the sample size was very small, particularly in the comparison group, analyses demonstrated a significant difference over time in the intervention group regarding self-efficacy and OCAIRS scores, but not in the comparison group. Significant change in GSE scores were noted between baseline and six-month follow-up but not between shorter intervals, suggesting this is a long-term, slow change that may be impacted by many factors. However, this change was not present in the comparison group, thus it may be related to participation in the theatre intervention. Significant changes in OCAIRS scores were observed at each point of measurement, illustrating steady and more rapid change. Fenech (2009) used interactive drama to determine its effects with individuals with neurological deficits at a long-term care facility. Results indicated that 73 percent of staff and 81 percent of residents at this facility reported a positive change in community spirit (p. 122). Sixty-seven percent of residents attributed positive meaning toward rehearsals, including feeling valued and liked by their peers (Fenech, 2009). Nearly 90 percent of residents also reported being so engaged in rehearsals that they lost track of time (Fenech, 2009, p. 122). Similar to THEATRE AND ADDICTIONS 19 findings in the current study, Fenechs findings demonstrate positive social engagement and enhanced self-efficacy through participation in an interactive drama project. Another study using a theatre-based approach for patients in a mental health hospital also indicated positive effects. Eighty-five percent of patients reported feeling lighter after participation in just one rehearsal (Konopik & Cheung, 2012, p. 16). Other positive changes included enhanced self-worth and awareness, as well as recognition of emotions and innermost thoughts from a new viewpoint (Konopik & Cheung, 2012). Implications for OT Findings suggest participation in theatre along with TAU may produce positive changes over time that do not occur with TAU alone. These findings provide promise for the use of theatre as an occupation-based intervention for early SUD recovery. Wasmuth, Crabtree, and Scott (2014) have suggested that addiction is an occupation and that people in early recovery who are abstaining from their addiction are experiencing extreme occupational deficit. Considering this occupational deficit may help OT better understand the low treatment compliance and high relapse rates that exist for people with SUD in early recovery (Wasmuth, et al., 2014). It is imperative that OT provide new occupations to address occupational deficit and bolster recovery efforts. Theatre as an intervention incorporates several components that literature highlights as important for SUD recovery including cognitive challenges, such as reading and memorizing scripts, social participation during rehearsals and performances, and attention to future performances (delayed gratification). Exploration of other occupation-based interventions that incorporate these factors may be beneficial. Future Work THEATRE AND ADDICTIONS 20 Future studies of theatre interventions should aim to include a larger sample size. Researchers in this study attempted to recruit from numerous facilities with hundreds of potential participants, yet this remained a challenge. Therefore, one suggestion is performing this intervention with an inpatient population. Fenech (2009) was able to recruit and retain thirty-one inpatient residents with various neurological disabilities for a drama program with positive outcomes. However, performing theatre with an inpatient population may allow researchers to recruit and retain more participants, it would likely produce different results. For instance, the GSE and OCAIRS scores may be higher in the inpatient population because individuals days are structured for them, they are surrounded by other people in recovery, and there are often rules about maintaining abstinence to remain in the facility. They have less access to drugs and more immediate access to support, and have potentially fewer environmental stressors. By contrast the outpatient population may have less access to direct, continuous support, and greater access to their drug of choice. They may also be in an environment supporting addictive behaviors due to friends, drug dealers, and other triggers (MacDonald et al., 2011; Vallejo, 2011). Therefore, using an inpatient population may increase sample size, it would not provide information about the effectiveness of theatre for people living within the community during the recovery process. However, it may be worth exploring whether the theatre intervention used in this study, adapted for an inpatient population, produces positive outcomes once participants resume community living. Limitations A major limitation to this study is the small sample size due to limited recruitment of participants, as well as participant dropout. Some studies indicate people with addictions identify as being in a process of self-change (p. 81), and are therefore more difficult to recruit THEATRE AND ADDICTIONS 21 for research-related interventions, and, if recruited, are more likely to drop out (GarciaRodriquez, et al., 2009). Illustrating this point, in the current study, researchers attempted to recruit hundreds of individuals from multiple different treatment centers and open 12-step meetings, yet only retained 15. Five participants were lost due to dropout by the end of this study. In addition to being in a process of self-change, dropout rates are particularly high for this population due to several reasons including sociodemographic variables, withdrawal symptoms, anxiety sensitivity at treatment entry, addiction severity, cognitive performance, personality variables, and variables related to treatment programs and client perception (Lpez Goi, Fernndez Montalvo, & Arteaga, 2012). In this study, recruiting from multiple sites including treatment centers and open 12-step meetings was an attempt to address this problem. Considering the finding that greater variance existed in self-efficacy among dropouts, researchers may consider having a minimum GSE cutoff score to participate - this may reduce incidences of dropouts but will not address the difficulty of recruiting more participants. This latter difficulty may be also be due to the nature of the intervention in this study, which requires a significant time commitment and being on stage; public performance is reported to be the most common social fear among the general population (Jackson, Compton, Thornton & Dimmock, 2017). Another limitation of this study is the use of a convenience sample from within a limited geographical area, which may not accurately represent the more general SUD population. A third limitation is that all participants were not receiving the same TAU. Participants were recruited from multiple facilities and programs, hence some participated in outpatient treatment and 12-step programs, and some were involved in just one or the other. Others discontinued their involvement in any treatment. This variability may have impacted both groups because intervention and comparison groups were both also receiving TAU at the time of recruitment. THEATRE AND ADDICTIONS 22 Furthermore, although all participants expressed interest in participating in a theatre intervention, some were placed in the comparison group due to scheduling conflicts. This may have limited continued motivation to participate in the study. Conclusion Theatre-based intervention in addition to TAU resulted in a statistically significant, positive change from baseline to 6-month follow-up in the areas of GSE as well as the constructs measured by the OCAIRS, which include values, roles, personal causation, interests, habits, and environment. This change over time did not occur in the comparison group. Theatre includes elements of cognitive challenge, self-efficacy, delayed gratification, and social participation. 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... A Predictive Study of Fall Risk in Cardiac Phase II Rehabilitation Patients Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Marcia K. Himes, PT, DPT Copyright September 7, 2017 By: Marcia K. Himes, PT, DPT All rights reserved Accepted by: Barbara S. Robinson, PT, DPT, Committee Member Todd E. Daniel, PhD, Committee Member Elizabeth S. Moore, PhD, Committee Chair Laura Santurri, PhD, MPH, CPH Director, Postprofessional Programs Stephanie Kelly, PT, PhD, Dean, College of Health Sciences University of Indianapolis PREDICTIVE STUDY OF FALL RISK ii Acknowledgements After two very intense years, today is the day: writing this note of thanks is the finishing touch on my doctoral project. I am not only grateful for this awesome learning opportunity, but for the personal and professional growth that I have experienced. This process has pushed me to my limits and prepared me to pursue the career of my dreams. I would like to take this opportunity to thank the people who have supported and helped me so much throughout this journey. First, I would like to thank my husband Joe and my kids. Words could never express how much your unconditional love and support mean to me. You have been my rock and have helped me stay the course. To my mom and Max, you have always encouraged me to pursue my dreams and never give up. I love you all dearly and thank God for blessing me more than I deserve. Next, I would like to thank my committee members Dr. Elizabeth Moore, Dr. Susan Robinson, and Dr. Todd Daniel. Your collective expertise and wisdom have guided me in the right direction, allowing me to successfully navigate and complete my doctoral project. To all of my colleagues at Missouri State University Jeanne, Patty, Beth, Jason, Jim, Sean, and Scott, thank you for your encouragement, wise counsel, and sympathetic ear. To my phenomenal professors at UIndy Dr. Julie Gahimer, Dr. Jennifer Fogo, Dr. Stephanie Combs-Miller, Dr. Lisa Borrero, and Dr. Laura Santurri, I am grateful for your mentorship and wouldnt be where I am today without you. Finally, where would I be without my friends? To Becky and Elizabeth, thank you for the numerous hours we have spent chatting, texting, emailing, and collaborating. Your hard work and dedication is inspiring and I appreciate all that I have learned from you. I wish you both the best of luck! With Deepest Gratitude, Marcia K. Himes September 7, 2017 PREDICTIVE STUDY OF FALL RISK Table of Contents Acknowledgements ii Table of Contents iii List of Tables iv Abstract v Chapter 1: Introduction 1 Purpose 2 Chapter 2: Literature Review 2 History 2 Reduced Lower Extremity Strength and Fall Risk 4 Reduced Lower Extremity Blood Flow and Fall Risk 6 Fall Risk in the Cardiac Rehabilitation Population 8 Significance of the study 10 Chapter 3: Method 11 Study Design 11 Participants and Recruitment 11 Data Collection 12 Data Analysis 17 Chapter 4: Results 18 Chapter 5: Discussion and Conclusion 20, 21 References 26 Appendices 35 iii PREDICTIVE STUDY OF FALL RISK iv List of Tables Table 1 Descriptive Statistics for Demographic Data 32 Table 2 Descriptive Statistics for Study Variables 33 Table 3 Multiple Regression Results for ABI, CST, and FGA 34 PREDICTIVE STUDY OF FALL RISK v Abstract Fall prevention, and the subsequent reduction of fall-related injuries, is critically important for preserving independence among older adults. Cardiac phase II rehabilitation (CR) is a comprehensive medically supervised program allowing individuals with certain cardiac diagnoses or cardiac procedures to exercise in a safe environment. The relationship among lower extremity strength, lower extremity blood flow, and fall risk in community-dwelling older adults has been established; however, that relationship in the CR population remains unknown. This cross-sectional study used exploratory analysis to determine if the 30 second chair stand test (CST) and the ankle brachial index (ABI) could predict the score on the Functional Gait Assessment (FGA). A convenience sample (N = 57) of individuals aged 50 years and older, enrolled in a CR program, were selected. Data were collected during a single testing session. No correlation was found between the ABI and FGA score (r = .02, p = .438). A significant positive correlation was found between the CST and FGA score (r = .71, p < .001). Moreover, the CST significantly predicted the overall FGA score, accounting for 45% of the variance, F(2,54) = 23.97, p < .001, R2 = .47. Coefficient analyses revealed that the ABI was unrelated to FGA scores (b = -0.05, p = .608) and could be ignored; however, the CST was a significant predictor of FGA scores (b = 0.69, p <.001) and could be used by CR healthcare professionals as a fallrisk screening measure. Keywords: fall risk, cardiac phase II rehabilitation, 30 second chair stand test, ankle brachial index, Functional Gait Assessment, predictive ability PREDICTIVE STUDY OF FALL RISK 1 A Predictive Study of Fall Risk in Cardiac Phase II Rehabilitation Patients Fall prevention, and the subsequent reduction in fall-related injuries, is critically important for preserving health and independence among older adults. Falling, or fear of falling, can predispose an individual to falls, which may result in self-limited activity, disability, or even death (Toebes, Hoozemans, Furrer, Dekker, & van Dien, 2015). Falls are the leading cause of injury-related deaths and are the most common cause of nonfatal injuries and hospital admissions for trauma among adults aged 65 years or older (Burns, Stevens, & Lee, 2016; Carroll, Slattum, & Cox, 2005; Centers for Disease Control and Prevention [CDC], 2016). Falls have great financial impact on the individual and society. Medical costs incurred due to injuries sustained from a fall increase rapidly with age (Stevens, Corso, Finkelstein, & Miller, 2006; Ward et al., 2015). In 2000, health care systems in the United States (U.S.) spent $19 billion for care attributed to falls among older adults. By 2012, that figure increased to $30 billion, and in 2015 direct medical costs submitted to Medicare associated with falls totaled over $31 billion (Burns, Stevens, & Lee, 2016). Falls typically result from a complex and interdependent mix of medical and physical factors. For example, Aoyama, Suzuki, and Kuzuya (2015) found that reduced lower extremity strength predicted falls in community-dwelling older females. Cho, Bok, Kim, and Hwang (2012) described how decreased lower extremity strength was associated with increased fall risk in the elderly and McDermott et al. (2002) indicated lower extremity blood flow measurements were highly correlated with lower extremity function. Additionally, Davies and Kenny (1996) reported that cardiovascular issues accounted for a large percentage of patients who were seen emergently for unexplained or recurrent falls. PREDICTIVE STUDY OF FALL RISK 2 Cardiac phase II rehabilitation is a comprehensive medically supervised program allowing individuals with a diagnosis of myocardial infarction, stable angina, heart failure, valvular heart disease, or individuals post-surgical procedures such as coronary artery bypass grafting and cardiac transplantation to be monitored and to exercise in a safe environment (Price, Gordon, Bird, & Benson, 2016). Due to physiological changes and cardiac issues superimposed on the typical aging process, cardiac phase II rehabilitation patients may be at increased fall risk compared to community-dwelling older adults. The relationship among lower extremity strength, lower extremity blood flow, and fall risk in community-dwelling older adults has been established; however, that relationship in the cardiac phase II rehabilitation population remains unknown. The purpose of this study was to determine if lower extremity strength and lower extremity blood flow were predictors of fall risk among cardiac phase II rehabilitation patients. To address the study purpose, the following hypotheses were tested: 1) Hypothesis 1: there will be a statistically significant positive relationship between ankle brachial index (ABI) values and the functional gait assessment (FGA) scores, 2) Hypothesis 2: there will be a statistically significant positive relationship between 30 second chair stand test (CST) scores and the FGA scores, and 3) Hypothesis 3: the ABI and the CST will statistically significantly predict the FGA score among participants. Results of this study provide insight into characteristics which may lead to increased fall risk. Information from this study may be used to identify patients who are at increased fall risk, facilitate intervention to reduce fall risk, while improving the quality and length of life in the cardiac phase II rehabilitation population. Literature Review Prediction of fall risk is important in facilitating patient education, fall prevention, and interventions to reduce fall-related injuries. Each year, 2.5 million older adults fall, resulting in PREDICTIVE STUDY OF FALL RISK 3 injuries that must be treated in an emergency room. One-fifth of those falls result in serious injuries such as fractures or traumatic brain injuries, and over 700,000 adults are hospitalized each year due to fall-related injuries (CDC, 2016b). Additionally, only around 50% of those who are hospitalized after a fall will live longer than one year (Rubenstein, 2006). Falls have great financial implications on the individual and society. In the year 2000, expenditures reached $198 million for medical treatment for fall related injuries in the U.S. (Stevens, Corso, Finkelstein, & Miller, 2006). By 2010, the total lifetime cost related to fatalities, hospitalizations, or treatment in an emergency department for unintentional injuries due to falls exceeded $111 billion (Verma et al., 2016). In 2015, direct medical costs for fatal and nonfatal fall related injuries surpassed $31.9 billion. The incidence of falls and subsequent fall-related injuries in older adults is trending upward each year and costs associated with medical treatment related to falls are a substantial financial burden on the U.S. economy (Burns, Stevens, & Lee, 2016). The National Institute on Aging (2016) reported that several medical and physical risk factors may lead to increased fall risk: muscle weakness, especially in the legs; poor balance; postural hypotension; medications; and sensory deficits. Shubert, Schrodt, Mercer, BusbyWhitehead, and Giuliani (2006) indicated that early detection of mobility and balance impairments is critical for maintaining independence in older adults. Increased fall risk in older adults can be multifactorial in origin and may be caused from a combination of intrinsic or extrinsic factors, predisposing an individual to falls (Berry & Miller, 2008; Dionyssiotis, 2012). According to Lee, Lee, and Khang (2013), the strongest independent fall risk factors for older adults include previous falls, weakness, gait or balance impairments, and psychoactive PREDICTIVE STUDY OF FALL RISK 4 medications. In addition, frailty has been linked to increased fall risk in this population (deVries, Peeters, Lips, & Deeg, 2013). Tinetti, Speechley, and Ginter (1988) indicated that a positive correlation exists between the number of risk factors and fall risk. As the number of risk factors increase, there is a subsequent increase in fall risk (Tinetti et al., 1988). Older adults who have cardiac conditions often possess multiple intrinsic and extrinsic risk factors related to increased fall risk, which may render this population more susceptible to falls than their healthy counterparts (Afilalo, Karunananthan, Eisenberg, Alexander, & Bergman, 2009; Goel et al., 2010). Therefore, it is critical that we investigate how falls are related to health factors in people with cardiac conditions throughout the stages of care in order to enhance services. Reduced Lower Extremity Strength and Fall Risk Sarcopenia, or age-associated loss of muscle tissue, is responsible for the loss of skeletal muscle fiber mass and can result in profound muscle weakness (Roubenoff & Hughes, 2000). Doherty (2003) indicated that individuals whose age is in the 70s and 80s demonstrated a 2040% reduction in maximum voluntary muscle contractile strength due to sarcopenia. The amount of reduction in skeletal muscle mass has been positively correlated with the degree of functional limitation, disability, and fall risk in older adults (Roubenoff & Hughes, 2000; Doherty, 2003). In addition to age related changes in skeletal muscle mass, strength impairments in specific groups of lower extremity muscles, such as ankle dorsiflexors and hip extensors have been associated with falls (Daubney & Culham, 1999). Moreland, Richardson, Goldsmith, and Clase (2004) conducted a systematic review and meta-analysis to determine if muscle weakness was a risk factor for falls, which muscles groups were potentially involved, and the magnitude of muscle weakness associated fall risk in older adults. Results of this study indicated that lower PREDICTIVE STUDY OF FALL RISK 5 extremity weakness is a clinically important and statistically significant risk factor for falls; however, the relative contribution of specific muscles or groups of muscles could not be determined (Moreland et al., 2004). More recently, Ding and Yang (2015) investigated the contribution of specific muscles groups for balance recovery after a slip (near fall) in older adults. Weakness in the knee flexor and extensor muscle groups was found to be linked to sliprelated falls during gait. Furthermore, muscle weakness was determined to be a limiting factor for balance recovery in older adults. For example, a one-unit reduction in knee extensor strength more than tripled the odds of a slip-related fall (Ding & Yang, 2016). Additionally, Pijnappels, van der Burg, Reeves, and van Dien (2008) described how leg extension strength is important during the recovery process following a loss of balance episode to restore balance and stability. Reduction in the ability to perform activities of daily living and a decline in functional mobility have been associated with decreased muscle strength and can be a predictor of fall risk (Pijnappels et al., 2008). For example, Berry and Miller (2008) and Ward et al. (2015) reported the inability to rise from a chair without the use of arms and reduced lower extremity strength increases fall risk. Seo, Yates, Norman, Pozehl, and Kupzk (2014) supported this finding and described that lack of lower extremity strength affected an individuals ability to perform activities such as transitioning from sitting to standing, walking, or stair climbing, any of which can significantly impact quality of life. McDermott, Fried, Simonsick, Ling, and Guralnik (2000) reported that patients with peripheral arterial disease (PAD) exhibited walking difficulty and a reduction in lower extremity strength. Papa, Garg, and Dibble (2015) described how reduced lower extremity strength was linked to a degradation of postural control, which increased fall risk. Finally, Guralnik, Ferrucci, Simonsick, Salive, and Wallace (1995) further indicated that PREDICTIVE STUDY OF FALL RISK 6 decreased lower extremity strength may result in the inability to perform daily activities and predicts future disability. Reduced Lower Extremity Blood Flow and Fall Risk Overall reduction in blood flow and vascular conductance is a typical phenomenon of the healthy aging process (Dinenno, Jones, Seals, & Tanaka, 1999). Skeletal muscle accounts for the vast majority of total tissue in the lower extremity and places a great demand on the cardiovascular system due to oxygenation and blood flow requirements (Dinenno et al., 1999). With the addition of cardiovascular disease risk factors, such as metabolic syndrome, reduction of peripheral blood flow may be further compromised due to increased sympathetic nervous system activity. Sympathetic nervous system activation leads to vasoconstriction of the vasculature in the lower limbs, resulting in the inability of the cardiovascular system to augment blood flow to the lower extremities and may lead to limitations in functional mobility (Dinenno et al., 1999). Whole body thallium-201 scintigraphy has been used to evaluate blood flow distribution during exercise in older adults with cardiac dysfunction. Using this technique, maldistribution of blood flow to the lower extremities was found during exercise and could be a contributing factor of exercise intolerance (Wada et al.,1997). Secher and Volianitis (2006) supported this finding and indicated that blood flow distribution to the lower extremities may be limited if cardiac output is compromised, which may be the case in patients with cardiac dysfunction. A reduction in cardiac output may lead to increased peripheral resistance and a reduction in lower extremity blood flow by increasing sympathetic nervous system activity (Secher & Volianitis, 2006). Heart failure has also been implicated in the reduction of lower extremity blood flow in older adults. Lindsay et al. (1996) found that individuals with heart failure demonstrated a PREDICTIVE STUDY OF FALL RISK 7 reduction in blood flow in the lower extremities compared to their healthy counterparts. Moreover, the severity of heart failure dictated the amount of absolute blood flow in the lower extremities. This reduction in lower extremity blood flow is due to impairment in endothelium function and vasodilator response (Lindsay et al., 1996). Additionally, Shiotani et al. (2002) indicated that blood flow in the legs was markedly reduced during upright exercise in older adults who have heart failure. This result was attributed to a reduction in venous pressure caused by an ineffective muscle pump and attenuation of the lower extremity vasodilating response during exercise. Blunted blood flow in older adults with heart failure may lead to a vicious cycle where reduction in blood flow may lead to compensatory activation of the sympathetic nervous system and further exacerbation of the problem (Shiotani et al., 2002). Peripheral arterial disease is a common diagnosis encountered in older adults who have cardiovascular disease. It causes degeneration and destruction of the arteries, leading to a reduction in oxygenated blood flow to the lower extremities. Weiss, Casale, Koutakis, Nella and Swanson (2013) reported that PAD resulted in oxidative damage and a reduction in the myofiber cross-sectional area of the gastrocnemius by 29.3%. Furthermore, McDermott et al. (2002) indicated that the reduced blood flow caused by PAD is linked to shorter walking distance, slower walking velocity, lower levels of physical activity, and impaired standing balance. Ultimately, decreased functional performance, such as the inability to rise from a chair, has been linked to increased fall risk in older adults (Ward et al., 2015), impacting quality of life in older adults (Lefebvre et al., 2013). Reduced lower extremity blood flow has not been directly linked to fall risk; however, McDermott et al. (2002) indicated that reduced lower extremity blood flow is related to impairments in standing balance and a lower level of physical activity. According to Papa et al. PREDICTIVE STUDY OF FALL RISK 8 (2015), impairments in standing balance, postural control, and muscle fatigue may increase fall risk; therefore, it is reasonable to hypothesize that reduced lower extremity blood flow may lead to increased fall risk. Many individuals enrolled in the cardiac phase II rehabilitation