Research Proposal and Program Plan

for Grant Submission

Project iCOnnECT

Connecting Occupational engagement and Everyday Community Technology

USC University Hospital

Department of Occupational Therapy

Contributors to Data Collection for this proposal at USC University Hospital

Occupational Therapists: Kathy Gross, Phuong Nguyen and Janice Rocker

Special thanks to: Professor Aaron Hagedorn and Heather Kitching for guidance in this proposal

Table of Contents

Executive Summary

Project iCOnnECT has been developed as an innovated therapeutic treatment approach, utilizing current mainstream technologies for improved patient outcomes.  The approach is expected to be especially beneficial to inpatients at risk for social isolation, decreased occupational engagement, and physical deconditioning due to extended hospitalizations.  It will be implemented within occupational therapy treatments at the USC University Hospital (and USC Norris Cancer Center) at the University of Southern California. 

Mission

The mission of Project iCOnnECT is to use everyday technology to create a more collaborative, interactive and normalizing hospital environment. We are dedicated to the prevention and reduction of psychological distress, enhancement of patient quality of life, improvement in health literacy and health promoting behaviors through occupational engagement.

Vision

As Occupational Therapy seeks to advance its practice and serve the needs of its clients, demand for technology development and further research is necessary. The proposed program aims to examine new and innovative ways technology can be applied to treatment and their therapeutic outcomes.

Four treatment areas will focus on:

·         Occupational Engagement

·         Community Reintegration

·         Patient Education/ Health Literacy

·         Motor Rehabilitation/ Prevention of Physical Deconditioning

Collaborating with the hospital Information Technology Department and the Volunteer Services, Occupational Therapists will be finding ways to support and create a healthier and more enriching hospital environment through technology.

USC University Hospital and USC Norris Cancer Center

Department of Occupational Therapy

1500 San Pablo
Los Angeles, CA 90032
(323) 442-8500

“The USC University Hospital is a private, non-profit 411-bed acute care hospital and provides nationally recognized skilled and specialized services for complex medical needs.  Among the hospital’s advanced services are neurointerventional radiology, minimally invasive cardiothoracic surgery, robotic surgery and interventional cardiology.  Surgical specialties include organ transplantation and neurosurgery, as well as cardiothoracic, bariatric, esophageal, orthopaedic, and plastic and reconstructive surgeries” (www.uscuniversityhospital.org). Occupational therapy has been an integral service within the hospital since it’s opening in 1991. 

Development of Project

Concerned with promoting physical, emotional and psychosocial recovery and the return to one’s daily routine, Occupational Therapists at University Hospital have encouraged and facilitated the use of personal electronic aids pertaining to patient rehabilitation goals since their involvement with patient care. Traditionally, patients best-served by these interventions have been patients who own and utilize this equipment prior to their admission into the hospital. As technology is becoming more available and affordable, this population and the use of these technologies are growing. (See Key Trends)

However, accessibility to these devices while in the hospital is difficult for some patients whether due to financial constraints or because of logistical concerns such as having no one to bring the technology into the hospital. Project iCOnnECT aims to remedy this obstacle by accommodating to the growing use and interest of everyday technology for those who are unable to access them and expanding the services and clientele that may benefit from technological interventions.

The exploration of technology for therapeutic use for Project iCOnnECT began in November of 2010 as preliminary data was collected on case studies with individuals of varying diagnoses such as individuals waiting for an organ or multi-organ transplantation, individuals with cystic fibrosis and other conditions that may require lengthy hospitalizations. With the free Wi-Fi services for patients and their families provided by the hospital, individuals on the University Hospital and Norris Medical Cancer Center campuses are able to connect to wireless internet for e-mail, health resources, web browsing, and more.

Currently, the Occupational Therapy department has procured the use of one laptop and one iPad for patient use and interventions. These devices have been used to create patient webpages and blogs to update family members, a means for diversion and entertainment as well as motivational tools to facilitate increased participation in therapy. Initially, needs assessment objectives were to examine the psychosocial effects of increased occupational engagement with accessibility to internet and participation in social connectivity through patient social networking sites such as CarePages. However, in the process of gathering and assessing this information, we observed similar therapeutic benefits to psychosocial and emotional health from the use of other types of technology such as portable DVD players, camcorders and gaming consoles and we wish to expand this investigation.

