Question 1

To practice in primary care, the occupational therapist must be a(n):

Accepted Answer

Primary health care is the "provision of integrated, accessible health-care services by clinicians who are accountable for addressing a large majority of personal health-care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (Institute of Medicine [IOM], 1994, p. 1). According to the American Academy of Family Physicians (AAFP, 2011), primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health-care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals and utilizing consultation or referral as appropriate (AAFP, 2011, para. 3-4). This broader conceptualization provides opportunities for the infusion of occupational therapy services in primary health care. However, to be effective in this setting, "an occupational therapist must be a true generalist who is competent across all age spans and the entire domain of occupational therapy practice" (Muir, 2012, p. 509).

Question 2

Which of the following provide the majority of primary health-care services?

Accepted Answer

Primary health care is continuous, comprehensive care designed to maximize health and prevent disease that is provided near where people live, work, and play (Edelman & Mandle, 2002). The term primary care physician "is used to describe all physicians whose practice includes the provision of medical care for well individuals and who act as 'gatekeepers' to specialist services" (Goel & McIsaac, 2000, p. 230). The physicians who today provide the bulk of primary health care are family and general practitioners, medical internists, and pediatricians. In addition, there are obstetrician-gynecologists for women's primary health care and psychiatrists for primary mental health services. Physician extenders, such as nurse practitioners and physician assistants, are also involved in the delivery of primary care services.

Question 3

In primary care, the patient hopefully engages with the physician's office as their:

Accepted Answer

The long-term relationships that primary care physicians develop and share with those in their care make the primary physician the entry point in accessing the health-care system. Ideally, the primary physician's office is the patient's medical home. The primary care medical home "is accountable for meeting the large majority of each patient's physical and mental health-care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, counselors, educators, and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities" (Agency for Healthcare Research and Quality [AHRQ], n.d., para. 2).

Question 4

Occupational therapy delivery in primary care is different from traditional models of OT delivery in which of the following ways?

Accepted Answer

The nature of primary care is such that practitioners follow a panel of patients intermittently over an extended period, providing health promotion, prevention, and treatment services at times of need. This is much different from typical occupational therapy services, which are often provided continuously and intensely over a short period. However, patients may need fewer visits for intervention because they are seen at an earlier stage of the health problem. Therefore, occupational therapists working in primary care settings must be flexible, adaptive, and readily available when the physician refers a person or family with a particular need.

Question 5

Mr. Janousek is a 67-year-old who presents to primary care with angina. The primary health-care team recognizes that this event has made Mr. Janousek concerned about his health and takes the opportunity to connect him with resources on weight management and smoking cessation. The primary health-care team is taking advantage of:

Accepted Answer

Primary care physicians' offices are ideal settings for disease prevention and health promotion. Physicians are generally viewed as authoritative and credible sources of information and advice on health and illness. A significant number of studies have demonstrated that physician advice is a strong determinant of adherence to preventive practices, such as mammograms. In addition, brief office interventions have demonstrated effectiveness for smoking cessation, reducing alcohol consumption, and other health-related behaviors. Teachable moments, when direct links can be made between symptoms, behavior, and outcome, occur routinely during office visits. For example, an office visit for angina is a teachable moment to address smoking cessation, nutrition, and weight loss with a patient. However, due to time constraints, physicians may not be able to utilize these opportunities effectively.

Question 6

An appropriate health promotion theoretical approach in primary care is which of the following?

Accepted Answer

The role of occupational therapy in health promotion has been conceptualized as having three critical functions: the promoting of healthy lifestyles for all clients, emphasizing occupational participation as an essential component of health promotion efforts, and providing interventions for populations, particularly those experiencing health disparities (AOTA, 2013). Occupational therapists providing services in primary care settings need to recognize that health promotion and prevention interventions do not immediately resolve health problems, and that individuals will progress in their own incremental and idiosyncratic ways. Appropriate health promotion theoretical approaches for use in primary care settings include the PRECEDE-PROCEED Model (Green & Kreuter, 2004) and the Transtheoretical (or Stages of Change) Model (TTM).

Question 7

In type 2 diabetes, a common psychosocial comorbidity is:

Accepted Answer

Depression and/or anxiety are frequently comorbid with diabetes. Persons with diabetes have a 60% higher rate of major depressive disorder and a 123% higher rate of generalized anxiety disorder than the general population (Fisher et al., 2008). The relationship between diabetes and depression is bidirectional. Individuals with depression are at higher risk for developing diabetes, and individuals with diabetes are at higher risk for developing depression, particularly if they are experiencing secondary complications. In addition, persons with diabetes and comorbid depression often have greater symptom severity and disease burden. This is likely due to the fact that depression often hinders a person's ability to initiate and maintain chronic disease self-management behaviors (Lin, et al., 2010). This highlights the need for mental health services in addition to medical care for the management of diabetes.

Question 8

Which of the following is a significant predictor of metabolic disturbances and disease risk?