program are diagnosed with conditions such as heart failure, PAD, and coronary artery disease, conditions which can lead to restricted blood flow to the lower extremities; this may make them more susceptible to falls. Fall Risk in the Cardiac Rehabilitation Population It has been established that increased fall risk in older adults can be attributed to risk factors such as decreased muscle strength or reduced blood flow in the lower extremities; however, Berg, Alessio, Mills, and Tong (1997) indicated that there is likely an underestimation of the role that cardiovascular abnormalities play in fall risk. Mozaffarian et al. (2014) reported that 85.6 billion adults have been diagnosed with some type of heart disease and 5.7 million of those individuals have heart failure. Moreover, symptoms linked to heart failure such as decreased exercise tolerance, shortness of breath, cognitive dysfunction, and postural hypotension have been associated with falls (Saczynski et al., 2013). A systematic review by Lee, Pressler, and Titler (2015) indicated that patients with heart failure had 1.86 times greater odds of falling, especially when on medications such as benzodiazepines and digoxin, when compared to the general population of older adults. In the cardiac rehabilitation setting, older adults are predisposed to several of the aforementioned risk factors due to their cardiac condition or multiple co-morbidities (Kreizman & Allen, 2005). Vascular disease of the myocardium and peripheral vasculature are often superimposed on age-related factors, resulting in a reduction of functional mobility and strength (Lakatta, 1993). Jansen et al. (2016) indicated that cardiovascular disorders such as heart failure, PREDICTIVE STUDY OF FALL RISK 9 low blood pressure, and arrhythmias are strongly correlated to fall risk and must be considered when evaluating fall risk. Kuys et al. (2013) described how older adults with heart failure may be more susceptible to falls as a result of musculoskeletal pain, polypharmacy, orthostatic hypotension, reduced sensation, and shortness of breath with household activities. Additionally, van der Velde, Stricker, Roelandt, Cate, and van der Cammen (2007) found that certain diagnoses such as pulmonary hypertension and heart valve regurgitation were indicative of increased fall risk. Heart valve regurgitation has been directly linked with a reduction in peak cardiac output, which can lead to the inability to meet circulatory demands. If circulatory demands are unmet, an individual can sustain a fall due to poor cerebral perfusion. Valvular issues were positively and strongly associated with fall risk. As the severity of valve regurgitation increased, the likelihood of an individual sustaining a fall increased (van der Velde et al., 2007). Individuals enrolled in a cardiac phase II rehabilitation program have had a recent cardiac-related surgery or some other type of cardiac event. After cardiac surgery, there is often a decline in functional mobility (Cahalin, LaPier, & Shaw, 2011). A coronary artery bypass graft (CABG) is a surgical procedure that is widely used for revascularization of the heart. Following a CABG procedure, individuals are restricted from performing certain types of movements to reduce complications from surgery and to promote healing of the chest cavity (Cahalin, LaPier, & Shaw, 2011). Additionally, these individuals may self-limit physical activity due to pain and are more likely to develop functional impairments such as the inability to rise from a chair, which may translate into a permanent functional disability (LaPier, 2014). Due to the direct effects of coronary heart disease related to cardiac performance and indirect effects, such as incisional infections or hemodynamic instability, this population may fear physical activity and PREDICTIVE STUDY OF FALL RISK 10 self-limit their daily activity (LaPier, 2014). Both of which have been shown to increase fall risk (Renfro, Maring, Bainbridge, & Blair, 2016). In summary, several cardiovascular associations with falls have been identified. Older adults admitted to a cardiac rehabilitation program may have multiple comorbidities and risk factors that could lead to increased fall risk. These findings highlight the need to determine tests and measures that would enable practitioners to assess fall risk in the cardiac rehabilitation population and in a cardiac rehabilitation setting. Significance of the study A thorough review of peer-reviewed, English journals has identified gaps in the literature regarding specific risk factors such as the ability of lower extremity strength or lower extremity blood flow to predict fall risk in the cardiac phase II rehabilitation population. Several studies support premises that reduced lower extremity strength may lead to increased fall risk in the older adult population and a reduction in lower extremity blood flow may be linked to postural instability. Specific studies regarding the ability of reduced lower extremity strength and lower extremity blood flow to predict fall risk in the cardiac phase II rehabilitation population have not been reported. Several investigators cite the need for future studies to determine the specific factors related to fall risk and the importance of reducing fall risk in the cardiac phase II rehabilitation population. For example, Puthoff and Saskowski (2013) described the need for implementation of physical performance assessments and fall risk screening in the cardiac population. Kuys et al. (2013) indicated that education regarding falls, modifiable risk factors, and strategies to improve balance were lacking in the cardiac rehabilitation population. Insight into the predictive ability of lower extremity strength and lower extremity blood flow to determine fall risk may expedite the use of appropriate interventions to prevent fall-related PREDICTIVE STUDY OF FALL RISK 11 injuries, reducing overall fall risk, thus improving the quality and length of life of cardiac phase II rehabilitation patients. Method Study Design This cross-sectional, exploratory study was conducted at the CoxHealth cardiac rehabilitation department in Springfield, Missouri from April 1, 2017 to July 13, 2017. The Institutional Review Board at the University of Indianapolis and Missouri State University and the legal department at CoxHealth approved the study prior to recruitment and enrollment of participants. Participants A convenience sample of cardiac phase II patients receiving rehabilitation services at CoxHealth was recruited and consecutively assigned to the study until the required sample size was achieved. The nurses in the cardiac phase II rehabilitation department recruited participants during the enrollment process into the cardiac phase II rehabilitation program (CRP) by providing each individual who was admitted to the CRP with a flyer explaining the research project, giving each individual an equal opportunity to participate. If a patient was interested in participating in the study, the cardiac nurse provided the primary investigator with contact information and the investigator made contact with the patient to set up an appointment. An a priori sample size estimation was conducted using G*Power, version 3.1 (Faul, Erdfelder, Lang, & Buchner, 2009). The calculation was based on using a linear multiple regression, fixed model, single regression coefficient test with two predictor variables and the following parameters: two-tailed test, alpha of .05, power of .80, and a moderate effect size of PREDICTIVE STUDY OF FALL RISK 12 eta = 0.15. The study required a minimum of 55 participants to detect a statistically significant effect, if one existed. Only patients who met the following inclusion criteria were eligible to be included in this study: (a) age 50 years or older, (b) no history of neurological disorders affecting the central nervous system including stroke, traumatic brain injury, or spinal cord injury, and (c) able to read and understand the English language. Patients were excluded from the study if they met any of the following exclusion criteria: (a) taking medication than could affect balance and reporting dizziness due to the medication, (b) cognitively unable to perform test procedures as determined by the individuals inability to complete a three-step command, (c) unable to stand independently for 20 minutes, or (d) an orthopedic injury, surgery, or a fracture within the last six months. Data Collection Data collection took place at CoxHealth cardiac rehabilitation department. Demographic and participant characteristic information (age, race, and gender) were collected from a chart review. All participants were screened for the following co-morbidities and potential confounding variables during the inclusion and exclusion criteria screening process: medications that might cause dizziness, orthopedic injuries, neurological issues, and impaired cognitive ability. Each participant was assigned a unique identification number that was recorded on all paperwork in order to de-identify the data. The following outcome data were collected: lower extremity blood flow as measured by the ankle brachial index (ABI), lower extremity strength as measured by the 30 second chair stand test (CST), and fall risk as measured by the Functional Gait Assessment (FGA). Data were recorded into a password protected Excel spreadsheet by the primary investigator (M.K.H). PREDICTIVE STUDY OF FALL RISK 13 Operationalization of variables. Fall risk was measured using the FGA. Lower extremity strength was measured by counting the number of sit-to-stand repetitions completed in 30 seconds during the chair stand test, and lower extremity blood flow was examined by comparing the systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery using the ABI. Instrumentation Ankle brachial index. The ABI is a non-invasive screening tool used to identify PAD or a lack of blood flow in the lower extremities by comparing systolic pressures in the lower leg to systolic pressures in the upper arm (Wound Ostomy and Continence Nurses Society, 2012). In a clinical setting, the ABI is used to determine perfusion status of the lower extremities. A ratio of 1.0 is considered normal, less than 0.9 indicates lower extremity arterial disease, and a ratio of greater than 1.3 is prognostic of elevated perfusion or incompressible vessels (Wound Ostomy and Continence Nurses Society, 2012). The ABI demonstrates good inter-rater reliability (ICC .423) (Holland-Letz et al., 2007), has high specificity (83.3% - 99.0%), and good accuracy (72.1% - 89.2%) when used to diagnose peripheral arterial disease (Xu et al., 2010). 30 second chair stand test. The CST is an assessment of lower extremity strength and endurance (CDC, 2016). The participant is assessed on the number of sit to stand repetitions completed in a 30 second time frame. The CST has excellent test-retest reliability (.84 < R < .92) and criterion validity (r = .77, 95% CI [0.64, 0.85]) in community dwelling older individuals (Jones, Rikli, & Beam, 1999). Functional Gait Assessment. The FGA is a tool that is used to assess an individuals ability to maintain balance during 10 different gait tasks (Wrisley, Marchetti, Kuharsky, & Whitney, 2004). The maximum score for the FGA is 30 points and a score of less than or equal PREDICTIVE STUDY OF FALL RISK 14 to 22 indicates a significant fall risk in community-dwelling older adults (Wrisley & Kumar, 2010). The FGA demonstrated excellent interrater reliability (ICC = .93, p < .001) (Walker et al., 2007) and criterion validity when compared to the Berg Balance Scale in community dwelling older adults (r = .84, p < .001) (Wrisley & Kumar, 2010). Due to subjectivity when scoring the FGA, reliability of the investigators ability to score the FGA was assessed prior to data collection. The investigator watched video administration and scored a FGA on five individuals. Additionally, the investigator rescored the videos weekly for three weeks. Reliability testing was conducted prior to data collection with an average ICC value of .998 (95% CI [.99, 1.00], p < .001). Procedures The primary investigator met with each patient who expressed interest in participating in the study to determine eligibility. During the interview, the investigator had the individual follow a three-step command to determine whether the individual had the cognitive capacity to complete the testing sequence for the research study. The patient was asked to (a) say Hello, (b) tap the arm of a chair three times, and (c) say Im ready. If the individual successfully completed the screening procedure, the remainders of the inclusion and exclusion criteria were reviewed to determine if the patient was eligible to participate in the research study. If the patient met the eligibility requirements, the investigator explained the purpose of the research study, as well as the risks and benefits of participating in the research study. The researcher then explained the HIPAA requirements, including how data would be utilized and secured. Potential participants were encouraged to ask questions, and the primary investigator reviewed any unclear information and answered all questions. At that point, all patients who wished to participate in the research study were asked to complete the informed consent form. PREDICTIVE STUDY OF FALL RISK 15 Before the testing procedure began, the primary investigator collected demographic information and entered it into an Excel spreadsheet. The same investigator administered all tests to each participant. Identical instructions on how to complete each test were given to each participant. Tests were administered in the following order for all participants: ABI, CST, fiveminute rest break, and then FGA. Randomization of the tests was considered to reduce test order bias; however, it was determined that due to the physical requirements of the CST and FGA and potential fatigue effect of the CST, the order should remain consistent. The five-minute rest break was given to each participant between the CST and FGA to avoid potential interference with scores on the FGA if the patient was fatigued after the CST. Participants wore a gait belt during the CST and FGA, which enabled the investigator to assist if balance was compromised, reducing fall risk. No participants fell or required use of the gait belt during the study. Data were recorded after each test into an Excel spreadsheet. The ABI test was administered after the participant had rested in a supine position for 10 minutes. The investigator calculated the ABI by taking the systolic blood pressure of the posterior tibialis artery in the ankle on both legs and the brachial artery in both arms using a sphygmomanometer and a Huntleigh M2 Doppler ultrasound (Doppler) (Huntleigh Diagnostics, 2016). Initially, the sphygmomanometer was placed around the ankle and the Doppler signal of the posterior tibialis artery was located. The sphygmomanometer was inflated until the Doppler signal disappeared. Once the Doppler signal disappeared, the sphygmomanometer was inflated an additional 20 mmHg and then slowly deflated until the Doppler signal reappeared. The value on the sphygmomanometer at which the Doppler signal reappeared was recorded for the ankle. The process was repeated on the other leg and then both arms using the brachial artery. The highest value obtained for the ankle and the highest value for the arm were obtained, the highest PREDICTIVE STUDY OF FALL RISK 16 value obtained in the ankle was divided by the highest value in the arm (Wound Ostomy and Continence Nurses Society, 2012). The CST was administered using a straight back chair with no arms and a seat height of 17 inches. The investigator read a script providing the participant with instructions on how to complete the testing procedure. Prior to beginning the test, the participant was instructed to cross their arms, placing them across their chest. When the investigator was ready to initiate the test, the investigator said go. The participant then assumed a full standing position and then sat back down, repeating the procedure as quickly as possible for 30 seconds. When 30 seconds had elapsed, the investigator instructed the participant to stop and recorded the number of sit to stand repetitions completed by the participant. If the individual was over halfway to a standing position when the investigator said stop the repetition was counted (CDC, 2016a). Finally, the FGA was administered and the participant was required to complete 10 activities while walking. The investigator read the standardized instructions for the activity prior to initiation of each activity. After each activity was completed, a score ranging from 0-3 was assigned by the investigator for the activity. After all 10 activities were completed, the investigator totaled the individual scores and assigned an overall score. The maximum score that could be assigned for the FGA was 30. After completion of the third station, the primary investigator reviewed the results of the tests and answered any questions. Total time to complete the study was approximately 45 minutes. To ensure participant privacy, all data were secured in a locked filing cabinet at Missouri State University in the Department of Physical Therapy. Data Screening and Analysis PREDICTIVE STUDY OF FALL RISK 17 The raw data for each participant were entered into a password protected Excel spreadsheet. Data analyses were conducted using IBM SPSS for Windows, Version 24 (IBM Corp., Armonk, NY). Data screening was used to identify accuracy, missing data, outliers, linearity, and heteroscedacity. No violations of the data assumptions were found. Descriptive statistics were calculated; nominal data were reported as frequencies and percentages, and continuous data were reported as means and standard deviations (Table 1). Normality of the data was assessed using the Shapiro-Wilk test. Bivariate comparisons were conducted on patient demographic variables to look for differences between those at risk for falls. Continuous variable comparisons were conducted using an independent ttest. No significant differences were found. Nominal data were compared using a Fishers exact test, and correlations were performed using a Pearson product-moment coefficient of correlation. If a correlation was found to be statistically significant, correlation strength was interpreted using Munros descriptive terms: r = .00 -.25: Little, if any correlation; r = .26 - .49: Low correlation; r = .50 - .69: Moderate correlation; r = .70 - .89: High correlation; and r = .90 - 1.00: Very high correlation (Keller & Kelvin, 2013). A multiple linear regression was used to test the research hypothesis and assess the predictive relationship between the variables to determine if lower extremity strength and lower extremity blood flow could predict the score on the functional gait assessment, indicating the presence or absence of fall risk. Variables were introduced into the regression model simultaneously using the Enter method. All tests were two-tailed, and an alpha level of .05 was considered statistically significant. Results A total of 60 participants were enrolled in the study. When verifying the data input into the excel spreadsheet, an error was found in an age calculation and one participant did not meet PREDICTIVE STUDY OF FALL RISK 18 the minimum age requirement. Two participants were unable to complete the testing procedures. Scores from these three participants were excluded from the data analyses (n = 57). An exploratory data analysis using a Shapiro-Wilk test revealed that neither the ABI nor the FGA variables significantly deviated from normality beyond p < .05; however, the CST was not normally distributed. Residuals met the assumption of independence (Durbin-Watson = 2.15) and no autocorrelation was found. Linearity and homoscedasticity were assessed visually using a plot of standardized residuals against the predicted values. Collinearity statistics indicated that multicollinearity was not an issue (ABI, Tolerance = .99; CST, Tolerance = .99) and met the assumption of collinearity with a VIF < 10 and Tolerance > .01 (Field, 2013). Participant Characteristics The final sample of 57 cardiac phase II rehabilitation patients were predominantly male (73.7%) and White (92.9%), with a mean age of 68.58 years old. Of the 57 participants, 61.4% were at risk for falls. Details regarding demographics of the sample are contained in Table 1. Descriptive Statistics Descriptive statistics for age, ABI, CST, and the FGA are contained in Table 2. Results for Correlational Analyses The relationship among the ABI, CST and FGA. Hypothesis 1 stated that the ABI would relate significantly positively with the FGA among participants. A Pearson productmoment correlation coefficient was used to test Hypothesis 1. As shown in Table 3, the ABI was very weakly and positively correlated with the FGA, r = .02, p = .438, and was not statistically significant. Therefore, hypothesis 1 was not supported. The r2 value of .0004 means that only .04% of the variance in the FGA was explained by the ABI. PREDICTIVE STUDY OF FALL RISK 19 Hypothesis 2 stated that the CST would relate significantly positively with the FGA. Hypothesis 2 was tested using a Spearmans rho correlation due to the non-normal distribution of the CST. The CST was statistically significantly moderately positively correlated, with the FGA, r = .71, p < .001. Hypothesis 2 was supported. The r2 value of .46 means that 46% of the variance in the FGA was explained by CST indicating a small to medium effect size (Cohen, 1988). Procedure and Results for Multiple Regression Test Procedure for multiple regression. A multiple regression analysis was used to test hypotheses 3 relating to the relationship between the ABI, CST, and FGA. The two predictors (ABI and CST) were regressed to the dependent variable (FGA) in a forced entry regression analysis. The prediction of the FGA from the ABI and CST. Hypothesis 3 stated that the ABI and the CST would statistically significantly predict the FGA score among participants. In the final model, the CST significantly predicted the overall FGA score and accounted for just over 45% of variance, F(2,54) = 23.97, p < .001, R2 = .47. Analyses of the coefficients revealed that the ABI was largely unrelated to FGA scores (b = -0.05, p = .608); however, the CST was a significant predictor of the score on the FGA (b = 0.69, p < .001). Overall, Hypothesis 3 was supported. Regression coefficients and standard errors can be found in Table 3. Binomial Logistic Regression A binomial logistic regression was performed to ascertain the effects of the CST on the likelihood that participants were at risk for falls, as determined by an FGA score of less than or equal to 22. The model was statistically significant, X2(1) = 25.90, p < .001. The model explained 49.6% (Nagelkerke R2) of the variance in FGA scores and correctly classified 80.7% PREDICTIVE STUDY OF FALL RISK 20 of the cases. Sensitivity was 77.3%, specificity was 82.9%, positive predictive value was 73.9%, and negative predictive value was 85.3%. Higher scores on the CST were associated with better scores on the FGA, indicating reduced fall risk. Discussion The purpose of this study was to investigate whether the ABI or CST could predict the score on the FGA. As expected, the CST did predict a significant portion of the score on the FGA; however, the ABI was a poor predictor. The results of this study both support and expand previous research. Consistent with the literature, no correlation was found between the ABI and fall risk as measured by the FGA (r = .02, p = .438). Moreover, the standardized beta value for the ABI (b = -.05, p = -.516) indicated that the ABI did not significantly contribute to the model and should be removed. In a previous study, Gardner and Montgomery (2001) described that the ABI was not significantly correlated with balance and falls in individuals with intermittent claudication (p > .05). In this study, although the ABI was not significantly correlated with scores on the FGA, a definite trend was observed. When examining individual participant scores, as the ratio approached 1.20 or was less than 0.90 the scores on the FGA tended to be lower and most were indicative of fall risk. In a cardiac rehabilitation setting, if a healthcare practitioner performs an ABI and the results are less than 0.90 or approaching 1.20, further testing may be warranted to rule out fall risk in this population. The CST was found to be significantly and positively correlated with the FGA. More importantly, the CST was found to be a positive predictor of the FGA (b = .69, p <.001, accounting for 45.1% of the variability in the FGA (R2 = .47, p < .001), and was a significant contributor to the explanatory power of the model. For every one unit of change in the CST, PREDICTIVE STUDY OF FALL RISK 21 there was a .68 unit change in the FGA score. Ward et al. (2015) reported a similar finding using the 5-repetition chair stand test (5CST). A time of greater than 16.7 seconds on the 5CST was an independent predictor of injurious falls in the older adult population. Moreover, times of greater than 16.7 seconds on the 5CST were associated with increased fall risk. A logistic regression was conducted to determine how the study results could be applied clinically. The CST was highly sensitive and specific, indicating that the score from the CST could identify individuals who were at risk for falls 77.3% of the time and identify those individuals who were not at risk for falls 82.9% of the time. Additionally, the CST demonstrated a moderately high positive predictive value, which would allow cardiac rehabilitation clinicians to predict fall risk using the CST with 73.9% accuracy. Reider and Gaul (2015) reported a similar finding using the 5 repetition sit to stand test (5RSTS) in community-dwelling older adults. In this study, the 5RSTS test was an effective screening tool that could identify older adults who were at high risk for falls (Reider & Gaul, 2015). Study Limitations Limitations of this study include that participants in this study were a nonrandom sample of convenience from a single outpatient cardiac rehabilitation program. This may limit the ability to generalize findings to other patient populations. Studies have shown that co-morbidities can increase fall risk in the older adult population. A quick screen was conducted to determine if the patient met the inclusion and exclusion criteria for the study (i.e., had chronic medical conditions that may impact test results); however, data on specific co-morbidities were not collected. The outcome assessments used did not have established validity in this patient population. Finally, the mean ABI score was 0.98 (essentially normal) with only 12% having a score of less than 0.90 PREDICTIVE STUDY OF FALL RISK 22 or greater than 1.20. The lack of ABI scores outside these ranges may have affected the ABI study results. Conclusion Results of this study indicate that the ABI was not an effective predictor of fall risk; therefore, the ABI scores can be ignored. The CST predicted a significant portion of the FGA score and may be substituted for the FGA as a fall-risk screening measure in the cardiac rehabilitation population. 