Starting April 2011, benefits of interventions beyond self care (ie. exploration of leisure in the hospital) including technological interventions is being examined using the Hospital Anxiety Depression Scale as well as qualitative observations on patient initiation, motivation and level of participation. The Hospital Anxiety and Depression Scale (HADS) has been tested for factor analysis among several diagnoses and has been determined as an appropriate measure for three domains of psychological distress with both male and female participants (Hunt-Shanks, et al. 2010). As development of our program continues, we plan to follow clients of our program and use an established quality of life assessment, RAND SF-36, to assess factors associated with patient quality of life post discharge. 

Program Description

From grant funding we will purchase the following listed technologies: laptops, iPads, Wii, X-Box Kinect, Kindle and camcorder/Flipcam. These items are to be available for use by patients during their stay in the hospital. After receiving physician referral for participation in the program, an Occupational Therapist will conduct a battery of assessments (as mentioned afore) for baseline data to track psychosocial outcomes involved with the engagement and use of these technologies. The occupational therapist will also assess if there are any other functional or activity needs of the individual at this time, as well as determine the individual’s familiarity, performance and skills using the equipment. One-on-one instruction and training will be provided for the individual if the individual shows interest in using the equipment, but does not know how to use it. An Occupational Therapist will then collaborate with the client 2-3 times a week in creating health promoting goals using these technologies. After entered into our program, clients may check out equipment through a loan checkout procedure.

Therapists will target four occupational therapy areas of patient concern: occupational engagement, community reintegration, patient education and motor rehabilitation. The equipment we plan to purchase will be used as tools facilitating clients of our program to these goals and these interventions will be tailored to suit client needs. Below is a description of the four areas of focus and a table of the technology (Table A) that will be acquired and their potential uses.

Occupational Engagement: Supported by occupational science literature, it has been demonstrated that the environment and occupational behavior contribute to our health, habits and routines. Due to the sterility, a hospital environment may sometimes create occupational and sensory deprivation which can lead to psychosocial and emotional distress (Wood, 1998). Everyday technology may increase their opportunities for engagement as they participate in such activities as social connectivity, creative expression and leisure occupations.

Community Reintegration: Everyday technology may also enhance community reintegration by providing resources such as online cookbooks, music and movie making software to return to activities they previously engaged in. This technology can also foster legacy building and family bonding for those who have a progressive and critical illness.

Education/Health Literacy: Using web resources, therapists may enhance patient understanding of their condition or illness and also guide them to resources such as support groups, and websites such as the American Heart Association that provide valuable information about the management of their disease.

Motor Rehabilitation: Current research is also supporting the use of virtual reality for potential in motor rehabilitation. Gaming consoles can assist in encouraging therapeutic exercises and prevent physical deconditioning from long hospital stays. Games can also be used to integrate the family and aid in the restoring of a patient’s role as a parent or grandparent as they play with their children and grandchildren.

For more information on CPT billing codes and what these intervention goals correspond to see Appendix (A ).

Table A

*For a list of iPad Apps and possible applications please see Appendix (B )

Key Trends

Trends in Internet Usage

The Pew Research Center (2011) reports that 84% of American own a cell phone and/or tablet computer. Another Pew Research Center study (2010) showed accessing mobile health information through wireless technology is on the rise with a reported 78% of wireless internet users looking up health information online.

Despite its wide use nation-wide, hospital usage of the internet is much lower. Although we observe a growing trend of use of laptops and electronic forms of communication and entertainment in our patients, gathered from census data and therapist surveys, data from surveys of 29 patients on the occupational therapy caseload, only 31% of these individuals possess a device with internet capabilities (ie. laptop or smartphone) and only 14% are using wireless services to access the internet. Therapists were also asked to identify candidates likely to benefit from the program as well as identify the reasons and conditions why a patient would not be appropriate for the program. Therapists identified factors barring participation in program as medical needs too critical, somnolent disposition, low arousal, lack of attention, cognitive impairments, severe vision impairments, and short length of stay and likely discharge within 24 hours. Table B summarizes these findings.

Table B

Technology Trends in Other Hospitals
Other hospitals and rehab centers have also made effots to enrich the technological experience of their patients. Many hospitals have begun using iPads, Wii and supply Wi-Fi for their patients. These trends of a few notable hospitals such as Get Well Network at All Children’s Hospital, Northridge Hospital, Rancho Los Amigos National Rehabilitation Center, and Cedar Sinai Medical Center will be discussed in more detail in the Competition Section of this proposal.