Accepted Answer

The National Heart, Lung, and Blood Institute (NHLBI) guidelines for the prevention of cardiovascular disease recommend a target body mass index (BMI) between 18.5 and 24.9 regardless of age (NHLBI, 2018). Of the approximately 70% of adults who are overweight (BMI greater than or equal to 25), 36% are obese (BMI greater than or equal to 30), 15% are very obese (BMI greater than or equal to 35), and 6% are extremely obese (BMI greater than or equal to 40) (Flegal, Carroll, Kit, & Ogden, 2012). Several studies have indicated that abdominal obesity, regardless of overall weight, is a significant predictor of metabolic disturbances and disease risk. Even persons with a BMI in the normal range can be at higher risk if they have a large waist circumference. Therefore, waist circumference measurements are recommended as part of a routine physical examination (Dobbelsteyn, Joffres, Mac Lean, & Flowerdew, 2001). A waist circumference of more than 36 to 40 inches in men and more than 32 to 35 inches in women is highly correlated with obesity-related conditions, such as hypertension, sleep apnea, diabetes, and heart disease (Dobbelsteyn et al., 2001; Mosley, Jedlicka, LeQuieu, & Taylor, 2008).

Question 9

What is the most common musculoskeletal complaint seen in primary care medical practice and is a major source of activity limitation and disability?

Accepted Answer

Low-back pain (LBP) is the most common musculoskeletal complaint seen in primary care medical practice and is a major source of activity limitation and disability. LBP is experienced by one in five adults each year and affects 60-80% of adults at some time in their lives. It is often persistent or recurrent and incurs a significant cost to individuals, businesses, and society. It is the fifth most common reason to seek health care. LBP can be due to a single event resulting in acute injury or to a cumulative process of stress and strain (Gaunt, Herring, & O'Connor, 2008; Rosenwax, Semmens, & Holman, 2001).

Question 10

Mental health conditions typically seen in primary care are reported by patients as:

Accepted Answer

Approximately 25% of patients seen by primary care providers present with physical and mental health comorbidities. According to the National Institute of Mental Health (NIMH, 2017), at least 50% of mental health care for common psychiatric disorders is provided in primary care settings. Mental health problems in primary health-care settings are frequently manifested by physical symptoms such as chronic pain, insomnia, gastrointestinal disturbance, headaches, and difficulty breathing, among others. In addition, addressing the emotional and psychological issues related to chronic medical conditions has been shown to improve overall health and is cost-effective (Dahl-Popolizio, Doyle, & Wade, 2018).

Question 11

Michael is a 47-year-old who visits his primary care provider to lose weight. He claims he has "no time to exercise" and works a sedentary job. The primary care provider refers him to occupational therapy to explore weight-loss options. The occupational therapist would:

Accepted Answer

Mosley et al. (2008) provide a succinct overview of the role of occupational therapy in prevention and intervention for obesity in children and adults. They address the importance of occupation in weight reduction and the prevention of obesity. In addition, they describe adaptations and modifications that can be made to facilitate bariatric clients' abilities to perform and participate in daily life activities. Occupational therapists can assess an individual's overall pattern of daily activity and make recommendations for occupational participation in instrumental activities of daily living (IADLs), work, and leisure that increase the level of physical activity in which the person engages. Increasing the frequency and duration of physical activity will enable a person to maintain or lose weight more easily.

Question 12

George is a 42-year-old male with complaints of low-back pain to his primary care provider. He is having difficulty sitting at his computer to get work done. One strategy the OT might provide as intervention is:

Accepted Answer

For persons with subacute LBP, the grading of activities as the client progresses can enable a return to work more quickly with less disability. In addition, there is moderate evidence to support workplace intervention involving the worker, medical team, and employer to facilitate a prompt return to work. Occupational therapists can make recommendations for workstation design and the modification of work tasks, provide instruction on appropriate body mechanics in job performance, and address psychosocial risk factors in the work environment (Rosenwax et al., 2001).

Question 13

In order to meet the mental health needs of primary care patients, the collaborative care movement is developing and implementing models of care including:

Accepted Answer

Mental health problems, particularly major depressive disorder, impose a significant burden on society in terms of lost work productivity, increased use of health services, and increased morbidity and mortality from chronic illnesses, and are a leading cause of disability. In addition, mental disorders have adverse effects on adherence to medical regimens and health habits, including poor diet, increased alcohol consumption and smoking, and sedentary lifestyle (NIMH, 2010). In order to meet the mental health needs of primary care patients, the collaborative care movement is developing and implementing models of integrated care. Integrated care "blends the expertise of mental health, substance use, and primary care clinicians, with feedback from patients and their caregivers. This creates a team-based approach where mental health care and general medical care are offered in the same setting" (NIMH, 2017, para. 3). Mental health professionals can address the psychosocial challenges that affect patient self-management and health behaviors, as well as address the needs of persons with psychiatric conditions. Integrated care has been shown to increase access to mental health services, improve patient outcomes, reduce hospital readmission rates, and lower health-care costs (Buche et al., 2017; Ward, Miller, Marconi, Kaslow, & Farber, 2015).