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Vascular Medicine, 15(5), 361-369. PREDICTIVE STUDY OF FALL RISK 32 Table 1 Descriptive Statistics for Demographic Data (N = 57) M SD Minimum Maximum 68.58 9.10 51.00 86.00 N Percent Male 40 70.1 Female 17 29.9 White/Caucasian 53 92.9 Latino/Hispanic 4 7.1 Age (years) Gender Race PREDICTIVE STUDY OF FALL RISK 33 Table 2 Descriptive Statistics for Study Variables (N = 57) Variable M SD ABI Age (years) 68.58 9.10 ABI 0.98 0.09 CST 11.35 4.20 .105 FGA 20.21 6.18 .021 CST .68** Note: ABI = ankle brachial index; CST = chair stand test; FGA = functional gait assessment; **p < .01, two-tailed. PREDICTIVE STUDY OF FALL RISK 34 Table 3 Multiple Regression Results for ABI, CST, and FGA (N = 57) Variable B SE t p 95% CI ABI -3.39 6.56 -0.52 .608 [-16.54, 9.76] CST 1.02 0.15 6.92 < .001 [0.72, 1.31] Model 1 Note: ABI = ankle brachial index; CST = chair stand test; FGA = functional gait assessment; CI = confidence interval. PREDICTIVE STUDY OF FALL RISK 35 Appendix A PREDICTIVE STUDY OF FALL RISK 36 Appendix B Can lower extremity strength and lower extremity blood flow predict the score on the Functional Gait Assessment in cardiac rehabilitation phase II patients Certification of Informed Consent I hereby agree to participate as a volunteer in a research project to determine if lower extremity strength and lower extremity blood flow can predict the score on the Functional Gait Assessment in cardiac rehabilitation phase II patients. Lower extremity strength will be measured by the 30 Second Chair Stand Test. Lower extremity blood flow will be measured using the ankle brachial index. Functional balance will be measured using the Functional Gait Assessment. Description of Procedures: The ankle brachial index will be used to assess blood flow in your legs. The blood pressure in your arm will be compared to the blood pressure in your leg. You will also complete the Functional Gait Assessment (FGA) and the 30 Second Chair Stand Test (CST). The FGA will test how well you walk while doing different tasks such as walking while turning your head. The CST will test your leg strength. Completion of test procedures will take approximately 40 minutes. I understand that the Institutional Review Board has access to records that identify subjects by name, but other than this, confidentiality will be maintained except as required by law. Records will be kept in a locked filing cabinet housed in the Department of Physical Therapy at Missouri State University. Benefits of Participation 1) I may gain knowledge of my relative risk for falls and specific risk factors for falls. Knowledge of fall risk may help prevent future falls. Additionally, individuals participating in the project may be referred to a physician or physical therapy if they are at risk of falling. 2) Measuring my risk for falls prior to participation in the cardiac rehabilitation phase II program may help prevent falls that could occur during treatment Risks for Participation 3) The risks associated with this study are minimal and include the following: a) Participants may be at risk for falls during the assessment. In order to minimize that risk, I understand that I will be required to wear a gait belt to facilitate guarding by an investigator. b) My scores on the balance and strength assessments may indicate that I am at risk for falls. This may make me less confident in my ability to avoid falls in the future. An investigator will discuss these results with me and advise me of appropriate actions to take in order to minimize their risk for future falls. These actions may include referral to a physician for further examination. c) If my scores on the balance assessments indicate that I am not at risk for falls, I may feel more confident in my ability to avoid falls in the future. An investigator will discuss these results with me and advise me of appropriate actions to take in order to minimize PREDICTIVE STUDY OF FALL RISK 37 their risk for future falls. Low risk of falling does not guarantee I will not fall in the future. 4) I am free to refuse to participate in this research project or to withdraw my consent and discontinue participation in the project at any time without prejudice to me, or effect on my relationship with this institution. 5) I understand that the procedure will take approximately forty-five minutes to finish. 6) The primary investigators, Marcia K. Himes, DPT and Barbara S. Robinson, DPT, will answer any questions that I have concerning my participation in this research project. 7) Participation in this research project is voluntary, without being coerced or forced, and is without compensation. 8) If I suffer personal injury as a result of participation in this investigation, no compensation is or will be available for payment of my lost wages or other losses. I fully understand that Missouri State University assumes no liability for any damages. I certify that I have read and understand this document of informed consent and was given the opportunity to have questions answered by the investigators and consent to participate in this research project. Subject Name Date Signed Signature of Subject Signature of Witness I have discussed with this subject the procedures involved in this study, as well as the possible benefits and risks involved. I believe he/she understands the contents of this consent form, and is competent to give legally effective and informed consent. I hereby agree to conduct this investigation in accordance to the procedures set forth in the project description, to uphold the ethical guidelines set forth in the Code of Federal Regulations 45 CFR 46, and to report to the committee any outcomes or reactions to the balance assessment that were not anticipated in the risks description and might influence the committees decision to sustain approval of the project. Signature of Responsible Investigator A COPY OF THIS FORM HAS BEEN GIVEN TO ME. Date Signed (Subjects Initials)  ...

... Running head: A PILOT WELLNESS PROGRAM 1 A Pilot Wellness Program for Pageant Participants in the Miss Indiana Organization Kaytlyn Eberly Doctoral Occupational Therapy Student May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Beth Ann Walker, PhD, OTR A PILOT WELLNESS PROGRAM 2 A Capstone Project Entitled A Pilot Wellness Program for Pageant Participants in the Miss Indiana Organization Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kaytlyn Eberly Doctoral Occupational Therapy Student Approved by: Faculty Capstone Advisor Date . Doctoral Capstone Coordinator Date . Date . Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy A PILOT WELLNESS PROGRAM 3 Abstract Background: Participants of the local and Miss Indiana pageants, experience a surge in occupations which potentially imposes a threat to overall wellness. In order for these women to maintain their wellness during each phase of competition, they need a balance between mind body and spirit. These young women are key members and leaders in society through their platform advocacy and community service, and considered role models to many. In order to positively impact the wellness of the younger population, it is important to increase the overall wellness of these contestants. Purpose: The purpose of this project was to a) determine the need for wellness programming, b) design and implement a wellness program. Method: A needs assessment was conducted through distribution of online surveys to Miss Indiana board members, local pageant directors, and past participants. Results: Based on wellness program literature and the needs assessment, a three-hour wellness program, entitled balance2bewell, was created. Program interventions included wellness education, two activities and introduction and practice of several wellness techniques. Four programs launched around the state of Indiana produced a total of 12 wellness group participants. A pre-posttest design demonstrated increased wellness based on self-report after the program. Conclusion: It is recommended that MAO provide wellness education for participants at all levels of competition to ensure healthy role models and further demonstrate the mission to empower women. A PILOT WELLNESS PROGRAM 4 Acknowledgements I would like to express my appreciation for the support and guidance provided by the Miss Indiana Executive Director, Aren Straiger. She has shown her good character by meeting with me, answering all my questions, and working hard to help spread awareness of the wellness program to increase participation. I would also like to thank Dr. Beth Ann Walker for her time spent to help me with program development and writing this paper. I had the pleasure of working with wonderful people from four universities where programs were held including the University of Indianapolis, Indiana University of Kokomo, Manchester University, and Indiana State University. All of the balance2bewell participants, Miss Indiana board members, local directors, and past participants provided information crucial to this project, so I thank them for their time and dedication to the organization. None of this would have been possible without the love and support of my family and friends. Thank you to Danyele Clingan for constant calls and texts as well as spending time with me while on campus. Thank you to my parents, Scott and Darla Eberly for pushing me to step out of my comfort zone and helping me to believe in something bigger than myself. Finally thank God for giving me the most wonderful man I soon get to marry that has put up with long distance so I can work toward my dream, and that has never let me give up on myself. A PILOT WELLNESS PROGRAM 5 A Pilot Wellness Program for Those Participating in the Miss Indiana Scholarship Pageants at All Levels Introduction The Miss America Organization (MAO) hosts one of the most renowned scholarship pageant competitions in North America, as it has existed for nearly 100 years with over 10,000 contestants at all levels each year (Miss America, 2017). Pageants within MAO exist at local, state, and national levels for young women between the ages of 17 and 25, who are U.S citizens, portray the MAO character criteria, are in good health, and have the ability to meet the time and commitment requirements (Miss America, 2017). A participant must first be crowned a local title, followed by state level competition, in which the winner continues on to the national level, one participant from each of the 50 states as well as one from the District of Columbia (Miss America, 2017). The Miss America Organization aids young women in becoming strong, confident leaders of society, good role models, and leaders in community service. The organization crowns a young woman that holds potential for all these attributes and represents the four points of the crown: scholarship, success, style, and service (Angeli, 2017). The scholarship point indicates that the representative strives to earn scholarship for the purpose of furthering her education and achieving [her] personal and professional goals ("Fourpoints of the crown and four winning tips", 2013). Success represents the life experiences gained while representing the organization, and working on worldly issues through the promotion of her platform ("Fourpoints of the crown and four winning tips", 2013). Unique personal qualities of each woman are celebrated by MAO through the style point of the crown, as well as what personally looks and feels good to the individual ("Fourpoints of the crown and four winning tips", 2013). The final A PILOT WELLNESS PROGRAM 6 point of the crown represents service, demonstrated through a title winners dedication to her platform and additional community service opportunities ("Fourpoints of the crown and four winning tips", 2013). Many former Miss Americas describe how their lives have been changed by obtaining this new title and being associated with this organization in interviews such as ones with Cosmopolitan. Mallory Hagan expressed how being Miss America helped her gain the ability to speak about various topics to culturally diverse populations, including speaking with five year olds as well as the president (Coyne, 2016). A majority of the women interviewed for this article discussed the positive impact of being Miss America which helped them become strong and confident role models and leaders in society (Coyne, 2016). For example, Heather French Henry felt like she could make a difference by promoting her platform at a national level (Coyne, 2016). Another former Miss America, Nicole Johnson became a major advocate for her platform, Type 1 Diabetes awareness, and continued full time advocacy for eight additional years beyond her year of service (Coyne, 2016). Today, Johnson continues advocating for increased awareness of Type 1 Diabetes and was appointed the Board of the Diabetes Empowerment Foundation in 2016 (Johnson, 2016). Many of the women also discussed that the organization provides a family and support system for contestants and volunteers that far surpasses the pageant contest (Coyne, 2016). Hagan, for example, expressed that even though the perks of obtaining the title end, the friendships made last a lifetime (Coyne, 2016). Many past Miss Americas still speak out for their platforms and are often still in the limelight as voices for the voiceless. This organization embraces incredible values and missions to empower women, including, but not limited to, providing scholarship to women in business and Science, Technology, Engineering, and Mathematics (STEM), thus giving them direction in their future A PILOT WELLNESS PROGRAM 7 endeavors and increase the overall wellness of girls while also instilling confidence (Miss America foundation, 2015). There are several different views about the impact on wellness result of pageant participation. An opposing view is of those who believe pageants have a negative impact on self-esteem and wellness of girls, for example a past participant reported that by participating in Miss America, she lost a part of her self-confidence that she could never reclaim (Maddox Deitering, 2001). Both views have been publicly debated throughout the years in magazines, news reports, blogs, and across social media platforms, even more recently in light of changes and issues within the Miss America Organization. Negative views of this organization have been more prominent in news stories and social media in recent months due to the actions of former Chief Executive Officer (CEO) of the organization, Sam Haskell, and other board members. Haskell began in the member of the board in 2005 then quickly progressed to the CEO position where he lead for nine years (Ali, 2017). With the help of his board members, Haskell destroyed the pageant that he was once given credit for restoring (Kuperinsky, 2017). Three years worth of internal email exchanges between Haskell and other board members were released which enclosed body shaming, slut shaming, name calling, and other derogatory comments about former Miss Americas (Stapleton & Andone, 2017). Social media was immediately flooded with comments of people believing this to be the end of MAO, as well as comments of people fighting for its continuation (Kuperinsky, 2017). Many sponsors, including Dick Clark Productions, cut ties with the organization after the news was released in order to no longer be connected to the bullying actions that were portrayed in these emails (Stapleton & Andone, 2017). Former Miss Americas, including Hagan who was often the topic of Haskells crude comments, immediately spoke up (Ali, 2017). Hagan stated that with light brought to this situation, she finally felt validated in her feelings, as this was A PILOT WELLNESS PROGRAM 8 something she had tried to share during and after she held her title in 2008 (Kuperinsky, 2017). Another former Miss America, Gretchen Carlson, stated that every person involved should resign immediately, and that the almost 100 year old tradition of female empowerment & scholarship, deserves better (Stapleton & Andone, 2017). Former Miss Americas pushed for Carlson to become the new CEO of the organization (Post, 2018). Carlson ensures that she plans for the organizations mission to be 100 percent about empowering women (CBS/AP, 2018). Carlson was crowned Miss America in 1989, and has since been a successful news anchor and T.V. personnel for Fox News and CBS News (Carlson, 2017). The organization sees her as an appropriate leader for MAO as she has dedicated her life to building confidence in women through mentorship, publications about empowering women, hosting pageants for women with disabilities, creating the Gift of Courage fund to help encourage women to fulfill their dreams of the future, and her constant voice to empower women (Carlson, 2017). Many believe MAO to be a good competition for women that inspires and empowers participants, and helps them to have a greater impact on society through the expression of their passions and platforms. Savvy Shields, Miss America 2017, promoted her platform Eat Better, Live Better throughout her year of service to encourage others to make healthy choices leading to a happier life, after she struggled herself with making bad choices (Cooper, 2016). Shields (2017) continues a blog, in which she dedicated one post, to expressing that even though she felt she had conquered all insecurities prior to being crowned Miss America, many quickly surfaced throughout her year of service. Although she claims to still be working on these insecurities, Shields (2017) discusses her immense change and how much MAO helped her achieve this growth. An outside business women, Ashley Margeson, expressed her appreciation for the Miss A PILOT WELLNESS PROGRAM 9 America pageant in terms of providing young girls with a positive role model to assist in demonstrating the importance of building peers up rather than tearing each other down (Margeson, 2017). A past Miss America, Sharlene Wells, stated, the pros outweigh the cons when referring to her participation in the pageant (Maddox Deitering, 2001). Alyssa Gum (2017) was crowned Miss Teen Ohio United States, and spoke about how pageants of all circuits empower women, by stating that the ability to advocate for a personal platform, as well as the platform of the pageant organization, increases confidence in the participants. Gum (2017) declines to agree with those that believe a swimsuit competition is sexist as she sees it as encouragement for women to embrace their body, and expresses that the modeling industry and media place a stronger focus on body image, while pageants embrace all types of women and thus increase the confidence of contestants. Negative views of participation also exist, and some of the most profound are expressed by past participants. One former Miss America, Kira Kazantsev, highlighted in a blog post how she and her fellow contestants vowed to make healthy life choices including self-love and viewing oneself as beautiful without comparing ones image to others, avoiding the mindset one once had when competing in swimsuit competitions (Kazantsev, 2017). This goes to show that even after being so successful in pageantry, insecurities may continue to linger. A history professor at California State University who has written on this topic many times, believes that the lifestyle and fitness category, or swimsuit competition, sexualizes the bodies of the contestants and pushes the women to attempt to live up to unachievable standards (Roberts, 2013). Further, a former Miss America contestant expressed that competing caused her to lose self-esteem and experience emotional bankruptcy (Maddox Deitering, 2001). A PILOT WELLNESS PROGRAM 10 One of the most discussed controversial issues related to MAO is the belief or disbelief that pageant participation increases eating disorders and body image issues. The Huffington Post conducted research of the Body Mass Index (BMI) of past Miss Americas in comparison to the average woman (Vagianos, 2015). When the Miss America pageant began in 1921, the BMI of the average American woman was considered underweight, while the BMI of Miss America was in the normal, healthy range (Vagianos, 2015). The BMI of the average American woman has steadily increased over the past several years to the overweight category, while the BMI of the past Miss Americas has steadily decreased into the underweight category (Vagianos, 2015). Eating disorders among contestants dominates public interest and the majority of literature, and many contestants have shared their stories of suffering from eating disorders. One past Miss America, Kirsten Haglund, developed anorexia nervosa as an adolescent and went through treatment before she ever started competing in pageants (Morrow, 2017). Today, Haglund is still very careful about how she shares her story as she never wants it to become thinspiration for others (Mapes, 2013). While her eating disorder was well managed prior to competition, another participant Leighton Jordan, Miss Georgia 2012, shared a story about her experience with eating disorders during her pageant competition (Rice, 2013). While Jordan expressed that she had developed and overcome anorexia nervosa as a child, during pageant competition she had begun to develop bulimia nervosa as well as habits of dieting with use of laxatives (Rice, 2013). Fear of developing a bad reputation for herself and the pageant system, kept her from sharing her story until she saw a little girl at an event with all too familiar signs of suffering from an eating disorder (Rice, 2013). Jordan wanted to inspire healing for others experiencing the same thing, which led her to get the help she needed (Rice, 2013). Occupations of Pageant Contestants A PILOT WELLNESS PROGRAM 11 Every participant must first compete in a local pageant within the Miss Indiana Organization, then if awarded a title, she continues on to the Miss Indiana pageant which is a preliminary contest for the Miss America pageant (Miss Indiana, 2017). In Indiana, 35 local pageants are held which begin in July and continue through March (Miss Indiana, 2017). Of these 35 pageants, 12 have are an open-entry status meaning that anyone meeting the requirements of MAO guidelines, and who is a resident, full-time employee, or full-time student at a college or university in Indiana can participate (Miss Indiana, 2017). The remaining pageants have a closed-entry status in which participants have to live, work, or go to school within a certain county in Indiana (Miss Indiana, 2017). For some girls, pageant preparation could consume an entire year, involving getting ready for the fitness competition with workouts and nutrition, interview practice, study of worldly and political issues, paperwork preparation, wardrobe shopping and altering, and talent development and practice. Prior to the start of competition at any level, each contestant is required to submit a resume, a signed local contract, and platform statement which is an opportunity for the participant to be a voice for something she is passionate about (Miss Indiana, 2017). Although they are encouraged to raise copious amounts of money, for each pageant in which they wish to compete, contestants are required to raise $100 for Childrens Miracle Network (Miss Indiana, 2017). This additional work has deadlines during their other occupations of schoolwork, working a job(s), and any other activities they are involved in. During each pageant level contestants compete in different areas worth different percentages including, a 10 minute private interview with a panel of judges by whom questions are formed about contestants worldly views and opinions, personal questions from resumes, and character questions, worth 25% of the total score ("2018 Miss America competition scoring A PILOT WELLNESS PROGRAM 12 guide", 2018). The remainder of the judging occurs in front of a live audience. These phases of competition include the lifestyle and fitness in swimsuit competition worth 15%, the talent portion worth 35%, evening gown competition worth 20%, and onstage question worth 5% (Miss Indiana, 2017 & "2018 Miss America competition scoring guide", 2018). Guidelines for local participants are expressed through the contract each girl is required to sign, which closely mimics the contract for both state and national levels (2018 local contestant contract, 2018; 2017 state contestant contract, 2017; 2018 national contestant contract, 2018). Some of the criteria for participation includes being of good moral character meaning demonstrations of honesty, good character, talent, poise, intellect, leadership and good judgement (2018 local contestant contract, 2018). Other criteria includes having no criminal record, never having been married or pregnant, never having performed any acts that MAO could consider indecent or immoral, and being in good health for ability to participate in all activities (2018 local contestant contract, 2018). Once being awarded with a local title, the young woman begins her year of service (Miss America, 2017). The year of service is well known within MAO competitions, where in the new title holder spends her year continuing community service while representing her local pageant, school, and/or region as well as promoting her platform on a larger level (Miss Indiana, 2017). Some local pageants provide an additional contract or set of guidelines to depict what is expected during this year thus providing an additional list of occupations for the year in which she holds her title. The Sweeps Scholarship Pageant (SSP), which crowns two participants, for example, requires title holders to have weekly communication with directors during the preparatory months leading to the Miss Indiana competition (SSP Year of Service). The title holder for the SSP is encouraged to participate in events and appearances with approval from the A PILOT WELLNESS PROGRAM 13 directors, however some are required for her to attend (SSP Year of Service). Also within this secondary contract, the title holder is required to devote the time necessary for preparation for the state competition, promote and further develop her platform, demonstrate good time management and punctuality, and only use ones cell phone for emergencies while representing the SSP during events and appearances (SSP Year of Service). All shopping for the state competition wardrobe must be completed with a SSP director, any communication with director (i.e. email, text, phone call) must be answered within 24 hours, directors are to be notified with out of state travel ahead of time, and the title holder must also do her best to recruit women for the following years competition while representing MAO (SSP Year of Service). Many of the local pageants have adopted these guidelines for their title holders year of service like the Miss Indiana University pageant, Miss Harvest Homecoming pageant, Miss South Central pageant, Miss Vincennes pageant, and Miss Central Indiana pageant, among others. The Miss Indiana competition, known as Miss Indiana Week, last six days, four of which are reserved for evening competition which requires the same preparatory measures and competition factors as the local pageants (Miss Indiana, 2017). Participation involves staying in a hotel with another contestant, traveling to several events and appearances around the city, and the competition itself (Straiger, 2017). Scheduled events include the opening ceremony, a tour and visitation at Rileys Children Hospital, visit with the Boys and Girls Club, self-defense class, rehearsals, Lions