Trends in Referral Rates

Referral rates in November of 2010 for occupational engagement were 1-2 per month, mostly initiated by Occupational Therapists after routine functional assessment. In April 2011 identify 8 candidates appropriate for our program from our current Occupational Therapy caseload.

Clients referred for occupational engagement are seen on a daily basis with a frequency of 2-3 times a week. The OT program length for these individuals span from two weeks to three months depending on discharge date and health condition. On average, we plan to work with each client referred to our program for the duration of 1.5 months.

As our clients tend to have a low turn-over rate, we estimate that we will have a weekly stream of eight clients referred for occupational engagement with a steady growth of 2 clients a month as the program expands. At the program’s peak, we plan to work with 20% of the hospital’s total population excluding common diagnoses of orthopedic surgeries that generally warrant length of stay less than one week and traumatic brain injuries or neurological conditions that contribute to severe cognitive deficits.

USC University Hospital Trends

The following census data was supplied courtesy of Chief of Occupational Therapy at USCUH, Kathy Gross, OTR/L. (Please do not use or reproduce without consent of author.)

*Excluded from this chart are the units 6 No and 7No. Patients of 6 No are typically orthopedic surgeries such as total knee arthroplasty, total hip arthroplasty, ankle surgeries that average a 3-5 day length of stay. Patients of 7No are primarily admitted for neurological injuries or trauma that may result in cognitive impairments.

Matching census and survey data, our estimated clientele of ~20% of total inpatients (avg. 110 inpatients) from 7 units combined ( 4 ICU, 5 No, 6 So, 7 ICU, 8 W, 8E, 9 E/W) is 22 clients a month.

Target Market

Project iCOnnECT’s target consumers are inpatients at USC University Hospital (ages 17 and older) who have been admitted to the hospital have been in the hospital for two weeks or longer and either exhibit or is at risk for developing psychological distress, anxiety or depressive symptoms. Populations targeted for automatic referrals are individuals waiting for heart transplantation, patients participating in allogeneic stem cell treatment, and admitted for exacerbation of the condition of cystic fibrosis. Other clients will be taken by a referral basis through a physician.

Current Literature

Depression and Anxiety in Critical Illness

The importance of addressing psychological distress in acute care patients is a growing concern as more research suggests the impact of psychological disorders and their associations with morbidity and health-related quality of life. Survivors of general critical illness, those admitted into the intensive care unit (ICU), are at increased risk for developing psychological disorders such as post-traumatic stress and major depression (Davydow, Katon & Zatzick, 2009). For heart transplant patients, depression and anxiety are two increasingly recognized risk factors for adverse clinical outcomes and mortality (Kop, 2009).

Incidences of psychological distress are high among various populations in the acute hospital. Senf and colleagues (2009) revealed that up to 56.3% of acute oncology patients were identified as highly distressed and in need of psycho-oncological treatment using the psycho-oncology short form (PO Bado SF). For those awaiting transplantation, increased distress, depression and anxiety can result from prolonged waiting time, uncertainty regarding the availability of organs for transplantation and stress related to coping with a life-threatening illness (Kop, 2009; Sherwood et al., 2007).

Many studies are now looking at the potential for preventive care and early intervention. For example, Rutledge et al. (2006) suggest providing successful psychosocial interventions during the pre-transplant phase may contribute to better surgical outcomes, decrease in organ rejection, survival rate and quality of life post-transplant. Similarly, Flaatten (2010) suggests early mobility in the ICU prevents a number of impairments both physical and mental from occurring such as pulmonary issues, muscular dysfunction, pain, psychological disorders and lower health related quality of life. Perhaps, early intervention with engagement will produce similar results.

Technology Literature

Currently, no studies exist examining tailored interventions using everyday technology for psychosocial and emotional health.

Some sensitizing research of web-based and internet interventions for cardiac patients is included in Appendix (C ).

Few studies have focused on mental health during the pre-transplant phase (Dew et al., 2004), and fewer still involving the use of interactive technologies. For cardiac disease specific conditions, internet and web based interventions for education and socialization showed positive results in psychosocial outcomes. For the population involving cardiovascular disease, internet interventions may be useful in creating behavioral change, providing patient education, improving psychosocial adjustment and offsetting financial burdens (Kuhl et al, 2006).