Question 14

Mr. Wu is 58-year-old Chinese immigrant who has lived in the United States for 10 years. He has recently had a stroke and needs some durable medical equipment. He speaks and reads English well but his wife does not. They have many questions about the shower chair provided to them from a recent hospitalization. When explaining the purpose of the shower chair, the occupational therapy practitioner should consider:

Accepted Answer

Health literacy refers to "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (USDHHS, 2000, pp. 11-20). Osborne (2005) believes that health literacy goes beyond the individual and that it is the mutual responsibility of the health-care provider to communicate information in ways that can be understood and applied. The national emphasis on health literacy is based, in part, on research that demonstrates relationships among health literacy, health disparities, and health outcomes. According to the National Center for Education Statistics, "adults with low literacy levels are more likely than those with high literacy levels to be poor and to have health conditions which limit their activities" (National Network of Libraries of Medicine, 2006, p. 3). Low health literacy is also linked to higher hospitalization rates, more frequent use of emergency room services, less compliance with health recommendations, and more frequent errors with medication management. Studies on health literacy and health outcomes have elucidated the connections between low health literacy and cancer incidence, mortality, and quality of life (Merriman, Ades, & Seffrin, 2002), glycemic control and rates of retinopathy in persons with type 2 diabetes (Schillinger, Grumbach, Piette, and Wang, 2002), and other health conditions (Williams, Baker, Honig, Lee, & Nowlan, 1998; Williams, Baker, Parker, & Nurss, 1998).

Question 15

Which of the following could an occupational therapist working in primary care provide as a brief office intervention for the purpose of changing a health behavior?

Accepted Answer

Brief office interventions are short, targeted interactions between patients and health-care professionals for the purpose of changing health behaviors. They are practical and cost-effective and can be implemented by a variety of health-care professionals, including occupational therapists (Moyers & Stoffel, 2001). The Counseling and Behavioral Interventions Work Group of the U.S. Preventative Services Task Force (USPSTF) evaluated the features of six models of behavior change and recommended an adaptation for brief office interventions in primary care settings. The model, briefly described in Table 25-1, is based on the five A's: Assess, Advise, Agree, Assist, and Arrange (Jaen, 2003).
Medication adherence is a significant concern in primary care practice that can be addressed by occupational therapists through brief office interventions. Barriers to medication compliance, which are magnified with advancing age and increased medical, cognitive, and psychiatric problems, include multiple drugs, multiple doses per day, problematic side effects or interactions, and a lack of family/social support. Even a change from one medication to another, or from one dosing schedule to another of the same medication, may be confusing to some patients and present a challenge to adherence. Effective motivational strategies to improve medication adherence include using daily reminder charts and daily pill holders, packaging medications in combination, training in self-determination, enlisting social/family support, and offering phone calls from nurses and phone-linked computer counseling (Domino, 2005).

Question 16

Mr. Bruner is a 55-year-old male seen in primary care reporting depression due to a recent job loss. To understand the health needs of Mr. Bruner the occupational therapy practitioner could perform which of the following?

Accepted Answer

Health risk appraisals (HRAs) are assessments that profile an individual's risk factors and estimate the probabilities of manifesting certain diseases. HRAs ask the participant a number of questions related to health behaviors and thereby raise awareness about the impact of lifestyle on health. In addition, some HRAs provide suggestions for improving one's health status. These assessments are a useful tool for initiating dialogue about lifestyle concerns and may motivate the individual to action. Educating patients regarding their health status is the next logical step. Information tailored to the individual's needs can enable and empower the individual to assume more responsibility for his or her health.

Question 17

In establishing occupational therapy in a primary care setting, which assessment tool provides an excellent opportunity for the occupational therapist to gain an understanding of the patient's needs, desires, and priorities as a basis for individualized health promotion planning?

Accepted Answer

The third step is to establish a protocol that outlines how patients will be evaluated, potential interventions that may be used, and community resources that are available as support services. The protocol should include clear referral criteria and describe the services the occupational therapist can provide. Administering the Canadian Occupational Performance Measure (COPM) provides an excellent opportunity for the occupational therapist to gain an understanding of the patient's needs, desires, and priorities as a basis for individualized health-promotion planning (Law et al., 2005). Health behavior contracts that specify the number of sessions, goals, and strategies may enhance motivation and commitment to long-term change.

Question 18

You are an occupational therapist meeting with a physician and a health-care administrator to advocate they add OT to the primary care team. What benefit can OT bring to the primary care team?

Accepted Answer

The benefits to primary care physicians of utilizing occupational therapists (as an employee or a contractor) to provide health-promotion and prevention services in their practice settings potentially include:
• Availability of high-quality prevention and health-promotion services on-site, thus increasing the physician's time to focus on medical interventions,
• Better patient health outcomes as a result of comprehensive health-promotion services,
• Less need for medications and better compliance with self-management regimens,
• Identification of patients who have mental health needs not readily recognizable in a short medical office visit, including alcohol and drug abuse problems, domestic violence, depression, anxiety, and bereavement,
• Detection of performance deficits that may affect impact the safe participation in everyday activities, and
• Early identification of patient lack of adherence to medical treatment plans, thereby preventing secondary complications of medical conditions.

Quiz 25: Occupational Therapy in Primary Health-Care Settings Introduction

To practice in primary care, the occupational therapist must be a(n) :