Club cookout, Joys of Life Luncheon, Princess Brunch, Princess Program rehearsal, Elks Brunch, and meals at local restaurants or the hotel (Straiger, 2017). Wellness The term wellness has been defined and discussed within the healthcare field in great detail since the 1950s thanks to Halbert L. Dunn (Kirkland, 2014). Dunn, father of the wellness A PILOT WELLNESS PROGRAM 14 movement, provided early definitions and ideals about wellness, "[wellness is] an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable (Manley, Ardell, Allen, & Heien, 2015; Kirkland, 2014). Dunn discussed an overarching goal for wellness including to maximize the potential of environments in which people function (Manley, Ardell, Allen, & Heinen, 2015). His ideals of wellness surrounded his argument that the absence of disease is only a small portion of what health and wellness truly represents (Kirkland, 2014). Dunns theories influenced the development of wellness over the next several years, as many others continued to add and further cultivate theories. University of California, Berkeley has published a Wellness Letter since 1984 and has since become the leading online wellness resource nationwide (Berkeley Wellness, n.d.). Here, wellness has been defined as optimal physical, mental and emotional well-being, a preventive way of living that reducessometimes even eliminatesthe need for remedies. This definition emphasizes personal responsibility for making the lifestyle choices and self-care decisions that will improve the quality of your life with a focus on preventative wellness (Berkeley Wellness, n.d.). In 2008, the World Health Organization identified that wellness is holistic and includes both an absence of illness and a state of wellbeing (Miller & Foster, 2010). Occupational therapists treat clients with a holistic view and focus on how to help his or her overall well-being. Within the wellness model of practice, occupational therapists work to promote wellness by increasing the clients participation in meaningful occupations or activities (AOTA, 2013). Ann Wilcock identified the importance of having a balance between physical, mental, and social wellness, and believed that these things are achieved and balanced through participation in meaningful occupations (Cole & Tufano, 2008). Like many wellness researchers A PILOT WELLNESS PROGRAM 15 before her, Wilcock mentioned the importance of a goal to improve the population as a whole as well as individually as people are unique with various goals and potentials (Cole & Tufano, 2008). Occupational therapists are skilled at helping specific populations, while also analyzing the individual to help them strive to reach their goals. These practitioners can take the person as they are and help them go where they want and need to be. These gains in wellness led to the development of many wellness models, including the Six Dimensions of Wellness and the Seven Dimensions of Wellness. The Six Dimensions of Wellness was developed by a co-founder of the National Wellness Institute (NWI), Dr. Bill Hettler (Hettler, 1976). Hettler identified and discussed the six dimensions as intellectual, physical, spiritual, occupational, emotional, and social (Hettler, 1976). The discussion of interconnectedness included that this model is holistic in nature and allows one to work toward an increase in well-being (Hettler, 1976). The University of California at Riverside proposed the Seven Dimensions of Wellness based on the Six Dimensions of Wellness with one addition of environmental wellness (Chobdee, n.d.). This seventh dimension was added to increase the holistic balance and places a stronger emphasis on wellness no matter where one may be (Chobdee, n.d.). The American Occupational Therapy Association (AOTA) (2013) identified that the role of an occupational therapy practitioner within the wellness model is to promote healthy lifestyles, emphasize occupation as an essential element of health promotion strategies, and provide interventions, not only with individuals but also with populations (p. S50). Prevention of health issues is defined by AOTA (2013) at three different levels entitled primary, secondary, and tertiary. Primary prevention is identified by teaching people about health and wellness in order to decrease the risk of illness and injuries (AOTA, 2013). Secondary prevention includes A PILOT WELLNESS PROGRAM 16 what is known as typical therapy and is comprised of screening, early detection, and intervention after disease has occurred (AOTA, 2013). Tertiary prevention is used when a disease already exists to focus on improving quality of life and reducing symptoms (AOTA, 2013). Occupational therapy practitioners can promote health and wellness by providing wellness programs that help the general population by providing prevention strategies (Gupta, Chandler, & Toto, 2013). Examples of programs currently run by occupational therapy practitioners include backpack awareness day and car safety recommendation programs (Gupta, Chandler, & Toto, 2013). Backpack awareness day, for example, is a program given to school aged children to teach them how to lift, pack and carry a backpack. It also includes providing education of the proper ergonomic fit and weight of a backpack which helps to avoid back pain or injury (AOTA Backpack Awareness, n.d.). This is an example of primary prevention as it is working to educate children so they can avoid injury. Another wellness program, for example, provided to a group of typically healthy individuals (ie without diagnosed disease or illness) could benefit from a wellness program through occupational engagement in a scholarship pageant. With the use of primary prevention strategies, education of wellness techniques can be provided to a group of pageant contestants to improve their overall wellness. With the research of many wellness models previously created, the balance of mind, body, and spirit can help to improve the overall wellness of the program participants. Purpose of the Project Participants of the local and Miss Indiana pageants, experience a surge in their occupations which potentially imposes a threat to balance in their everyday which further A PILOT WELLNESS PROGRAM 17 impacts overall wellness. In order for these women to maintain their wellness during each phase of competition, they have to have a balance between mind body and spirit. These young women are key members and leaders in society through their platform advocacy and community service, and therefore are role models to many, thus in order to positively impact the wellness of the younger population it may first help to increase the overall wellness of these contestants. There is a lack of wellness programming designed for pageant contestants between the ages of 17 and 25 participating in MAO. A majority of those who participate in Miss America pageantry are in a period of emerging adulthood (18 - 25) (Ng, Boey, Mok, Leung, & Chan, 2016). According to Ng et al. (2016), emerging adulthood is a phase in which one experiences a heightened sensitivity to the process of identity development, self-focusing, possibilities, and instability while transition into adulthood. Research suggests that this population naturally experiences increased levels of stress and anxiety when experiencing challenges associated with this transition (Ng et al., 2016; Lane, Leibert & Goka-Dubose, 2017). The purpose of this project is to promote wellness in Miss Indiana contestants by increasing balance of mind, body, and spirit through occupation in the context of a pageant while also providing them with the tools to increase wellness in daily life. From literature, it becomes clear that the increase in occupations when competing in MAO pageants can cause a decrease in overall wellness. For example, many contestants of the Miss America competition reported immediately comparing themselves to others, thus decreasing their confidence (Maddox Deitering, 2001). Tamara Hext, a former Miss Texas, admitted to decreased self-esteem and development of an eating disorder throughout her pageant participation (Maddox Deitering, 2001). Former Miss America, Donna Cherry, expressed that she struggled with body image before and after pageant competition (Maddox Deitering, 2001). A PILOT WELLNESS PROGRAM 18 Methodology Screening Due to the lack of evidence in literature about the local level competition, it was important to gather perspectives from those that will be affected by the implementation of the wellness program. Surveys which each shared an introduction (see Appendix A), were developed for board directors and local directors in the Miss Indiana Organization, as they spend a large amount of time with contestants and thus develop an additional perspective not found in literature. Board members are not required to be involved, however based on personal experience, it is known that those involved in the Miss Indiana Organization are engaged in every contestant and every local pageant. Board members are around during the entirety of the Miss Indiana pageant and all of the appearances and activities pertaining to the organization. Board members travel to the local pageants to meet and support all contestants, and are very involved at each level of competition. A board member acts as Miss Indianas professional assistance during her year of service (Guidelines for Miss Indiana's year of service, 2018). Local directors are the main contact for communication with all contestants including those that do or do not make it to the state level of competition (Miss Indiana Director Manual, 2017). They are encouraged to promote their local pageant on social media and once a woman is crowned they are to help her prepare for the state competition with all pageant preparations (Miss Indiana Director Manual, 2017). Gaining board members and local director's perspective through survey completion allows for detailed understanding of current wellness issues of those involved in the pageant circuit. For board members and local directors (refer to Appendix B and C respectively), information was first gathered about how long they had been involved in the organization, how they got involved, and how much time they spend with the contestants during A PILOT WELLNESS PROGRAM 19 competition. Each survey contained questions about how much time was spent with contestants in order to identify the weight of the responders perceptions. The survey continued to gather information about their perspective of the overall wellness of the contestants during pageant competitions. These surveys included wellness questions such as what wellness strategies are currently involved within the Miss Indiana organization, wellness concerns they have for current participants, and what they believe these participants could benefit from in a wellness program. Another survey was developed for past participants (see Appendix D), to gain yet another perspective. This survey asked past participants to explain why they stopped competing, how long they competed, and if/how often they continued to compete at the state level. It further elicited information about their perceptions of wellness while competing, as well as, perceived wellness of fellow participants. Even after the competition is over, former Miss America contestants discuss the Post-Pageant Crash wherein the immediate decrease in occupations also decreases their overall wellness (Maddox Deitering, 2001). For example, some express not knowing how to fill the void of occupations and others discuss struggling to deal with the loss of the title they had been competing for (Maddox Deitering, 2001). Hext expressed her real sense of loss after losing the national competition by stating, You work so hard to come here, and all of a sudden, its over. Theres nothing more to work for (Maddox Deitering, 2001). Another former contestant, Miss Connecticut, Joanne Caruso, confessed of falling into depression following her time competing at the national level (Maddox Deitering, 2001). In addition to the wellness questions, the past participant survey also asked more personal questions about eating disorders and other mental illnesses. Within articles pertaining to pageantry, not any one circuit in particular, the concern of eating disorders is profound. The Odyssey published an article about how pageants impact the ideal of beauty and stated that A PILOT WELLNESS PROGRAM 20 participation in pageants can be disastrous to ones self esteem, especially if her body type does not fit that of the medias expectations (Graham-Hyatt, 2016). Many believe pageants to be involved in the development of eating disorders, for example, Coppa (2016) conducted a study to survey and interview the 2012 MAO title holders for eating disorders. Coppa (2016) reported that 26% of the female pageant contestants were told or perceived that they had an eating disorder and gathered a variety of views from past participants (Garner et. al., 1982, p. 6; Thompson et al., 2003, p. 1). A majority of views from those interviewed included that of appreciation and disbelief that pageants contribute to eating disorders, and others report that the competition makes participants compare their body to others thus causing issues with body image (Coppa, 2016). Therefore, for the current project, past participants were additionally asked about their personal experiences, specifically if they experienced eating disorders and/or mental illnesses. Information compiled from the surveys assisted the development of a wellness program for current participants. Of the 18 board members within the Miss Indiana Organization, survey emails were sent with a return of 13 responses. Board members time with the organization varied from 5 to 52 years and 61.5% of respondents claimed to spend the entire day each day with contestants during Miss Indiana Week. Respondents indicated many wellness strategies which exist within the organization and related events, such as healthy meals, community involvement, support systems in new found friendships, scheduled relaxation time, and an open door policy with board members for support. Concerns for contestants indicated by respondents included stress, sickness, not eating enough, a busy schedule, lack of sleep, and increased pressure from directors and family members. Every board members response indicated that they felt contestants would benefit from learning stress management relaxation techniques for A PILOT WELLNESS PROGRAM 21 increased wellness specifically time management techniques, mindfulness strategies, and how to balance mind, body, and spirit. Of the 62 local directors, who were sent surveys, 32 responded. Length of time as a director varied from less than one year to 33 years of active participation in the organization. A majority, 56.3 %, reported spending all day with contestants at the local level, and the others report a combination of being the primary contact prior to competition, with contestants for entire day of pageant, and/or available to assist backstage for entire pageant. Directors also reported various amounts of time, based on the woman, spent with their title holder in preparation for the state pageant including: 40 hours of meeting time, constant communication via text and phone, meeting a couple hours per week, and working over 100 hours total in preparation. When asked for their perspective of what might be the demands of the participants wellness during preparation and participation in these pageants, responses included pressure to regularly exercise and eat healthy, risk of decreased mental health, pressure from the competition, family pressure, time management for already busy schedules, decreased sleep, and managing additional appearances, fundraisers, promotion of their platform, and community service. Within their personal local pageants, local directors reported wellness strategies already in place such as providing healthy meals the day of competition, rest and downtime, verbal encouragement, chair massages, prayers, encouragement to make healthy choices during preparation of pageant, and for local title holders specifically, exercise programs and positive communication with the title holder leading up to the state competition. A majority of the local directors noted that the implementation of a wellness program with stress management, relaxation, mindfulness, and time management education, as well as education for how to balance mind, body, and spirit could increase participants overall wellness. A PILOT WELLNESS PROGRAM 22 Perhaps the most eye opening perspectives came from the survey responses of past contestants. Of the 53 former contestants who received a survey, 22 women responded. Over half of the responses (55%) came from women who last participated in the 2016 and 2017 pageant year. Many stopped participating because they aged-out or moved out of state and no longer compete. However most respondents indicated making it to the state level at least once during their competitive years. Previous contestants reported a decrease in their overall wellness while competing as evidenced by loss of confidence in talent, abilities, and physical appearance, decreased mental wellness with increased pressure and stress to be successful, decreased sleep, unhealthy relationship with food, loss of relationships due to busy schedules, and overall decreased self-esteem. While preparing for pageants and throughout participation, respondents reported a significant increase in exercise and strict diets while maintaining busy schedules with work and school obligations, meeting deadlines and expectations, and long hours of both preparation and competition. They described concerns they held for fellow contestants or perhaps those still competing such as contestants being obsessed with posting the perfect social media feed during state competition, eating disorders, mental illnesses, increased stress and pressure, decreased balance of mental, physical and emotional needs, decreased self-esteem, falling into the perception to look a certain way, competing with injuries, and becoming obsessed with the competition. Eight of 22 (36.4%) of the respondents indicated they had experienced an eating disorder at some point, either before or after competition, and 85% reported experiencing depression, anxiety, or other mental health issues both during and after competition. They also reported decreased wellness upon completion of pageant participation such as, statements of never feeling as beautiful as [she] was when [she] competed, decreased confidence after gaining weight post pageant, and depression from moving on after the loss of Miss Indiana so A PILOT WELLNESS PROGRAM 23 many times. Past participants indicated that current participants would benefit from a wellness program that addresses stress management, mindfulness strategies, spiritual guidance, relaxation techniques, time management, and education to balance mind, body, and spirit. Evaluation To measure the effectiveness of the wellness program, a pre and post assessment (see Appendix E and F respectively) will be used. This will assess the level of knowledge each participant has of overall wellness as well as how they rate their current personal wellbeing, what they do for wellness, and how it applies to pageant competition prior to implementation of the intervention. Another assessment that will be used in conjunction with the program is the How Healthy Are You developed by Rebecca Donatelle and published in Health: The Basics (2009) (refer to Appendix G). The assessment is comprised of questions pertaining to ones physical, social, emotional, environmental, and spiritual health as well as personal health promotion (Donatelle, 2009). This assessment is thought to help the participant fully understand the importance of wellness and where they are currently within their wellness journey. Intervention Prior to the program implementation, a flyer was created to disperse the program information. This flyer was emailed to current participants based on email lists from the executive director of the Miss Indiana pageant which included some but not all current participants. It was also sent to local directors with a request that they share it with their local contestants. The program information was also provided directly to contestants during local pageants with the opportunity that they could ask questions or express concerns. Some reliance was placed the current Miss Indiana, and current contestants to relay information to other eligible participants. The flyer presented the dates, times and places in which the programs would be A PILOT WELLNESS PROGRAM 24 held, personal contact information, a quick wellness overview, and encouragement to visit the website. A website was created spread awareness of the program, provide education and be a continuous resource for the participants. The website was composed of the mission and values of the program director, a simple overview of the program directors background, purpose, and credentials, and information about the programs. Also included in the website are a wellness blog and wellness tips and resources. Resources included demonstrated techniques and strategies to maintain wellness with articles, videos, phone applications, and links to helpful websites. It is also an easy way to sustain contact with the girls while they continue on their wellness journey. Based on the results of survey responses and literature findings, a wellness program was designed around the wellness model which focuses on the balance of body, mind, and spirit through participation in the occupation of pageantry. Many wellness programs have been designed around this ideal, however with different populations. For example, a body-mind-spirit intervention program was conducted with emerging adults working toward their higher education in Hong Kong (Ng et al., 2016). According to Ng et al. (2016), the well-being increased after participating in a 2-day intervention program with a small group integrating mind, body, and spirit techniques. The program consisted of four sessions entitled, awareness of self and others, discovering inner strength, love, care, and forgiveness, and transformation and preparation for the future (Ng et al., 2016). Another wellness program structured to help decrease stress and anxiety in college students was compiled of lecture, discussion, practicing skills, and weekly discussion of practice (Deckro et al., 2002). The six week intervention, composed of relaxationresponse-based skills, cognitive behavioral interventions, individual practice and log, and lecture A PILOT WELLNESS PROGRAM 25 and discussion topics of stress and relaxation and mind/body connection, resulted in reduced stress and anxiety (Deckro et al., 2002). From the research a modified one day, three hour wellness program, entitled balance2bewell, was designed for contestants within the Miss Indiana Organization, offered in four different areas of the state. These pageant participants are very active and busy individuals, and experience increased occupations due to pageant preparation and participation that provides an additional source of stress. Therefore this program required efficiency within the short time available, rather than following the design of Ng et al. or Deckro et al. The balance2bewell program included two activities in conjunction with wellness education, teaching and practicing wellness strategies. Each activity is designed around the principles of Marilyn Cole in the text, Group Dynamics in Occupational Therapy, and tailored to pageant occupations (2012). In this book, activities are explained with an introduction, which includes the purpose and a brief outline of the group, the activity, and an opportunity to share with the group (Cole, 2012). The book is written to allow leaders to ask questions to the group assisting them in processing and generalizing the session, followed by an opportunity to summarize the session (Cole, 2012). The first activity implemented is known as the Coat of Arms activity which allows the individual to complete self-exploration by answering prompts with writing and/or drawing (Hayes, 2011). Hayes (2011), reports when completing this activity with various groups in which people share as much as they feel comfortable about achievements and challenges, the team as a whole becomes stronger. This is a great way to help the participants increase self-awareness prior to more in depth group activities (Bolster, 2013). Developing a personal coat of arms can also increase discussion, help participants to discover common traits among one another, and inspire strong emotional connections (Neimeyer, 2016). These opportunities to share and connect A PILOT WELLNESS PROGRAM 26 reflect the relationships or communication between people (Interpersonal Oxford Dictionary, n.d.). According to Colorado State University, These interpersonal interactions can provide group members an opportunity to deepen their level of self-awareness and learn how to relate to others (p.1.), therefore is a critical part of the program protocol. For balance2bewell, the activity prompts included: what you like about yourself, your greatest achievement, your most prized possession, what you value most in life, a symbol of your personality, and three words to be remembered by. The balance2bewell program outline for this activity is attached in Appendix H. Following activity one, group centered wellness activities were taught and practiced. Wellness techniques available were based on results from surveys, and personal requests of the current participants; all of which included strategies of stress reduction, time management, mindfulness, healthy eating and living strategies. First, meditation activities and breathing exercises were done in a group format. Meditation has become increasingly more popular as a wellness technique for increased mindfulness, meaning bringing attention to the present moment (Concotelli, 2007). There are many health benefits of meditation including increased relaxation, decreased blood pressure, anxiety, depression, and anger, and better sleep (Concotelli, 2007). Neuroscientist, Richard Davidson, presented research that meditation causes happier emotions and healthy immune system activities as evidenced by increased left-sided brain activity (Concotelli, 2007). One meditation that has presented positive effects for wellness is known as the Loving-Kindness Meditation derived from Buddha practices (Rana, 2015). This meditation has been known to cultivate an attitude of unconditional love, kindness and compassion for oneself and others (Rana, 2015). A study by Seppala et al,. (2014) shows that completion of this meditation for 10 minute sessions can increase feelings of connectedness, and can be a viable, A PILOT WELLNESS PROGRAM 27 practical, and time-effective way to increase mindfulness (Rana, 2015). With a print out of the words (refer to Appendix I), one can easily meditate and take the time needed at each level of the meditation (Loving-kindness meditation). Following the meditation, the group reflected, answering questions such as, Was this easy or hard for you?, What were you feeling during the meditation?, and How are you feeling now?. The group then stated how they were feeling in order to decide on a breathing exercise: stressed, tired, anxious, happy, etc. Based on group dynamics, a breathing exercise was then completed from a PDF by University of California at Berkeley (attached in Appendix J) which includes breathing exercises like paced breathing and abdominal breathing (Breathing exercises, n.d.). Breathing exercises of all types have several health benefits including increased oxygen and blood flow, mentality and overall health, and decreased stress (Gabbay, 2002). Then the group indicated activities they wanted to learn and practice after provided the options including: arts and crafts (coloring, playdough, Buddha Board, puzzle, spirographs), poetry reading and writing, journaling, prayer journaling and reflection devotionals, identifying gratitude (jar and journaling), organization and time management, and nutrition education. Participants completed each activity independently for 10 minutes after verbal directions, and followed by reflecting and sharing on the experience. Each activity described below was easily adapted to fit each member of the group as instructions were open to interpretation to allow for implementation of unique interventions. Participants were provided options for arts and crafts including coloring books, playdough, Buddha Board, puzzles, and spirographs, and given time to explore and create. Arts and crafts help to decrease stress as it allows one to fall into a meditative state, and has become more popular with the production of adult coloring books (Alban, 2018). This activity also A PILOT WELLNESS PROGRAM 28 encourages out-of-the-box thinking which encourages use of left and right hemispheres of the brain and promotes neuron growth (Alban, 2018). Completing arts and crafts has been found to increase the release of dopamine which promotes concentration and ambition (Alban, 2018). Participants were instructed to read from the provided poetry personally written by the program director. Reading poetry allows the emotional connection with others and when read aloud provides rhythmic sounds that promote joy (Gafford, et al., 2018). After participants read, they were reassured that there is no wrong way to write a poem, poems do not have to rhyme, and the most important thing is to write what is felt. They were then instructed to write a short poem without restrictions. Writing poetry can be therapeutic by providing an emotional outlet, increased self-awareness and reflection, and encourages critical thinking and cognitive function (Donovan, 2016). Both reading and writing poetry allows for cathartic release of emotions (Gafford, et al., 2018). Instructions were combined for both journaling and prayer journaling as participants were given the option to complete either one for a personal entry. Journaling regularly can help to decrease asthmatic and arthritic symptoms, and strengthen immune cells (Purcell, 2018). This activity also helps to reduce stress, and increase self-awareness (Purcell, 2018). Writing a prayer journal has similar health benefits including decreased stress (Routledge, 2014). Participants were given 1 minute to write down at least three things they were grateful for. The time for this activity was short in order to show participants how quickly this technique can be done. Completion of a gratitude jar or gratitude journal increases physical health, energy, attention span, determination, sleep, self-esteem, connectedness, and empathy, and decreases stress, frustration, and depression (Morin, 2017; Robinson, n.d.) A PILOT WELLNESS PROGRAM 29 It was important for each participant to write down a routine that currently exists in her life, and was asked to write either morning or nightly routine. Once completed, one on one conversation occurred to determine if there was any wasted time and where in her schedule a new wellness technique could fit. Education was provided about time management and organization which can help to reduce stress, inspire better eating and sleeping habits, and increase energy (Flourentine, 2016). One on one nutrition education was also provided and important for obvious reasons as good nutrition can reduce risk of disease and illness and increase energy and overall wellness (Tufts, n.d.). InBody testing was discussed to stress the importance of providing ones body the necessary amount of nutrients as this assessment provides a body composition of weight, fat, protein, mineral and water, and describes a basic metabolic rate which is how many calories ones body burns in a day doing nothing (What is body composition?, 2018). Participants were given the analogy of filling a car with gasoline: if one lets a car run out of fuel then the car no longer runs, and food is fuel for the body. Cookbooks, like Whole 30, and calorie counting applications were also discussed with some participants. Participants were also provided education and overview of techniques including: Advocare nutrition supplements, essential oils and diffusers, aromatherapy sleep spray, stress balls, sleep masks, head massager, noise maker, and crystals. Most activities were completed during each session, with the exception of one or two due to increased sharing time at some sessions. Advocare is a nutritional company that is based in science and faith to increase the health through products for wellness, performance, fitness, weightloss, and active lifestyles (Advocare, 2018). Essential oils and aromatherapy products are made for several different uses ranging from digestion assistance, increase energy, balance hormones, decrease headaches, and A PILOT WELLNESS PROGRAM 30 promote feelings of relaxation (Axe, 2018). These can be used in many formats including, rollers, sprays, lotions, and diffusers, and are now able to be placed on jewelry items. In order to demonstrate options, different types of stress balls were presented including the typical, foam ball one gets for free and one that is more malleable filled with small beads. Stress balls can help to reduce stress through the stimulation of the limbic system which is connected to emotions (Brooks, n.d.). Sleep masks are used to block out light and improve sleep (Ivey, 2018). Masks come in different styles from bulkier styles that cover but do not suppress the eyelids to slimmer gel filled masks (Ivey, 2018). Scalp massages provide a release of serotonin in the body which helps to decrease stress, can help to increase peace and allow for better sleep (Oliver, 2016). A sound machine during meditation or sleep can help to block the external noises that may negatively impact your sleep, like cars, trains, coyotes, ect (Osmun, 2015). Crystals are used to increase mindfulness, help with relationships, promote protections and decrease feelings of fear and mental illness (Askinosie & Jandro, 2018). Many also believe crystals to have physical healing powers like relief from asthma and bronchitis, and decrease physical pain regardless if the one in need of healing doubts the process (Vantol, 2008). The balance2bewell program continued on with the second activity. The second activity was adapted from an activity presented by Cole (2012) entitled Professional Self-Awareness Collage to better fit the population of pageant contestants. The activity involves participants using magazines to find pictures that represent personal qualities and are then pasted on a folded piece of paper in which the qualities shown to others are on the outside, and the qualities typically hidden are on the inside of the folded paper (Cole, 2012). In a study from the University of Central Lancashire, Preston, UK, Brandon Williams used a collage over any other forms of art as a communication tool between different professionals (Williams, A PILOT WELLNESS PROGRAM 31 2002). Williams discussed the decrease in anxiety with the use of a collage because the activity does not require an abundant of artistic ability, therefore participants would be more likely to share (Williams, 2002). Completing a collage has been identified as more powerful than other crafts as an activity (Carter, Nelson, & Duncombe, 1983; Nelson, Thompson, & Moore, 1982). A collage also allows for more self-expression and self-awareness (Nelson, Thompson, & Moore, 1982). Stefon Napier discussed the importance for student leaders to intentionally strive for selfawareness and stated it allows leaders to challenge and understand themselves more fully (Napier, 2016). An outline of the activity is attached in Appendix K. At the conclusion of the wellness program, a final opportunity was provided for reflection followed by one on one discussion about the addition of a new wellness occupation into ones schedule. At the completion of the program a personalized flyer was sent to each participant to summarize their experience (refer to Appendix L and M for examples). Each flyer contained wellness techniques each participant could benefit from based on assessment results and reflection and sharing during the program. These client centered flyers also help the longevity of balance2bewell and its effects by encouraging continuation of wellness techniques. Leadership Skills Leadership skills were demonstrated during program implementation following the development and analysis of a needs assessment via surveys for board members, local directors, and past participants. Leadership skills were also exhibited by completion and dispersion of flyers to provide information about the program through emails provided by the Miss Indiana pageant executive director, and directly to eligible participants during local pageant competitions. The writer has worked with local pageant directors to increase the overall wellness of their contestants. For example, after wellness education provided by writer, one local director A PILOT WELLNESS PROGRAM 32 implemented chair massages in her pageant day itinerary to help her contestants feel calm throughout their daily preparations. Leadership skills were continuously utilized when presenting the program at the local director meeting with demonstrations of activities at the program and educational components. Communication with the Miss Indiana pageant executive director has consisted of educational components in order to help the staff, i.e. local directors and board members, become more aware of ways to increase the wellness of the contestants. Outcomes The purpose of balance2bewell was to increase the overall wellness of pageant contestants within the Miss Indiana Organization, through the development of a one day wellness program. Outcomes were derived from a post-survey, related to the pre-survey, as well as completing the previously completed assessment again within a week post program. Of the 11 program participants (Program 1: 0, Program 2: 2, Program 3: 5, Program 4: 4), all completed the post-survey (see in Appendix F) immediately following the program in order to measure its effectiveness (N = 11). This outcome measure was designed to measure the change in participants self-reported perceptions of their wellness, including mind, body, spirit, and balance of these aspects. The survey also gathers information of what the participant does to maintain wellness for each aspect, what threatens their wellness, and questions specifically about balance2bewell. These survey responses were used to maintain quality of the intervention and allowed for changes to be made if necessary before the next program. Results of the pre and post surveys were compared and analyzed to determine the effectiveness of the program. These results indicated that little change occurred after one program, however implied possibilities of positive changes in participants wellness as indicated by feedback. When asked to expand on how the program helped them, three themes emerged including: education, A PILOT WELLNESS PROGRAM 33 encouragement, and connectedness. A majority of participants expressed that they gained knowledge of wellness and techniques to increase wellness. One participant stated, I loved learning about the different aspects of wellness and how I can focus on each one. Formerly, I would have combined mental wellness and spiritual wellness, but I learned techniques that can improve each one for better overall wellness (Participant 4). Participants were asked how the program could be improved, Many of the responders stated the program required no improvements. One participants stated, I cannot think of any ways that the program could be improved, I felt very comfortable and relaxed (Participant 3). Another participant wished the program could have been longer, and one requested all questionnaires to be completed prior to the program date. In hopes to increase participation, the program was kept to a concise three hours, though could have easily been extended. The pre-test survey was completed prior to the program, however a photo release form and the How Healthy Are You survey were completed the day of the program to ensure correctness as many responders had questions when completing these. Two participants requested more specific activities including more physical activity or more nutrition information. This was included in each program, however the techniques were adapted to appease each group as a whole, rather than one participant. Each session included an overview of several techniques in hopes of providing a well rounded pool of information. The How Healthy Are You assessment was given 66 days following the completion of the program in order to assess their wellness after given the chance to implement a newly learned technique (Donatelle, 2009). Due to the time restraints for the Doctoral Capstone Experience (DCE), assessments were not returned in time for submission of this paper, however will be included if given the chance to present at the AOTA Conference in 2019. Quality Improvement/Meeting Societal Needs A PILOT WELLNESS PROGRAM 34 The balance2bewell program helped the participants overall wellness as evidenced by results of the outcome measures previously discussed. Information derived from past participants surveys indicated that wellness issues can surpass pageant competition such as body image issues, depression and anxiety. Therefore, a wellness program like balance2bewell is important to provide pageant contestants with support and guidance to improve their overall wellness. Regardless if the participant plans to continue in pageantry with local, state or national levels, or not, her wellness is important throughout the entirety of her life. To ensure continuous quality improvements, there was constant communication and reflection with the Miss Indiana Organization executive director which helped the program stay on the right track throughout the entirety of the DCE. The program was an open format which allowed for individualized needs assessments in hopes of providing client centered care that will assist participants during pageant life and far beyond even as life stressors change. The post-survey included questions directly tied to balance2bewell to gather perceptions of how the program helped, how the program could improve, and what wellness technique does the participant plan to implement. Based on feedback from the participants, a small group size was maintained, and information on finances and nutrition were discussed within the group as well as expanded on the website. Beyond the postsurvey immediately following completion of the program, participants were also asked to complete the How Healthy Are You survey again. Analysis of this survey was able to assess the longer term effects the program had on participants, and help to further establish areas of quality improvement to promote best practice. The ultimate goal of this delayed follow up survey was to increase effectiveness for program continuation. Discontinuation/Continuation A PILOT WELLNESS PROGRAM 35 As four programs were offered in different areas of the state, discontinuation of balance2bewell occured after completion of the fourth program. The balance2bewell website acts as a continuous resource for contestants which remains available to them far beyond the pageant world due to its inclusion of wellness resources (Eberly, 2018). Available resources on this website are valuable to the continuation of wellness for participants after discontinuation of the program because it provides them with up to date information of wellness techniques and tips to balance mind, body, and spirit (Eberly, 2018). Possibilities exist that this program can continue as an annual opportunity for pageant participants, however remains unconfirmed. Although time of the DCE will have elapsed, a wellness program during Miss Indiana Week will be provided for both miss and teen contestants. Overall Learning Summary Through completion of this DCE, I feel much more prepared for my future with the further development of my professional and interpersonal skills. I have been able to increase my effectiveness with time management, self-directed learning, and communication by fully engaging in increasing my skills. The prioritization of all tasks and set goals helped me to stay on track. I spent most days alone in the University library therefore self-directed learning was imperative. I was able to reach out to the Miss Indiana executive director and my faculty advisor when assistance was required. I stayed in touch with the board members, local directors, past participants and current participants all of which required different types of communication. For example, board members and local directors required highly professional forms of communication with email and in-person meetings and presentations. For past participants, I was professional, however provided short communication in hopes of increasing participation to fill out surveys. For current participants, I was much more relaxed with communication in order to A PILOT WELLNESS PROGRAM 36 build rapport and encourage program participation. Development of this program has given me the opportunity to be creative and use my skills, which will further help my future practice. In the future I can develop programs for my workplace to better provide care and service to clients. As previously mentioned, I spent a majority of my DCE in solitude, however I learned a lot when working with the Miss Indiana executive director. We worked together to determine the best form of communication with those involved, recruitment of program participants and program development. With her on my team, I learned ways to motivate the apathetic and how to deal with rejection. Initial objectives were met upon the completion of the DCE including the development of a website, wellness program, and a written paper for publication. The development of the balance2bewell website required the acknowledgement to whom the audience would be in order to appeal to the population. Throughout program development, constant communication with the Miss Indiana Organization Executive Director transpired through email and phone call. This required professional manners to present ideals and questions appropriately. To secure placements for where balance2bewell could be held, communications via meetings, phone calls, and emails were completed with program services at four different universities in Indiana. Also requiring professional communication, a presentation was given to the local directors in hopes to spread awareness of the wellness program and encourage participation of their contestants. Surveys were sent professionally through emails to board members, local directors, and past participants. Current participants were also contacted through email and facebook in order to increase program participation. Although this communication was geared toward a younger population than other forms of communication, and sometimes occurred over social media, it A PILOT WELLNESS PROGRAM 37 remained professional. Professional and effective communication was also completed in order to present and confirm continuation of this project at the Miss Indiana State level competition. When working with a group of people one must remain professional while also using the therapeutic use of self to connect and build rapport. This was done with every group session and during every presentation. When speaking and presenting to a large group of people this is still important, however more difficult. Maintaining professionalism while building rapport was demonstrated during a presentation to the Miss Indiana state level contestants, local directors, and board members simultaneously at the Miss Indiana Kick Off. Much of this project was completed individually which required a great deal of selfdirected learning. Research was completed, time management skills were enhanced, and communication skills were further developed on a large scale. A PILOT WELLNESS PROGRAM 38 References 2017 state contestant contract [PDF]. (2017). Miss America Organization. 2018 local contestant contract [PDF]. (2018, January 5). Miss America Organization. 2018 Miss America competition scoring guide [PDF]. (2018). Miss America Organization. 2018 national contestant contract [PDF]. (2018). Miss America Organization. Advocare. (2018). Our company. 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Former Miss America 2008 to speak at the College of New Jersey to raise awareness of eating disorders. PR Newswire. Retrieved from https://www.prnewswire.com/news-releases/former-miss-america-2008-to-speak-at-the-c ollege-of-new-jersey-to-raise-awareness-of-eating-disorders-300548669.html Myers, J. E., Sweeney, T. J., & Witmer, J. M. (2000). The wheel of wellness counseling for wellness: a holistic model for treatment planning. Journal Of Counseling & A PILOT WELLNESS PROGRAM 44 Development, 78(3), 251-266. Napier, S. (2016). The importance of self-awareness for student leaders. Campus Activities Programming, 49(1), 8-9. Nelson, D. L., Thompson, G., & Moore, J. A. (1982). Identification of Factors of Affective Meaning in Four Selected Activities. American Journal of Occupational Therapy,36(6), 381-387. doi:10.5014/ajot.36.6.381 Niemeyer, R. A. (2016). Techniques of grief therapy: Assessment and intervention. New York: Routledge. Ng A. H., N., Boey K., W., Mok, D., Leung E. 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WHAT: Occupational Therapists help people with anything that they need to do, want to do, or are expected to do on a daily basis. Therapists work with people to balance the mind, body, and spirit in order to increase his or her overall wellness. I am creating a wellness program for the contestants of Miss Indiana at the local and state levels, but I need your help to gather more valuable perspectives WHY: The purpose of this project is to promote wellness in the Miss Indiana Organization by balancing mind, body and spirit through occupations. As participants of the local and Miss Indiana pageants, young women are increasing their occupations with pageant preparations/participation, active role models, and service opportunities. This causes a loss of balance in their everyday lives and decreases their overall wellness. PURPOSE: The purpose of this survey to is obtain the perspective of those involved in the pageant, but are not participants. You have all seen several years of competition with different groups of wonderful young women. Please reflect upon your experiences to answer the following questions. ALL RESPONSES REMAIN ANONYMOUS - ANY IDENTIFYING INFORMATION WILL BE REMOVED A PILOT WELLNESS PROGRAM 48 Appendix B Board Member Survey * Required 1. Name * 2. Email Address * Involvement Volunteers with Miss Indiana 3. How long have you volunteered with the organization? * 4. How did you get involved? * Mark only one oval. -I was a participant that came back to help -My family member/friend talked me into it -Another volunteer asked me to help -I was looking for something to do -Other: ____________________________ 5. What is your role? Give a short description. * ____________________________________ ____________________________________ 6. About how much time do you typically spend with the contestants during Miss Indiana week?* Mark only one oval. -All day, every day -All day for a couple days, but not every day -Only for the nights of competition -Every day for only some of the time -Just a couple hours Less than an hour -I only see them from the audience -Other: ______________________________ Wellness For the purpose of this program, wellness is defined as the balance of the mind, body, and spirit through occupations. Occupations in this sense being anything a person wants to do, needs to do, or is expected to do in a day. Occupations, as well as wellness, are specific to each person and with a client centered approach, an occupational therapist can help to promote a holistic wellness for each individual. 7. What might be the demands of the participants' wellness during preparation and participation in these pageants? * ____________________________________ ____________________________________ 8. Describe wellness strategies that are already incorporated into this organization. (ex. healthy meals, prayer, etc). * ____________________________________ ____________________________________ ______9. Describe the wellness concerns you have had for participants. * ____________________________________ ____________________________________ ______10. What do you think pageant participants would benefit from in a wellness program to maintain their overall wellness prior to and during Miss Indiana week? Pick all that apply. * Check all that apply. Stress management techniques Mindfulness strategies to increase focus on the present moment Spiritual guidance Education on the balance of mind, body, and spirit Relaxation techniques Time management and organization strategies Other: ___________________________________ A PILOT WELLNESS PROGRAM 49 Appendix C Local Director Survey * Required 1. Name * 2. Email Address * 3. What local pageant do you direct? * Involvement Volunteers with Miss Indiana 4. How long have you been a local pageant director in this organization? * 5. How did you get involved? * Mark only one oval. I was a participant that came back to help My family member/friend talked me into it Another volunteer asked me to help I was looking for something to do Other: ____________________________ 6. About how much time do you typically spend with the contestants during the pageant?* Mark only one oval. All day, every day All day for a couple days, but not every day Only for the nights of competition Every day for only some of the time Just a couple hours Less than an hour I only see them from the audience Other: ______________________________ 7. Describe how much time you spend with the winner of your pageant in preparation for Miss Indiana. * ____________________________________ ____________________________________ Wellness For the purpose of this program, wellness is defined as the balance of the mind, body, and spirit through occupations. Occupations in this sense being anything a person wants to do, needs to do, or is expected to do in a day. Occupations, as well as wellness, are specific to each person and with a client centered approach, an occupational therapist can help to promote a holistic wellness for each individual. 8. What might be the demands of the participants' wellness during preparation and participation in these pageants? * ____________________________________ ____________________________________ rategies that are already incorporated into this organization. (ex. healthy meals, prayer, etc). * ____________________________________ ____________________________________ 10. Describe the wellness concerns you have had for participants. * ____________________________________ ____________________________________ 11. What do you think pageant participants would benefit from in a wellness program to maintain their overall wellness prior to and during Miss Indiana week? Pick all that apply. * Check all that apply. Stress management techniques Mindfulness strategies to increase focus on the present moment Spiritual guidance Education on the balance of mind, body, and spirit Relaxation techniques Time management and organization strategies Other: ____________________________________ A PILOT WELLNESS PROGRAM 50 Appendix D Past Participant Survey * Required 1. Name * 2. Email address * Pageant Participation 3. When did you last participate? * 4. How many years total, did you participate? (teen and miss) * 5. Why did you stop participating in the Miss Indiana Organization pageants? * Mark only one oval. -Aged out -Got married -Moved out of state, not competing anymore -Moved out of state, still competing -Too busy - My choice -Financial reasons -Too difficult -Other:____________________________ 6. Did you make it to the state level? If yes, how many times? * ________________________________________________________________________ 7. Approximately how many locals did you participate in total? * ________________________________________________________________________ 8. What ties do you currently have to the contestants competing in locals and Miss Indiana? * Check all that apply. -My friends still compete. -I have family that competes. -I come to watch locals/state each year. -I volunteer with locals/state. -I am now a judge for the organization. -I now emcee. -I am no longer connected. -Other:____________________________ Perception of Wellness For the purpose of this program, wellness is defined as the balance of the mind, body, and spirit through occupations. Occupations in this sense being anything a person wants to do, needs to do, or is expected to do in a day. Occupations, as well as wellness, are specific to each person and with a client centered approach, an occupational therapist can help to promote a holistic wellness for each individual. A PILOT WELLNESS PROGRAM 51 9. Describe any decrease in overall wellness you experienced while competing. * ________________________________________________________________________ 10. What were some of the demands of the participants' wellness during preparation and participation in these pageants? * ________________________________________________________________________ 11. Describe the wellness concerns have you had regarding other girls you observed while competing in pageants or now while watching. * ________________________________________________________________________ 12. What do you think pageant participants would benefit from in a wellness program to maintain their overall wellness prior to and during Miss Indiana week?* Check all that apply. -Stress management techniques -Mindfulness strategies to increase focus on the present moment -Spiritual guidance -Education on the balance of mind, body, and spirit -Relaxation techniques -Time management and organization strategies Other:____________________________ The following questions are NOT required, but would assist in providing more insight. ALL RESPONSES REMAIN ANONYMOUS - ANY IDENTIFYING INFORMATION WILL 13. Have you ever had an eating disorder? Mark only one oval. -No -Anorexia -Bulimia -Combination -Other:___________________________ 14. If yes, when did it start and how long did/have you been experiencing it? ________________________________________________________________________ 15. Have you ever experienced depression, anxiety, or other mental health issues? Please explain. ________________________________________________________________________ 16. How did participating in the Miss Indiana Organization POSITIVELY impact these wellness issues? ________________________________________________________________________ 17. How did participating in the Miss Indiana Organization NEGATIVELY impact these wellness issues? ________________________________________________________________________ A PILOT WELLNESS PROGRAM 52 Appendix E balance2bewell Program Pre-Test The purpose of this survey is to obtain general knowledge of your current exposure and understanding of holistic wellness through occupations: balancing the body, mind, and spirit. Information gathered here will be compared to post-test upon completion of this program in order to evaluate the effectiveness of the implementation of a wellness program in the Miss Indiana Organization. ALL RESPONSES REMAIN ANONYMOUS - ANY IDENTIFYING INFORMATION WILL BE REMOVED * Required 12. Rate your current wellness: mind? * 1. Name * Mark only one oval. 2. Email address * 13. How do you currently maintain you 3. Platform with short description. * wellness of mind? * ____________________________________ ____________________________________ ____________________________________ ____________________________________ 4. As of now, will you be competing in the 14. Rate your current wellness: body? * Miss Indiana Pageant this year? * Mark Mark only one oval. only one oval. 15. How do you currently maintain you wellness of body? * -Yes! ____________________________________ -Not this year. ____________________________________ -Not yet, but I still have a chance. 16. Rate your current wellness: spirit? * -Other:_____________________ Mark only one oval. 5. If yes, what is your title? * 17. How do you currently maintain you --------______________________________ wellness of spirit? * ______ ____________________________________ 6. How long have you participated in ____________________________________ pageants? * 18. Rate your current balance of these ____________________________________ three aspects. * Mark only one oval. 7. How long have you participated in the 19. What harms your wellness? Check all Miss Indiana Organization? * that apply. * Check all that apply. ____________________________________ -Too many things to do 8. Have you made it to the state level? If -Decreased sleep yes, how many times? * -Stress ____________________________________ -Anxiety or depression 9. Approximately how many locals did -Eating disorder you participate in total? * -Other mental/emotional illness ____________________________________ -Imbalanced life Wellness -Finances 10. What is your definition of wellness? * -Relationships ____________________________________ -Poor time management/procrastination ____________________________________ -Poor habits 11. Rate your current overall wellness? * -Your daily environment Mark only one oval. -No daily routine A PILOT WELLNESS PROGRAM -Other:___________________________ Pageant Wellness 20. When do you feel most unbalanced in wellness during the pageant process? * Mark only one oval. -Getting ready for the pageant -Local level -State level -After it is all said and done -Never - always fully balanced -Other:____________________________ 21. When do you feel most unbalanced in wellness in the pageant itself? * Mark only one oval. -Before the pageant -Backstage -Opening number -Introduction -Interview -Onstage question -Swimsuit -Talent -Gown -Waiting for results -After the pageant -Other: 22. What aspect of the Miss Indiana Organization local and/or state pageants has helped to increase your overall wellness the most? * ____________________________________ ____________________________________ 23. What aspect of the Miss Indiana Organization local and/or state pageants has decreased your overall wellness the most? * ____________________________________ ____________________________________ 53 A PILOT WELLNESS PROGRAM 54 Appendix F balance2bewell Program Post-Test The purpose of this survey is to obtain general knowledge of your current exposure and understanding of holistic wellness through occupations: balancing the body, mind, and spirit. Information gathered here will be compared to post-test upon completion of this program in order to evaluate the effectiveness of the implementation of a wellness program in the Miss Indiana Organization. ALL RESPONSES REMAIN ANONYMOUS - ANY IDENTIFYING INFORMATION WILL BE REMOVED * Required 1. Name * 2. Email address * Wellness 3. What is your definition of wellness? * ________________________________________________________________________ 4. Rate your current overall wellness? * Mark only one oval. 5. Rate your current wellness: mind? * Mark only one oval. 6. How do you currently maintain you wellness of mind? * ________________________________________________________________________ 7. Rate your current wellness: body? * Mark only one oval. 8. How do you currently maintain you wellness of body? * ________________________________________________________________________ 9. Rate your current wellness: spirit? * Mark only one oval. 10. How do you currently maintain you wellness of spirit? * ________________________________________________________________________ 11. Rate your current balance of these three aspects. * Mark only one oval. 12. What harms your wellness? Check all that apply. * Check all that apply. -Too many things to do -Decreased sleep -Stress A PILOT WELLNESS PROGRAM 55 -Anxiety or depression -Eating disorder -Other mental/emotional illness -Imbalanced life -Finances -Relationships -Poor time management/procrastination -Poor habits -Your daily environment -No daily routine -Other:_____________________________ Pageant Wellness 13. In what ways did the wellness program help you the most?* ________________________________________________________________________ 14. How can the program improve to better help the participants?* ________________________________________________________________________ 15. What new wellness technique to you plan to place into your daily life?* ________________________________________________________________________ A PILOT WELLNESS PROGRAM 56 Appendix G Assess Yourself: How Healthy Are You? By completing the following assessment, you will have a clearer picture of health areas in which you excel and those that could use varying degrees of work. Taking this assessment will also help you to reflect on various components of health that you may not have thought much about. Use the results from this assessment as a guide and as a way to begin analyzing potential areas for improvement and/or maintenance. Answer each question, then total your score for each section. Your scores will appear in the Personal Checklist at the end of the assessment for a general sense of your health profile. Think about the behaviors that influenced your score in each category. Would you like to change any of them? Choose the area that youd like to improve, then complete the Behavior Change Contract at the end of this book. Use the contract to think through and implement a behavior change over the course of this class. Each of the categories in this questionnaire is an important aspect of the total dimensions of health, but this is not a substitute for the advice of a qualified health care provider. Consider scheduling a thorough physical examination by a licensed physician or setting up an appointment with a mental health counselor at your school if you think you need help making a behavior change. Instructions: For each of the following, indicate how often you think the statements describe you Key 1 - Never 2 - Rarely 3 - Some of the Time 4 Usually or Always PHYSICAL HEALTH I am happy with my body size and weight. 1 2 3 4 I engage in vigorous exercises such as brisk walking, jogging, swimming, or running 1 2 3 4 for at least 30 minutes per day, 34 times per week. I do exercises designed to strengthen my muscles and increase endurance at least 2 times per week. 1 2 3 4 I do stretching, limbering up, and balance exercises such as yoga, pilates, or tai chi 1 2 3 4 to increase my body awareness and control and increase my overall physical health. I feel good about the condition of my body and would be able to respond to most demands placed upon it. 1 2 3 4 I get at least 78 hours of sleep each night. 1 2 3 4 I try to add moderate activity to each day, such as taking the stairs instead of the elevator and walking whenever I can instead of riding. 1 2 3 4 A PILOT WELLNESS PROGRAM 57 My immune system is strong and my body heals itself quickly when I get sick or injured. 1 2 3 4 I have lots of energy and can get through the day without being overly tired. 1 2 3 4 I listen to my body; when there is something wrong, I try to make adjustments to heal it or seek professional advice. 1 2 3 4 SOCIAL HEALTH When I meet people, I feel good about the impression I make on them. 1 2 3 4 I am open, honest, and get along well with other people. 1 2 3 4 I participate in a wide variety of social activities and enjoy being with people who are different than I. 1 2 3 4 I try to be a better person and work on behaviors that have caused problems in my 1 2 3 4 interactions with others. I get along well with the members of my family. 1 2 3 4 I am a good listener. 1 2 3 4 I am open and accessible to a loving and responsible relationship. 1 2 3 4 I have someone I can talk to about my private feelings. 1 2 3 4 I consider the feelings of others and do not act in hurtful or selfish ways. 1 2 3 4 I try to see the good in my friends and do whatever I can to support them and help them feel good about themselves. 1 2 3 4 EMOTIONAL HEALTH I find it easy to laugh, cry, and show emotions like love, fear, and anger and try to express these in positive, constructive ways. 1 2 3 4 I avoid using alcohol or other drugs as a means of helping me forget my problems. 1 2 3 4 A PILOT WELLNESS PROGRAM 58 When viewing a particularly challenging situation, I tend to view the glass as half full rather than half empty and perceive problems as opportunities for growth. 1 2 3 4 When I am angry, I try to let others know in nonconfrontational and nonhurtful ways, trying to resolve issues rather than stewing about them. 1 2 3 4 I try not to worry unnecessarily and try to talk about my feelings, fears, and concerns 1 2 3 4 rather than letting them become chronic issues. I recognize when I am stressed and take steps to relax through exercise, quiet time, or other calming activities. 1 2 3 4 I feel good about myself and believe others like me for who I am. 1 2 3 4 I try not to be too critical and/or judgmental of others and to understand differences 1 2 3 4 or quirks that I may note in others. I am flexible and adapt or adjust to change in a positive way. 1 2 3 4 My friends regard me as a stable, emotionally well-adjusted person whom they trust 1 2 3 4 and rely on for support. ENVIRONMENTAL HEALTH I am concerned about environmental pollution and actively try to preserve and protect natural resources. 1 2 3 4 I buy recycled paper and purchase biodegradable detergents and cleaning agents whenever possible. 1 2 3 4 I recycle my garbage, purchase refillable containers when possible, and try to minimize the amount of paper and plastics that I use. 1 2 3 4 I try to wear my clothes for longer periods between washing to reduce water consumption and the amount of detergents in our water sources. 1 2 3 4 I vote for pro-environment candidates in elections. 1 2 3 4 I write my elected leaders about environmental concerns. 1 2 3 4 I turn down the heat and wear warmer clothes at home in winter and use the air conditioner only when necessary or at higher temperatures in summer. 1 2 3 4 I am aware of lead pipes in my living area, chemicals in my carpet, and other potential hazards and try to reduce my exposure whenever possible. 1 2 3 4 I use both sides of the paper when taking class notes or doing assignments. 1 2 3 4 I try not to leave the faucet running too long when I brush my teeth, shave, or shower. 1 2 3 4 A PILOT WELLNESS PROGRAM 59 SPIRITUAL HEALTH I believe life is a precious gift that should be nurtured. 1 2 3 4 I take time to enjoy nature and the beauty around me. 1 2 3 4 I take time alone to think about whats important in lifewho I am, what I value, where I fit in, and where Im going. 1 2 3 4 I have faith in a greater power, be it a God-like force, nature, or the connectedness of all living things. 1 2 3 4 I engage in acts of caring and goodwill without expecting something in return. 1 2 3 4 I feel sorrow for those who are suffering and try to help them through difficult times. 1 2 3 4 I look forward to each day as an opportunity for further growth and challenge. 1 2 3 4 I work for peace in my interpersonal relationships, in my community, and in the world at large. 1 2 3 4 I have a great love and respect for all living things, and regard animals, etc., as important links in a vital living chain. 1 2 3 4 I go for the gusto and experience life to the fullest. 1 2 3 4 INTELLECTUAL HEALTH I carefully consider my options and possible consequences as I make choices in life. 1 2 3 4 I learn from my mistakes and try to act differently the next time. 1 2 3 4 I follow directions or recommended guidelines, avoid risks, and act in ways likely to 1 2 3 4 keep myself and others safe. I consider myself to be a wise health consumer and check reliable information sources before making decisions. 1 2 3 4 I am alert and ready to respond to lifes challenges in ways that reflect thought and sound judgment. 1 2 3 4 I have at least one hobby, learning activity, or personal growth activity that I make time for each week; something that improves me as a person. 1 2 3 4 A PILOT WELLNESS PROGRAM 60 I actively learn all I can about products and services before making decisions. 1 2 3 4 I manage my time well rather than let time manage me. 1 2 3 4 My friends and family trust my judgment. 1 2 3 4 I think about my self-talk (the things I tell myself) and then examine the evidence to 1 2 3 4 see if my perceptions and feelings are sound. PERSONAL HEALTH PROMOTION/DISEASE PREVENTION I know the warning signs of common sexually transmitted infections, such as genital 1 2 3 4 warts (HPV), chlamydia, and herpes, and read new information about these diseases as a way of protecting myself. If I were to be sexually active, I would use protection such as latex condoms, dental 1 2 3 4 dams, and other means of reducing my risk of sexually transmitted infections. I find ways other than binge drinking when at parties or during happy hours to loosen up and have a good time. 1 2 3 4 When I have more than 1 or 2 drinks, I ask someone who is not drinking to drive me 1 2 3 4 and my friends home. I have eaten too much in the last month and have forced myself to vomit to avoid gaining weight. 1 2 3 4 I have several piercings and have found that I enjoy the rush that comes with each piercing event. 1 2 3 4 If I were to have a tattoo or piercing, I would go to a reputable person who follows strict standards of sterilization and precautions against blood-borne disease transmission. 1 2 3 4 I engage in extreme sports and find that I enjoy the highs that come with risking bodily harm through physical performance. 1 2 3 4 I am careful not to mix alcohol or other drugs with prescription and over-the-counter 1 2 3 4 drugs. I practice monthly breast/testicle self-examinations. 1 2 3 4 A PILOT WELLNESS PROGRAM 61 SCORING Here are your scores in each of the health dimensions. Compare them to what would be considered optimal scores. Which areas do you need to work on? How does your score compare with how you rated yourself in the first part of the questionnaire? Ideal Score Physical health 40 Social health 40 Intellectual health 40 Emotional health 40 Environmental health 40 Spiritual health 40 Personal health promotion and disease prevention 40 Your Score Initial Self Rating *If you receive a "No Answer" result in the Initial Self Rating column of this table, then selections from the previous page were not received. Please return to the previous section, mark your selections, and click "Evaluate". What Your Scores in Each Category Mean Scores of 3540: Outstanding! Your answers show that you are aware of the importance of these behaviors in your overall health. More important, you are putting your knowledge to work for you by practicing good health habits that should reduce your overall risks. Although you received a very high score on this part of the test, you may want to consider areas where your scores could be improved. Scores of 3034: Your health practices in these areas are very good, but there is room for improvement. Look again at the items you answered that scored one or two points. What changes could you make to improve your score? Even a small change in behavior can help you achieve better health. Scores of 2029: Your health risks are showing! Find information about the risks you are facing and why it is important to change these behaviors. Perhaps you need help in deciding A PILOT WELLNESS PROGRAM 62 how to make the changes you desire. Assistance is available from this book, your professor, and student health services at your school. Consider making a change by filling out the Behavior Change Contract at the end of this book. Scores below 20: You may be taking unnecessary risks with your health. Perhaps you are not aware of the risks and what to do about them. Identify each risk area and make a mental note as you read the associated chapter in the book. Whenever possible, seek additional resources, either on your campus or through your local community health resources, and make a serious commitment to behavior change. If any area is causing you to be less than functional in your class work or personal life, seek professional help. In this book you will find the information you need to help you improve your scores and your health. Remember that these scores are only indicators, not diagnostic tools. A PILOT WELLNESS PROGRAM 63 Appendix H Activity One: Coat of Arms Overall Group title: Miss Indiana Wellness Group Session title: Personal Coat of Arms Format: Warm up- 5 minutes Introduce activity- 5 minutes Instructions for activity- 5 minutes Activity- 25 minutes Discussion- 15 Summary- 5 minutes Supplies: Copies of Coat of Arms Paper Colored pencils, markers, pens, and pencils Description: 1. Introduction (5 points) 1. Introduce self, name and title of group, member introductions 1. Each member states name and tells their favorite pageant memory. 2. Warm-up 1. Toilet paper task. 1. Participants will around a roll of toilet paper and instruct participants to take as much as you need. Participants will take turns identifying their personal passions in life; identify one passion per square. 1. Explain the purpose 1. This warm up activity will help break the ice as you share things about yourself others may not know. 2. The purpose of this activity is to complete self-reflection and explore your own personality before sharing it with others. It is a great to get to know yourself, express it in words, then when everyone has an opportunity to share, it will build in team strength and bond the group. 2. Brief outline of session/time frame 1. Warm up- 10 minutes 2. Introduce activity- 5 minutes 3. Instructions for activity- 5 minutes 4. Activity- 20 minutes 5. Discussion- 15 6. Summary- 5 minutes 1. Activity -- Personal Coat of Arms 1. Each participant will receive a worksheet to fill out with words and/or pictures with the instructions: 1. Draw a picture or a write a small explanation in each square to represent the following: A PILOT WELLNESS PROGRAM 1. 2. 3. 4. 5. 64 2. Each square is for each prompt: 1. What you like about yourself 2. Your greatest achievement 3. Your most prized possession 4. What you value most in life 5. A symbol of your personality 6. Three words to be remembered by 3. Reference where the activity came from 1. Hayes, P. (2011). Leading and coaching to success: The secret life of teams. Maidenhead: Open University Press. Sharing: How will individual work be shared 1. At the end, participants can share how as much as they are comfortable 1. Remind them that the best part is that everyones will be different and that is the way it should be. 2. Then ask someone to volunteer to start and make them feel comfortable to share anything else about their personal coat of arms they would like to. Processing: Members express how they feel about the experience, leader, each other 1. How did it feel, to think about these prompts? 2. Have you thought of this before? 3. Was your coat of arms different or similar than others? How does that make you feel? 4. How did it feel to share your coat of arms? 5. Which prompt was the most difficult to answer? The easiest? Generalizing 1. What did you learn about yourself from todays activity? 2. What did you learn about others today? Application How the principles learned during group can be applied to everyday life 1. How can this activity help you with your daily life, or pageant life? 2. How can this come in handy during your pageant experiences? Summary (5 points) 1. Does anyone have anything you want to share to summarize the session? 2. Does anyone want to share anything new they learned? 3. You are not alone and now that we know a little more about one another I think our bond is stronger! 4. Thank you for your participation! A PILOT WELLNESS PROGRAM 65 Appendix I A PILOT WELLNESS PROGRAM 66 Appendix J A PILOT WELLNESS PROGRAM 67 Appendix K Activity Two: Self Awareness Collage Overall Group title: Miss Indiana Wellness Group Session title: Self-Awareness Collage Format: Warm up- 5 minutes Introduce activity- 5 minutes Instructions for activity- 5 minutes Activity- 25 minutes Discussion- 15 Summary- 5 minutes Supplies: Magazines Computer Paper Pens, pencils, colored pencils, markers Scissors Glue and tape Description: 1. Introduction (5 points) 1. Introduce name and title of group, member introductions 1. Each member states name and tells their most embarrassing pageant memory. 2. Warm-up 1. Reading people nonverbally. 1. The group will sit in a circle and attempt to count to any number (usually 10 or 15) as a group. Only one person can talk at once and if two or more people talk at once then the counting starts over. One participant says one and another participant says two and so on. Read your fellow group members in order to decide when to say a number. Everyone should participate. 1. Explain the purpose a. This warm up activity will help the group become more cohesive and bonded as it is a personal thing to read someones body language. b. The purpose of this activity is to complete self-reflection and explore the things you keep inside and the things you want others to see about yourself. Then they have an opportunity to share. After becoming closer throughout the program, they may be more willing to share things that are more personal and thus realize they are not alone in hiding. 2. Brief outline of session/time frame a. Warm up- 10 minutes b. Introduce activity- 5 minutes c. Instructions for activity- 5 minutes A PILOT WELLNESS PROGRAM 1. 1. 2. 3. 4. 5. 68 d. Activity- 20 minutes e. Discussion- 15 f. Summary- 5 minutes 3. Educational concepts/reference 1. Cole, M. B. (2012). Group dynamics in occupational therapy: The theoretical basis and practice application of group intervention. Thorofare, NJ: Slack Incorporated. Activity -- Self-Awareness Collage 1. Each participant will receive a blank piece of paper with instructions to fold it in half 1. The outsides of the paper represent the way others see you or the way you want others to see you 2. The insides of the paper represent the things that you dont want others to know or see about you, the things you hide 2. They will cut pictures and words out of magazines and glue them to the appropriate aspects of the paper. 3. Reference where the activity came from 1. Cole, M. B. (2012). Group dynamics in occupational therapy: The theoretical basis and practice application of group intervention. Thorofare, NJ: Slack Incorporated. Sharing: 1. At the end, participants can share how as much as they are comfortable 1. Remind them that the best part is that everyones will be different and that is the way it should be. 2. Then ask someone to volunteer to start and make them feel comfortable to share anything else about the collage. Processing: Members express how they feel about the experience, leader, each other 1. How did it feel, identify the things about yourself you share or hide? 2. Have you thought of this before? 3. Was your paper different or similar than others? How does that make you feel? 4. How did it feel to share your papers outside? What about the inside? Generalizing 1. What did you learn about yourself from todays activity? 2. What did you learn about others today? Application 1. How the principles learned during group can be applied to everyday life? 2. How can this activity help you with your daily life, or pageant life? 3. How can this come in handy during your pageant experiences? Summary 1. Does anyone have anything you want to share to summarize the session? 2. Does anyone want to share anything new they learned? 3. You are not alone and now that we know a little more about one another I think our bond is stronger! 4. Thank you for your participation! A PILOT WELLNESS PROGRAM 69 Appendix L A PILOT WELLNESS PROGRAM 70 Appendix M  ...

... Neandertal Dental Microwear Texture Analysis: A Bioarchaeological Approach Jessica L. Droke B. A., University of Tennessee: Knoxville, 2013 A Thesis Submitted in Partial Fulfillment of the Requirements for the Master of Science Degree in Anthropology at the University of Indianapolis June 2017 Dr. Christopher W. Schmidt, Advisor To my parents, Ann and Thomas Shearon Who have loved me unconditionally and supported all my academic endeavors And To my partner, Kristen A. Broehl Who has been an endless source of encouragement, a world-class editor, and my biggest fan Acknowledgments I would like to thank Dr. Christopher W. Schmidt for all of his guidance and support throughout this process and for allowing me to pursue such an ambitious and interesting project. Dr. Schmidt has been instrumental in helping to develop this approach and in bringing together the people and materials which made this study possible. I would like to thank Dr. Gregory A. Reinhardt for his advice and thoughtful edits throughout the writing process. I would also like to extend a special thanks Dr. Frank LEngle Williams and Dr. John C. Willman for providing the Neandertal dental casts used in this study, their willingness to work cooperatively, and for their suggestions along the way. I would like to thank the graduate students in the Anthropology program at the University of Indianapolis, especially Rose L. Perash and Arysa GonzalezRomero, for their investment in this project since its inception and above all for their excellent friendship. I thank my family, particularly my parents Ann and Thomas Shearon, my sister Sarah Droke, and my grandmother Joanne Van Cleave for their support and encouragement during the pursuit of my academic goals. I thank my partner Kristen A. Broehl for her anthropological insights, her belief in me, and for her love without which none of this would be possible. 1. Introduction Neandertals are best represented from marine isotope stages (MIS) 6 through 3 (30,000-190,000 BP). During this long period of time, Neandertals successfully occupied areas of western Eurasia and coped with drastic fluctuations in climatic conditions associated with alternating glacial/interglacial cycles of the Middle and Late Pleistocene (van Andel and Tzedakis 1996). Although the fossil and archaeological records indicate that their occupation of Pleistocene western Eurasia may have been discontinuous (Hublin and Roebroeks 2009), significant evidence suggests that Neandertals were environmentally successful. Their remains have been found in several habitats ranging from warm and forested to cold and open. Doubtless, these varying environments would have led to differences and fluctuations in resource availability and would have resulted in highly adaptive Neandertal subsistence patterns. As with geography, temporal changes in diet are key to understanding Neandertal cultural adaptations during the dynamic glacial period in which they flourished. Previous studies of their dental microwear indicate that divergent environments yielded significantly different microwear signatures (El Zaatari et al. 2011). The current study looks for similar evidence of microwear-based dietary differences by focusing on previously unstudied Neandertal remains and taking into account temporal and geographic differences. Given that previous studies have shown variability in Neandertal diet between ecological regions (e.g., El Zaatari et al. 2011, 2016), this study explores the ways in which microwear disparities manifest themselves with regard to age within a population. Recently, studies using dental microwear texture analysis (DMTA) have effectively detected subtle dietary differences in Middle and Late Pleistocene humans (Estalrrich et al. 2017; Remy et al. 2014). Furthermore, comparisons have been made between Neandertals and modern human groups. Archaeological populations from similar environmental contexts (i.e. the Inuit) mirror those found in some Neandertal groups (Krueger and Ungar 2012). Thus, this project is bioarchaeological; it takes a population-based approach that seeks to determine inter- and intra-population dietary nuances. It also assumes that decisions regarding diet are culturally mitigated and, as such, could vary based on social variables, including demography. In the end, the current study seeks to understand the variability we see in Neandertal dental microwear in relation to where they lived and their biological ages. 1.2 Neandertal diet studies Attempts to reconstruct Neandertal diet have been carried out using several different techniques, including the analysis of faunal assemblages (Antunes 2000; Aura Tortusa et al. 2002; Barton 2000; Boyle 2000; Conrad and Prindiville 2000; Finlayson et al. 2006; Finlayson et al. 2001; Patou-Mathis 2000); botanical remains (Hardy 2004; Lev et al. 2005; Madella et al. 2002); bone and tooth chemistry (Beauval et al. 2006; Bocherens et al. 1999; Bocherens et al. 2001; Bocherens and Drucker 2003; Bocherens et al. 2005; Bocherens et al. 1991; Fizet et al. 1995; Richards et al. 2000; Richards and Schmitz 2008; Richards et al. 2008; Richards and Trinkaus 2009); SEM-based dental macrowear (Fiorenza 2015; Fiorenza et al. 2011; Fiorenza and Kullmer 2013); dental calculus (Hardy et al. 2012; Henry et al. 2010; Weyrich et al. 2017); and DMTA of incisors (Krueger and Ungar 2012; Krueger et al. Under Review) and molars (El Zaatari et al. 2011; El Zaatari et al. 2016; Estalrrich et al. 2017; Perez-Perez et al. 2003). Zooarchaeological data indicates at least some level of geographic differences associated with Neandertal prey selection. Studies indicate that Neandertals from colder environments in northern and central Europe relied heavily on large-bodied herbivores (Conrad and Prindiville 2000; Patou-Mathis 2000), while those from warmer environments in southern/Mediterranean Europe increased their reliance on medium-sized herbivores (Aura Tortusa et al. 2002; Boyle 2000). The consumption of small-bodied and marine animals has been found in several Middle Paleolithic sites in Europes southern/Mediterranean region (Antunes 2000; Barton 2000; Finlayson et al. 2001). These studies may suggest temporal differences in Neandertal diets associated with climatic changes (Conrad and Prindiville 2000; Patou-Mathis 2000). Evidence further indicates plant-food exploitation, based on analyses of floral remains in site sediments (Lev et al. 2005; Madella et al. 2002), tools (Hardy 2004), and dental calculus (Henry et al. 2010). Stable isotope analyses conducted on 15 Neandertal individuals from different European sites indicate a general conformity in diet (Beauval et al. 2006; Bocherens et al. 1999; Bocherens et al. 2001; Bocherens and Drucker 2003; Bocherens et al. 2005; Bocherens et al. 1991; Fizet et al. 1995; Richards et al. 2000; Richards and Schmitz 2008; Richards et al. 2008; Richards and Trinkaus 2009). All of these individuals diets consisted almost entirely of meat from large, open-range herbivores, but it should be noted that this statement cannot be applied to all Neandertals because the specimens analyzed came only from northern and central Europe and all date to MIS 3, with one exception (dated to MIS 5) (El Zaatari et al. 2011). In contrast to the relatively homogenous diet indicated by stable isotope studies, dental macrowear in Neandertals indicates at least some degree of variability. When compared to modern hunter-gatherer populations with known diets, Neandertals show high degrees of dietary variability within Mediterranean evergreen habitats but a more restricted diet in upper latitude steppe/coniferous forest environments, which suggests a high consumption of meat resources (Fiorenza et al. 2011). A later study by Fiorenza (2015) reaffirms the consumption of animal proteins in cold-habitat environments, such as steppe and grasslands, and indicates potential dietary differences in chronological sequences, where warm periods correspond to higher diversity. Maxillary molar macrowear of the Saccopastore Neandertals also shows some degree of non-normal chewing behavior, suggesting the functional use of the dentition in nonmasticatory cultural behaviors (Fiorenza 2015). These wear patterns occur in both Neandertals and early Homo sapiens from Near Eastern Middle Paleolithic sites and have been interpreted as using the posterior teeth as tools for tearing, holding, and shaping objects (Fiorenza and Kullmer 2013). Unlike other lines of evidence whereby diet must be inferred, dental calculus studies provide a uniquely direct insight into Neandertal diet. Calculus collected at Shanidar III (Iraq) and from Spy I and II (Belgium) indicates that Neandertals were exploiting a considerable amount of plant materials including date palms, legumes, and grass seeds, which show damage indicative of cooking (Henry et al. 2010). Results from Spains El Sidrn site demonstrates the first molecular evidence for inhaling wood-smoke and bitumen and ingesting a wide range of cooked plant materials (Hardy et al. 2012). The El Sidrn case is also particularly significant because it marks the first report of Neandertal use of medicinal plants and supposes advanced knowledge of the surrounding environment and the various plant resources available for exploitation (Hardy et al. 2012). Most recently a study conducted by Weyrich et al. (2017) indicates that the Spy Neandertals were relying on a heavily meat-based diet that included wooly rhinoceros and wild sheep characteristic of the steppe environment they inhabited. In contrast, the El Sidrn Neandertals showed no evidence of meat consumption in their calculus; instead it had dietary components of mushrooms, pine nuts, and moss and reflects forest-based gathering behaviors. This distinction was further reflected in differences in oral bacterial communities between the two groups. The study confirmed the use of medicinal plants by an El Sidrn Neandertal who suffered from dental abscess and a chronic gastrointestinal pathogen (Weyrich et al. 2017). On the whole, the available calculus data indicate that Neandertals were exploiting meat resources but also had significant plant components in their diet, including those with medicinal properties. Neandertals are known to have used their anterior teeth in ways that led to extreme wear, creating what is commonly referred to as an inverse bevel on their labial surfaces (Ungar et al. 1997). Rounded wear is also common on the anterior teeth, and it has been noted that they are in general more worn than the posterior dentition (Molnar 1972). This phenomenon appears across both time and space in Neandertals, notable examples being Shanidar I (Iraq) and La Ferrassie (France) where crowns have been worn away completely (Heim 1976; Trinkaus 1983). Neandertal anterior teeth also demonstrate a high frequency of chipping or fracturing (Fox and Frayer 1997). Heavy attrition of the anterior teeth reflects non-dietary wear as seen in several different cultures (Molnar 1972). Eskimo cultures are particularly of interest in this regard as they display similarly high rates of wear and chipping, which stem from the use of teeth in cracking and splitting bone, opening mollusk shells, softening animal hides, using the front teeth to clamp one end of an object while it is being worked by the hands at the other end, and using teeth to cut and tear seal meat (Guatelli-Steinberg 2016). Dental microwear texture analysis studies conducted by Kreuger (Under Review) support the conclusion that Neandertals in coldclimate, steppe regions used their anterior dentition in a functional method similar to that of the Eskimo. Additional indicators of Neandertal dietary variability have been produced through DMTA conducted on buccal tooth surfaces (Perez-Perez et al. 2003). These samples demonstrate high intra-group variability, which correlates with changing paleoenvironmental conditions. Further studies by El Zaatari et al. (2011), conducted on molar occlusal surfaces, indicate a significant difference between Neandertal groups in wooded areas and those in open-steppe environments, as well as a general increase in consumption of plant materials alongside increases in tree cover. Karriger et al. (2016) reported that DMTA from the Croatian Neandertal groups of Krapina and Vindija was consistent with high-meat foragers, but also indicated that the Krapina Neandertals showed evidence of noteworthy plant consumption in their diet. An intra-group analysis of the El Sidrn Neandertals reveals sex-based differences in microwear; overall their microwear is similar to other Neandertals from wooded habitats and is interpreted as containing a mix of both meat and plant foods (Estalrrich et al. 2017). Interestingly, Neandertal dietary variations resemble those in humans from more recent archaeological populations. For example, Remy et al. (2014) found sex- and age-based differences in microwear among Roman-era Herculaneum people who were killed simultaneously by a pyroclastic surge from Mt. Vesuvius. Study of this population allowed analysts to see microwear variation within a large, diverse group who died on the same day. Despite the variety of people and huge array of available foods, some patterns emerged between young and old adults as well as males and females. In addition, the children tended to have diets very similar to those of the adults. That contrasts with the Medieval population at Canterbury, where the children tended to have elevated dietary hardness (Mahoney et al. 2016). The important nuances that emerge when looking carefully at intra-site variation in humans show it is prudent to carefully consider intra-site variation seen in Neandertals. In this study, the Neandertal population of lHortus presents a unique instance for a population-based approach. This is particularly encouraging given the previous results from El Sidrn, which found a sex-based difference in microwear texture (Estalrrich et al. 2017). Although the sample size represented herein is small by bioarchaeological standards, and more typical of paleontological sites, it nonetheless is suitable for detailed intra-site study in order to compare it properly to other sites. 1.3 Microwear texture Microwear forms on the enamel surface as food and exogenous grit particles impact a tooth primarily during the Power Stroke of the chewing cycle (Ungar 2015). It is important to note that food and grit particles do not have to be harder than enamel in order to create enamel wear (Xia et al. 2015), but they are generally of a hardness at or near it. Recent DMTA studies indicate that meat consumption tends to mitigate microwear formation (El Zaatari 2010). This is not to say that meat creates no microwear features, but fewer of them (Hua et al. 2015). This is supported archaeologically in that populations thought to consume large amounts of meat tend to have low microwear complexities (e.g., Schmidt et al. 2016). Thus, those individuals who consume high quantities of meat are likely to have less overall microwear formation than those who eat less meat and consume foods more likely to form microwear. Dietary reconstructions resulting from DMTA studies are based on surface characteristics including surface complexity, feature orientation, and feature depths that vary depending on the types of foods and the respective quantities of each food being consumed. 1.4 Hypotheses 1.) Given previous microwear studies that indicate intra-site dietary nuances (Estalrrich et al. 2017), it is hypothesized that DMTA from the site of lHortus will show age-based differences in diet. 2.) Neandertal DMTA has previously been shown to have an eco-geographic correlation (e.g. El Zaatari et al. 2011). The site of lHortus is located in the Mediterranean region of southern Europe, and it is hypothesized that this group will show continuity with other individuals from this ecological area. 3.) It is hypothesized that the DMTA signature of the Mediterranean ecological region should differ from those found in non-Mediterranean regions (e.g. steppe/tundra and coniferous forests). 4.) It is hypothesized that temporal differences should manifest according to glacial and interglacial periods, warmer periods showing continuity with other similarly warm climatic periods. 2. Materials In total, 17 individuals were included in the current study. I used age determinations from the following sources for each site (de Lumley 1973; Fraipont 1936; Gmez-Olivencia et al. 2009; Howell 1960; Klima 1962; Leroi-Gourhan 1988; Patte 1957; Svoboda 2005; Trinkaus 2016; Twiesselmann 1971). I was only able to assign two age categories: adult and sub-adult. Temporal designations came from the same sources used for age, and placed each individual into a marine isotope stage (MIS). This means of temporal placement was approximate because absolute dates are not available for each specimen. There are four MIS designations represented by the study group ranging from MIS 6 to MIS 3. Eco-zones data were constructed using deep ice core data provided in Van Andel and Tsedakis (1996). There are two eco-zones designations for this study: the Non-Mediterranean (including both steppe/tundra and coniferous forest environments) and the Mediterranean (which contains brush-like vegetation and some forested areas). Engis 2 Spy 1 Arcy-sur-Cure 1 La Quina 5 Pech de lAz 1 K lna vdv stl LHortus Montmaurin Kebara Tabun Figure 1: Map depicting the site locations of the specimens included in the study. 2.1 Non-Mediterranean Specimens (n =8 ) Arcy-sur-Cure (Grotte du lHyne): Arcy-sur-Cure 1 consists of an adult mandible and maxilla. Dates provided by Leroi-Gourhan (1988) based on the presence of gray lemmings (Lagurus lagurus ) place the specimen within MIS-5b. Similar sedimentary data from the site indicates a cold, open steppe environment (Leroi-Gourhan 1988). This classification is further supported by ice core data from Van Andel and Tsedakis (1996). Engis: Engis 2 comes from the site of Engis, Belgium, and constitutes the remains of a sub-adult (Fraipont 1936). It is clearly Neandertal, but the MIS it belongs to is unknown. Kulna: The Kulna I individual consists of four teeth present in a maxilla; its estimated age is 14 years (Svoboda 2005). Since people of this age tend to have an adult diet (and because this person has no deciduous teeth remaining) for the purposes of this study, this individual is classified as an adult. ESR dating from Kulna Cave dates the remains to 46,000 6,000 years old, thus within MIS-3 (Rink et al. 1996). The faunal assemblage associated with stratum 7a, where the Neandertal remains were found, contains predominantly reindeer, an abundant assemblage of mammoth, and the sporadic occurrence of elk and bovids common of the Wurm (Valoch 1970). Environmental reconstructions from Van Andel and Tsedakis (1996) suggest that the area was largely a steppe environment with interspersed coniferous tree cover (Valoch 1988). La Quina: The La Quina 5 individual was traditionally assumed to be female, although recent studies suggest that the remains are either male or indeterminate in nature (Trinkaus 2016). Lack of a pelvis makes specific age of this individual difficult to determine, but the remains are definitively adult. Although no absolute dates are available for the layers in which the specimen is contained, relative dating based on absolute dates for higher layers place La Quina 5 in either MIS 3 or 4 (Mercier and Valladas 1998). Reindeer and horse dominate the faunal assemblages, suggesting the prevalence of an open habitat (Henri-Martin 1966). Ice core data provided by Van Andel and Tsedakis (1996) suggest that the area would have been largely tundra/open steppe during this time period. Montmaurin La Niche: The Montmaurin mandible is presumably from an adult. The mandible is usually assigned to Pre-Neandertals (Howell 1960; Vallois 1955) and has been dated to the end of the Riss Glaciation, approximately 130 kyr BP, placing it within MIS-6 (Grun and Stringer 1991). Pollen analyses from the same stratigraphic layer as the mandible indicate that site vegetation was relatively open-steppe-like but also contained some low percentage of tree cover dominated by conifers interspersed with deciduous trees (Girard and Renault-Miskovsky 1983; Renault-Miskovsky and Girard 1998). Pech de lAz: The Pech de lAze individual is estimated to be 2-3 years of age, hence a subadult (Patte 1957); as such, no sex information is available. The remains have been dated to 51,000-41,000 years old and give the specimen temporal designation of MIS-3 (Soressi et al. 2007). Faunal remains from the site indicate that Neandertals there hunted red deer seasonally, which is consistent with a temperate, forested environment (Armand et al. 2001; Rendu 2010). Van Andel and Tsedakis (1996) indicate that this region would have been largely coniferous forest with interspersed deciduous vegetation. Spy: The Spy 1 individual comes from the site of Spy, Belgium, and is radiocarbon dated to around 36 kyr BP (Finlayson et al. 2006). The individual is believed to be a young adult female (Twiesselmann 1971). Horses and reindeer dominate the associated faunal assemblage, indicating open vegetation and cold conditions (Finlayson et al. 2001). These reconstructions are further supported by northern European pollen spectra, which show that an open vegetation (fluctuating between tundra/shrub tundra and steppe-tundra/temperate grassland) prevailed during MIS 3 (Hardy 2010; Lowe and Walker 2014). vdv stl (Ochoz): The vdv stl (Ochoz) 1 individual consists of a fragmentary mandible and maxilla of an adult (Klima 1962; Svoboda et al. 1996). The remains and associated assemblages have been dated to MIS-4 (Musil 2003; Svoboda et al. 1996). Faunal remains as well as deep ice core data support the eco-zone designation of coniferous forest (Musil 2003; van Andel and Tzedakis 1996). 2.2 Mediterranean (n=9) Kebara: The Kebara 2 individual is estimated to be an adult male (Gmez-Olivencia et al. 2009). Thermoluminescence dating places the burial at approximately 60,000 years old (MIS-4) (Valladas et al. 1987). Most common within the faunal assemblage are gazelle (Gazella gazelle) and fallow deer (Dama mesopotamic), both common within Mediterranean environments, but the site includes other taxa such as horse, red deer, wild boar, and aurochs (Bar-Yosef et al. 1992; Eisenmann 1992; Speth and Tchernov 1998; Speth and Tchernov 2001). Deep ice core data indicate the area would have been typical of a Mediterranean forest/brush environment (van Andel and Tzedakis 1996). LHortus: The site of lHortus is represented by six individuals: Hortus III, Hortus IV, Hortus V, Hortus VI, Hortus VIII, and Hortus XI. De Lumley (1973) assigns specific ages for each of the individuals, but, for the purpose of this study and in the interest of accuracy, the designations of sub-adult and adult will be the only categories. Hortus 2 is the only subadult in the assemblage. The remains of these individuals are dated to an occupation period approximately 60,00030,000 years ago and are placed in MIS-3 (Lumley et al. 1972). Dating to the Wurmian II period, the site of lHortus marks a transition from a cold and wet to a cold and dry climate (RenaultMiskovsky 1972). Pollen studies indicate the area was largely covered by coniferous forests with some evidence of interspersed deciduous trees such as birches and other Mediterranean species (Renault-Miskovsky 1972; Vernet 1973). Faunal remains recovered from the site include those typical of a coniferous forested area, such as ibex and deer, as well as a few more often found in the open steppe, such as wooly rhinoceros and horse (de Lumley 1973). Tabun: Both Tabun E2 and Tabun Series III are included in the study. The specimens, recovered from stratigraphic layer C, were dated by ESR to between 120 16 kyr and 140 21 kyr BP placing them both within MIS-5 (Grn and Stringer 1991; Mercier and Valladas 2003). Microfauna from layer C indicates mixed vegetation cover with a dense bush-forest, which was interrupted by grasses and lower vegetation typical of Mediterranean environments (Jelinek et al. 1973). Large mammal assemblages from the site cannot be used in the eco-zone designation because they likely contain a mixture of materials from layers C, D, and B (Jelinek et al. 1973). Site information coupled with ice core data support the designation of a Mediterranean environment (van Andel and Tzedakis 1996). Table 1: List of Neandertal specimens sampled in this study. The marine isotope stages (MIS) are inferred from the absolute or relative dates available for each specimen. The eco-zone designation for each specimen represents prevailing conditions during the time of deposition of the Neandertal remains. These classifications are largely derived from Van Andel and Tzedakis (1996), but also draw from sedimentary analyses and floral and/or faunal remains from the same layers/levels as the specimens. Age data for each specimen derives from the primary literature available. Site Arcy-sur-Cure (Grotte de l'Hyene) Engis Kulna La Quina Montmaurin (La Niche) Pech de lAz Spy vdv stl (Ochoz) LHortus LHortus LHortus LHortus LHortus LHortus Kebara MIS Individual Age Ecozone Designation 5b 1 Adult Non-Mediterranean --3 4 6 3 3 4 3 3 3 3 3 3 4 2 1 5 --1 1 1 III IV V VI VIII XI 2 Sub-Adult Adult Adult Adult Sub-Adult Adult Adult Sub-Adult Adult Adult Adult Adult Adult Adult Non-Mediterranean Non-Mediterranean Non-Mediterranean Non-Mediterranean Non-Mediterranean Non-Mediterranean Non-Mediterranean Mediterranean Mediterranean Mediterranean Mediterranean Mediterranean Mediterranean Mediterranean Tabun Tabun 5 5 E2 Series III Adult Adult Mediterranean Mediterranean 3. Methods In DMTA studies, the focus is placed on second mandibular molar facets because they have been found to be the most useful in distinguishing diet (e.g. (Krueger et al. 2008; Ungar 2011). The current study included all available molars in order to maximize sample size and is an approach used before in paleontological studies (e.g. Ungar et al. 2012). Therefore, data were collected from maxillary and mandibular first, second, and third molars from the adults as well as from deciduous first and second premolars in the sub-adults. For the molding process, teeth were cleaned using ethyl alcohol (95% ETOH) and a cotton swab to remove any dirt present on the occlusal surface. I molded cleaned teeth with a high-resolution impression material, Presidents Jet light body, a commonly used polyvinylsiloxane. I then used the molds to create resin casts using Super Hard Epoxy Resin, an ideal material for creating nearly bubble-free replicas. 1.3 Observing and calculating surface texture The high-resolution casts were then viewed using a Solarius Sensofar Pl 2300 (Solarius Development Inc., Sunnyvale, California) white-light confocal profiler (WLCP). I conducted observations within facet 9 on first and second upper and lower molars under a preliminary magnification of 10X. Once an area of interest was located, I collected data at a magnification of 100X (using a 100X-ELWD [extra long working distance lens]) from four contiguous areas covering a total area of 276 x 204 m. All four areas were then coalesced into a common data cloud through auto-stitching, establishing a total area of 242 x 182 m. This surface area is slightly smaller than those reported by Ungar and colleagues (e.g., Scott et al. 2012) and is due to the auto-stitching. This process can reduce study areas up to 10%, but data generated represent the entire area scanned as opposed to collecting data from each quadrant individually. The data from each specimen were imported into SolarMap (version 5.1.1), whereby the surfaces were leveled using a least-squares algorithm. Areas on each surface that were deemed unsuitable for study, such as those with adhering particles, were manually removed (cleaned) using the software. This is an essential part of the process, as the microsurface analysis software is sensitive to surface peaks and valleys. All dirt should be absent from the dataset so that the software does not include it in surface computations. In order to keep surface size for each specimen similar, specimens used in the study had cleaned areas that were less than 10% of their surface area. Any surface deemed to have non-masticatory wear, areas obscured by taphonomy or preservative, or that had more than 10% of the surface removed through cleaning were excluded from analysis. Data clouds were closely examined as both photosimulations and as 3D representations so as to determine that the surfaces represented true, unobscured microwear features. The 3D representations allowed for observing surface details and aided in determining the validity of certain pits by allowing the analyst to flip the image and study the shape of pits from the underside. Diet-related pits tend to be relatively shallow with a flatter base, while those that are non-diet related (often caused by flaws in casting or molding materials) are extremely deep and terminate in a point (Schmidt et al. 2016). These inspections helped ensure that data clouds were of the highest quality before analysis. Surface files suitable for analysis were imported into two programs that use scalesensitive fractal analysis in order to calculate surface characteristics (Scott et al. 2006). The first program was Sfrax, whereby each file was given a 5% valley suppression, run for textural fill volume, and saved as an .SDF file. The .SDF files were imported into Toothfrax software, which calculated the complexity and anisotropy values. Although these procedures are largely identical to those carried out by other DMTA labs, valley suppression is a notable exception. This procedure was undertaken to calibrate the WLCP at the University of Indianapolis with the University of Arkansas profiler and to make sure that cleaned areas were excluded from surface calculations. 3.2. Analysis of texture data In the present study, the texture variables are area-scale fractal complexity (Asfc), anisotropy (epLsar), and textural fill volume (Tfv). Asfc describes the surface complexity. In this case, more complex surfaces, particularly those dominated by large, deep features, have high Asfc values, while smoother surfaces have lower values. Humans from archaeological contexts tend to have mean population scores between 1.5 and 2 (Schmidt et al. 2016). Low complexity scores are usually below 1, with most groups scoring between 1 and 2 (Chiu et al. 2012; Frazer 2012; Remy et al. 2014; Van Sessen et al. 2013). Exact proportion length-scale anisotropy of relief (epLsar) measures feature orientation; high anisotropy means features are oriented in a common direction. In humans, this value reflects the degree to which the jaw moves in a consistent direction. Diets high in tough, fibrous food and/or homogenous foods (such as domesticates) generate higher anisotropy values, while diets that include harder foods or that are heterogenous generate lower anisotropy values (Chiu et al. 2012; El Zaatari 2010; Frazer 2012). If anisotropy values are contextualized within the available samples from the DENTALWEAR project, high anisotropy values tend to be around .0040, with low anisotropic values being around .0020 (Schmidt et al. 2016). Textural fill volume measures the amount of surface area removed during the creation of microwear features. Most individuals in the DENTALWEAR project have values that fall between 30,000 and 40,000 (e.g. Chiu et al 2012, Frazer 2012, van Sessen et al 2013, Remy et al 2014). 3.3 Hypothesis Testing 1) Age-based DMTA comparisons for lHortus are conducted qualitatively due to small sample size. 2) Similar qualitative assessments were conducted comparing lHortus with the other Neandertals from Mediterranean sites (i.e. Tabun and Kebara). 3) ANOVAs were conducted comparing the three DMTA variables (Asfc, epLsar, and Tfv) in Neandertals from the two eco-zone classifications (Non-Mediterranean and Mediterranean). 4) An ANOVA was conducted comparing the three DMTA variables (Asfc, epLsar and Tfv) in Neandertals from the four temporal categories (MIS-6, MIS-5, MIS-4, and MIS-3). 4. Results Table 2: Individual microwear data on the Neandertals analyzed in this study. Anisotropy Textural fill volume Complexity (Asfc) Specimen Tooth (epLsar) (Tfv) Arcy-sur-Cure 1 LRM1 1.77 0.0008 23829.5 Engis 2 dURM1 1.23 0.0020 60923.0 Kebara 2 LRM2 0.41 0.0051 52425.3 Kulna 1 URM1 1.83 0.0021 44919.0 La Quina 5 LLM1 0.75 0.0024 40127.6 Hortus III dLRM2 1.22 0.0009 26347.5 Hortus IV LRM1 1.36 0.0052 48948.8 Hortus V LLM2 1.00 0.0039 31866.1 Hortus VI LLM3 1.5 0.0041 42544.6 Hortus VIII URM1 1.18 0.0047 53577.8 Hortus XI URM3 1.54 0.0021 25393.6 Montmaurin LLM1 1.52 0.0017 39483.2 Pech de l'Az 1 dLRM2 3.73 0.0010 34325.8 Spy 1 LRM2 2.22 0.0032 25521.0 vdv stl 1 LLM1 1.06 0.0022 30363.5 Tabun E2 LLM1 1.56 0.0019 13063.7 Tabun Series III LRM2 0.69 0.0041 29939.6 A B C D E F Figure 2: Dental microwear images for the individuals at lHortus represented by 2D photo simulations (left) and 3D topographic surfaces (right). (A) Hortus III, (B) Hortus IV, (C) Hortus V, (D) Hortus VI, (E) Hortus VIII, and (F) Hortus XI Raw data for each of the Neandertal individuals are provided in Table 2. Representative 2D and 3D simiulations are provided for each of the lHortus individuals in Figure 2. 4.1 Hypothesis 1. DMTA from lHortus will show age-based differences in diet. Within lHortus, the adults show much higher anisotropy values (x = 0.0040) than the sub- adult (Hortus III) (anisotropy = 0.0009) (see Table 2). The sub-adult textural fill volume, of just over 26,000 m3, was within the range for the adults (25,394 - 53,578m3), although toward the low end. Likewise, the sub-adults complexity was 1.22, which fell within the adult range (1.00 to 1.54). Thus, only the sub-adult anisotropy distinguished it from the adults. The small sample size precludes quantitative analysis, but the difference between the lHortus sub-adult and its adult counterparts is notable and on a scale that produces statistically significant differences when encountered in human groups (e.g. Schmidt et al. 2016). Therefore, it is concluded here that an age-based difference is present. 4.2 Hypothesis 2. DMTA from lHortus will be similar to other Mediterranean Neandertals. Figure 3: Scatterplot depicting the relative complexity and anisotropy values for the site lHortus as well as the comparative Neandertal sample. The population of lHortus (n=6) was then compared to the remaining Mediterranean sample from Kebara and Tabun (n=3). The individuals from lHortus show a high anisotropy value (x = 0.0035) similar to that of Kebara and Tabun (x = 0.0034). The textural fill volume of the of the lHortus population was 38,113 m3 which is similar to the mean for other Mediterranean groups (x = 31,810 m3). Complexity values for lHortus (x = 1.30) are also slightly higher in value than those for Kebara and Tabun (x = 0.88). Therefore, it can be concluded that lHortus seems to coincide with other Neandertals from Mediterranean environments particularly in terms of anisotropy (Figure 3). 4.3 Hypothesis 3. DMTA from Mediterranean Neandertals will be different from NonMediterranean Groups Table 3: Mean complexity, anisotropy, and textural fill volume for Mediterranean and NonMediterranean Ecozones Asfc epLsar Tfv N Mean SD Mean SD Mean SD Mediterranean 9 1.16 0.37 0.0035 0.0015 36012 14030 Non-Mediterranean 8 1.76 0.92 0.0019 0.0008 37437 11987 Table 4: ANOVA output for Mediterranean/Non-Mediterranean Neandertal groups. Significant values (p < 0.05) are denoted in bold Sum of df Mean Square F p Squares Surface Complexity Between 1.535 1 1.535 3.196 0.094 (Asfc) Groups Within Groups 7.204 15 0.480 Between Anisotropy (epLsar) 0 1 0.000 6.869 0.019 Groups Within Groups 0 15 0.000 Textural Fill Between 8596706.99 1 8596706.99 0.05 0.826 Volume (Tfv) Groups Within Groups 2580698435 15 172046562.3 The ANOVA for eco-zone designation showed a significant difference for anisotropy (p = 0.019) but not for complexity and textural fill volume (Table 4). Neandertals from Mediterranean areas have, on average significantly higher anisotropy values than those from Non-Mediterranean areas. 4.4 Hypothesis 4. DMTA will differ between temporal categories Table 5: Mean complexity, anisotropy, and textural fill volume for the temporal designations (MIS-3, MIS-4, MIS-5, MIS-6). Asfc epLsar Tfv N Mean SD Mean SD Mean SD MIS-3 9 1.73 0.83 0.0030 0.0016 37,049 10,750 MIS-4 3 0.74 0.32 0.0033 0.0016 40,972 11,055 MIS-5 3 1.34 0.57 0.0022 0.0017 22,278 8,544 MIS-6 1 1.52 --- 0.0017 --- 39,483 --- Table 6: ANOVA output for temporal designation. No significant values were found. Sum of df Mean Square F Squares Surface Complexity Between 2.266 3 .755 1.412 (Asfc) Groups Within Groups 6.422 12 .535 Between Anisotropy (epLsar) 0.000 3 0.000 0.425 Groups Within Groups 0.000 12 0.000 Textural Fill Between 650029381.8 1 216676460.6 1.977 Volume (Tfv) Groups Within Groups 1314929967 12 109577497.2 The ANOVA for temporal designation showed no significant differences in DMTA. p 0.287 0.739 0.171 5. Discussion Table 7: Mean complexity (Asfc) and anisotropy for lHortus and comparative samples from Holocene H. sapiens. Sample LHortus Natufian, Israel Neolithic, Israel EBA (Early Bronze Age), England IA (Iron Age), England Nepal (Mebrak, Sam Dzong) Greece (Late Bronze/Early Iron Age) Indiana Archaic (Middle/Late) Kentucky Archaic (Middle/Late) Indiana Middle Woodland, East Indiana Middle Woodland Mongolia, Xiongnu Mongolia, Bronze Age/Iron Age Krapina Vindija Prot-Ag Ag 6 15 16 Asfc Mean 1.30 1.41 1.34 0.265 0.645 0.811 epLsar Mean 0.0035 0.0038 0.0034 0.0017 0.0017 0.0017 Ag 21 1.34 0.443 0.0041 0.0016 Ag 6 1.03 0.342 0.0039 0.0023 Ag 10 1.22 0.337 0.0036 0.0013 Ag 15 1.14 0.294 0.0036 0.0015 Abrasive food H/G 13 1.2 0.306 0.0025 0.0016 Abrasive food H/G 13 1.04 0.158 0.0029 0.0013 Hard food H/G 17 1.49 0.535 0.0026 0.0011 Hard food H/G 13 1.52 0.399 0.0021 0.0010 Past 29 0.92 0.293 0.0035 0.0017 Past 20 0.93 0.343 0.0033 0.0014 Abrasive food H/G High meat H/G 19 4 1.12 0.84 0.580 0.210 0.0043 0.0027 0.0020 0.0031 Subsistence N SD SD 5.1 Age-based differences in DMTA from lHortus The lHortus Neandertal population shows group continuity and forms a relatively cohesive population cluster in terms of DMTA although some nuances, especially with regard to age, are present. Asfc shows a moderate value (1.30 on average). That most of the individuals, including the sub-adult, share similar complexity values indicates that diet was consistently modest in hardness. Recall isotope data indicate that Neandertal diets have significant meat components (Bocherens et al. 2001; Bocherens and Drucker 2003; Bocherens et al. 2005). But the diet is not entirely meat, otherwise the complexity would be much lower; clearly there are enough hard and/or fibrous dietary elements to bring the complexity value to the 1.30 level. Modern Homo sapiens who eat high levels of meat and/or dairy products, like Mongolian pastoralists, have complexity values around 1.00 (Schmidt et al. 2016); it is agriculturalists who tend to have complexity values between 1.00 and 1.50 (see Table 7). The anisotropy values for the lHortus Neandertals demonstrate that the lHortus adults have elevated anisotropy with an average of 0.0040. This value too is similar to Holocene agriculturalists. But, the lHortus sub-adult has an extremely low anisotropy (0.0009), and the oldest individual has an anisotropy of 0.0021 placing it between the sub-adult and younger adults. Therefore, there are some intra-site nuances in diet. Low anisotropy values are associated with a greater variety of foods, such as those exploited by foragers whose jaws move in various directions to accommodate their varied diet (see Table 7). It may be that the sub-adult consumed a soft or heterogeneous diet. For the rest, the similarity between Neandertals and Holocene agriculturalists may suggest that the wild foods Neandertals were eating consisted of USOs, grasses, or sedges that required a consistent jaw movement during consumption. Interestingly, the same high anisotropy is also found at the Neandertal site of Krapina, which is located in a similar Mediterranean environment (Karriger et al. 2016). In order to address the age-related discrepancy in DMTA at lHortus several explanations must be explored including: the implications of differences in enamel thickness which exist between deciduous and adult dentition, potential differences in the biomechanics of adult and sub-adult chew cycles, or the manifestation of biocultural phenomena, such as weaning age dietary transitions or para-masticatory wear. One potential explanation for the distinct sub-adult microwear values is the differences in enamel thickness which exist between deciduous and adult dentitions. In modern H. sapiens, the enamel thickness of deciduous second molars is universally thinner than that which is present on adult first molars (Grine 2005). Even if differences in crown size are considered in the dentition, the trend of thicker enamel in more posterior dentition holds (Mahoney 2013). One hypothesis as to why this trend persists, is that thicker enamel may provide greater resistance to wear (Macho and Spears 1999; Molnar and Gantt 1977; Pampush et al. 2013). This concept appears to correspond with function, where molars, used for grinding, have thicker enamel than incisors, which are used for cutting and shearing (Mahoney 2013). Differences in enamel thickness within a tooth class are explained using the concept of bite force. In this scenario, the jaw acts as a lever during chewing with those teeth which are closer to the fulcrum, in this case the temporomandibular joint, experience more compressive forces as food is processed (Hylander 1975). Interestingly, a study by El Zataari (2010) shows no significant difference in M1 and M2 microwear despite reported differences in enamel thickness, and Perash (2017) found that this trend extends to M3. This suggests that enamel thickness may not contribute meaningfully to differences in DMTA, but further studies examining microwear from individuals with mixed dentitions (containing both deciduous and permanent molars) should be conducted in order to rule out this possibility. Differences in the mechanics of the chewing cycle between adults and sub-adults below a certain age may also account for the age-based difference seen in lHortus. Bite force has between shown to differ significantly between your and older children as the muscles of mastication gain size and strength with age (Kamegai et al. 2005). A greater bite force would allow for hard particles to be driven more deeply into the enamel as microwear is being formed. As such, differing bite forces could lead to different signatures in not only between younger and older children but also between children and adults (Kamegai et al. 2005; Mahoney et al. 2016). The way in which the jaw moves during chewing is also worthy of consideration. In children, the reduced size of the mandible will limit the lateral deviation of the jaw. As the mandible increased in size with age, this lateral deviation will increase providing a scenario in which longer scratches might be produced (Mahoney et al. 2016). These long scratches could potentially alter anisotropy values, but this does not necessarily have to be the case. Hortus III is estimated to be 6-7 years old (Lumley et al. 1972) which coincides with late weaning age in modern H. sapiens. Breast-feeding alone will produce no microwear signature, and therefore, it is during weaning period with the introduction of solid foods that microwear will begin to form (Mahoney et al. 2016). The exact time of weaning in Neandertal sub-adults is still uncertain (Humphrey 2010). A look at dental attrition rates indicates that Neandertal subadults lag behind Upper Paleolithic anatomically modern humans (UPAMH) up to the age of about 5 years (Skinner 1997). Skinner (1997) suggests that this indicates that dietary supplementation began roughly one year earlier in UPAMH and places the weaning age at approximately 2 years for UPAMH and 3 years for Neandertals. Contradictory results from barium distribution in one sub-adult Neandertal suggest that the weaning process may have begun as early as 7 months with complete cessation at 1.2 years (Austin et al. 2013). Regardless of which estimate is correct, the age of Hortus III indicates that at least some dietary transition is taking place. Mahoney et al. (2016) attributed lower anisotropy values for the ages of 2-4 years in their Medieval sample to the introduction of new items into the diet. Presumably, a more varied diet would result in more varied jaw movements and disorganized chewing. This would lead to the formation of DMTA features in various directions and lower anisotropy values. Another consideration could be the use of the teeth in non-masticatory activities. The effects of this type of activity on molar occlusal surfaces remain poorly understood (Fiorenza 2015; Fiorenza and Kullmer 2013; Grka et al. 2015), but para-masticatory wear on the posterior dentition (molars and pre-molars) has been documented in several populations ethnographically (Berbesque and Marlowe 2009; Berbesque et al. 2011; Lorkiewicz 2011; Molnar 2008; Molnar 2011; Molnar 1971; Molnar 1972). One way in which para-masticatory wear presents is in the form of grooves on the occlusal surface which are associated with softening and holding fibers in the mouth for the production of baskets and various forms of cordage (Minozzi et al. 2003; Molleson 1994; Schulz 1977; Scott and Jolie 2008), instances of dental chipping and the formation of notches associated with the breaking of hard materials like bone or stone (Scott and Winn 2011), holding objects during the lithic making process (Bonfiglioli 2002), or through contact with wood or bone points used as needles (Bonfiglioli 2002; Bonfiglioli et al. 2004). Estalrrich and Rosas (2015) note that Neandertals from El Sidrn, Spy and lHortus demonstrate evidence of chipping and labial scratching on the anterior teeth which they attribute to the use of the mouth as a third hand. Although these patterns are demonstrated on the anterior teeth of the lHortus adults, the posterior dentition contains none of the macrowear features which indicate para-masticatory processes. Likewise, the use of the dentition in this manner typically leaves distinctive microwear patterns which were not observed in the sample. This makes it unlikely that para-masticatory processes were the cause of the differences in anisotropy between adults and sub-adults at lHortus. 5.2 DMTA similarities between lHortus and other Mediterranean Neandertals Within the context of this study, the Mediterranean Neandertals (Kebara, Tabun, lHortus) showed moderate complexity values and high anisotropy indicating that this group consumed tough or homogenous plant foods and relatively few hard foods. As previously mentioned, this trend also extends to the Krapina Neandertals who inhabited a similar Mediterranean environment (Karriger et al. 2016) (See Figure 4 below). Higher anisotropy values are typically indicative of increased plant consumption and appear to be a signature of this environment. This is perhaps not surprising given that the Mediterranean during this time period was conducive to not only increased presence of plant resource but also greater varieties (Tzedakis and Bennett 1995). It follows that, given the relative stability of this environment across time and space, dietary strategies would have developed in a way which encouraged the exploitation of a wide range of the available plant resources. Figure 4: Scatterplot depicting the mean DMTA values of the Krapina Neandertals with the Neandertals for this study. 5.3 The Mediterranean as a distinct ecological zone The late Middle and early Late Pleistocene in western Eurasia were marked by dramatic climate fluctuations. This in turn force the Neandertals who inhabited these areas to adapt their dietary strategies in order to survive. Studies of floral and faunal remains from this period indicate that the distributions of both plants and animals were greatly affected by changing environmental conditions. In general, during times of glacial stadia, cold-adapted plant and animal species dominated over warm-adapted ones, while the opposite was true during interglacial and interstadial times (van Andel and Tzedakis 1996). Reconstructions of climate over time indicate that, in any given MIS, Western Europe and the Mediterranean could be divided into several ecological areas. In this study, areas which include southern Europe and the Levant, designated as Mediterranean, were shown to be a distinct environment. Northern areas witnessed local extinctions of plant and animal species, their retreat to more favorable environments during cold periods and re-colonization during warm periods. Mediterranean Europe, on the other hand, is characterized by more ecological continuity over time since glacial advance never affected this region. Although this study indicates that ecological differences correspond with a more fibrous diet in Mediterranean Neandertals, a holistic view of diet incorporating macrowear, dental calculus, microwear and stable isotopes must be implemented to assess its credibility. Dental macrowear shows similar differences in wear with regard to region, with Neandertals from Mediterranean environments indicating a high degree of dietary variability in relation to other Neandertals from cold habitats (Fiorenza 2015; Fiorenza et al. 2011). Dental calculus also indicates that Neandertals from areas with more tree cover will exploit more plant materials than those from steppe/tundra habitats (Hardy et al. 2012; Henry et al. 2010; Weyrich et al. 2017). El Zaatari (2011; 2016) also indicates an increased consumption of plants in more wooded environments, but it should be noted here that the elevated anisotropy values of lHortus, Kebara and Tabun are unique to this study and the data presented for the Krapina Neandertals (Karriger et al. 2016). Stable isotopes constitute the only area which appears to contradict the data provided here that suggests increased plant consumption (Bocherens et al. 1999; Bocherens et al. 2001; Bocherens and Drucker 2003; Bocherens et al. 2005; Bocherens et al. 1991; Fizet et al. 1995; Richards et al. 2000; Richards and Schmitz 2008; Richards and Trinkaus 2009). This is likely a result of the ecological context of the Neandertals included in these studies, which were mostly from Non-Mediterranean individuals and would have been more meat-dependent than their Mediterranean counterparts. Further isotopes studies which focus on Mediterranean samples should be conducted in order to confirm this hypothesis, but the DMTA data presented in this study largely corroborate previous studies which indicate dietary nuances between ecological regions and increased plant consumption in areas which contain more tree cover. 5.4 Differences in DMTA are not due to temporal differences This study failed to detect any significant difference between later and earlier Neandertals. This finding is not unexpected because there is (1) a known association between climatic change, environment, and availability and variety of food resources present and (2) paleoclimate data which suggest that climate change in Eurasia during the time period from MIS6 to MIS-3 was not a consistent change towards either warm or cold conditions but alternated between warm and cold phases (van Andel and Tzedakis 1996). The representative sample for each temporal category included individuals from a variety of ecological regions. Since dietary differences between ecological regions have already been detected, it follows that a comparison of means which does not discriminate based on environment would merely compare average DMTA values across regions yielding a relatively homogenous group with regard to time. 6. Conclusions In conclusion, a qualitative analysis of the lHortus Neandertals yielded age-based differences in diet between the Hortus 2 and the adult Neandertals from the site. While complexity values are cohesive for the group and indicate a diet of modest hardness, anisotropy values demonstrate that the lHortus adults are consuming a considerable amount of fibrous foods (i.e. tubers, grasses, and other botanicals) but the sub-adult is not. The trend of elevated anisotropy holds for the other Mediterranean Neandertals present in the study (Kebara, Tabun Series III, Tabun E2) as well as the Krapina Neandertals and suggests regional continuity in diet among these groups. Furthermore, Mediterranean Neandertals show dental microwear textures that indicate significantly more plant consumption than Neandertals from northern Europe. No temporal differences were found within the sample. The study provides additional information to the growing body of data indicating that Neandertals had complex diets. Furthermore, the study provides support for the effectiveness of bioarchaeological models in detecting differences within and between Neandertal populations. 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