As the population for technological interventions has recently expanded, more research will be conducted to explore these new directions particularly in cancer and cystic fibrosis. Preliminary research shows that interventions in other populations groups yielded mixed results, and more research is required to evaluate specific components of internet peer support interventions to detect possible harmful effects of different types of communication (Salzar et al., 2010). In addition, intervention conditions such as moderated, unstructured, structured, individualized, etc. have yet to be analyzed in regards to different types of internet interventions as well as further analysis on the interventions’ long-term effects.

Pilot Data for Project iCOnnECT

Case Studies

Below is a table of case studies that I have been involved with from November of 2010-May 2011 that have guided the direction and rationale for this proposal such as the target market, the areas of treatment focus and the technology that is being requested. Table C also includes the technology used in the interventions and the therapeutic benefits achieved.

Table C

Management Structure

Key management positions:

• Director of Occupational Therapy and Speech Therapy
• Chief of Occupational Therapy
• Program Coordinator

Mary Katherine Jordan, OTD, OTR/L, Director of Occupational Therapy and Speech Therapy at the USC Hospitals is also the Associate Chair of Occupational Therapy Clinical Service in the USC Division of Occupational Science and Occupational Therapy.  In this role, she integrates, supports, and expands the clinical occupational therapy services on all USC campuses.

Kathleen Gross, MA, OTR/L, Chief of Occupational Therapy at the USC Hospitals managesthe daily operations of the Department. Her experience includes 12 years of work in the field of adapted technology for persons with a wide range of physical and visual disabilities. She will collaborate with the Program Director on the daily operation of the program and programmatic or organizational issues that arise, assure all hospital requirements are met, interface with other departments, review reports.

Barbara Leung, MA, OTR/L, Program Coordinator, is currently completing a residency at the USC Hospitals for the completion of her Doctorate in Occupational Therapy degree from the USC Division of Occupational Science and Occupational Therapy.  During her residency she has explored the use of technologies and other activities as a positive intervention on mood, hope and a perceived sense of self control to mitigate the effects of long periods of hospitalizations. She is also familiar with technology trends and marketing concepts through her graduate level coursework in GERO 506 Technological Innovations for Aging. Her work has resulted in the initial pilot data which has stimulated the development of this project.  

Job Description and Responsibilities

(Job Description and Responsibilities developed by Kathy Gross, OTR/L)

Program Coordinator  

Duties will include the following: “oversee ordering of equipment, develop inventory control measures, interface with infection control personnel regarding appropriate cleaning of all equipment, train occupational therapy practitioners in the use and therapeutic applications of the technology, support practitioners with individual patients,  treat individual patients, interview and select volunteers, establish the volunteer schedule and train volunteers on duties, set up data tracking mechanisms, oversee tabulation of  data, analyze data and/or request assistance from USC OS & OT Division with data analysis, generate reports for funding agency.

Volunteers
To minimize costs we will utilize volunteers. Volunteers with some technology skills will be chosen to work on the project and will assist with cleaning equipment between users, charging batteries, storage of equipment, set-up of equipment, inventory control, and delivery and pick up of equipment for those patients who can work independently with equipment.”   

References

Bing, R. (1981). Eleanor Clarke Slagle Lectureship – 1981. Occupational therapy revisited: a paraphrastic

journey. American Journal of Occupational Therapy. 35(8), pp. 499-518.

Davydow, D., Katon, W.,  & Zatzick, D. (2009). Psychiatric morbidity and functional impairments in

survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: a review of the literature. International Review of Psychiatry. 21(6)

Dew, M.A., Goyocoolea, J., Harris, R., Lee, A., Zomak, R., Dunbar-Jacob, Rotondi, A., Griffith , B. and Kormos, R. (2004). An internet-based intervention to improve psychosocial outcomes in heart transplant recipients and family caregivers: Development and evaluation. Journal of Heart and Lung Transplantation. 23(6): 745-58.

Flaatten, H. (2010). Mental and physical disorders after ICU discharge. Current Opinion in Critical Care. 16, pp. 510-515

Koelling, T., Joseph, S., & Aaronson, K. (2004). Heart failure survival score continues to predict

outcomes in patients with heart failure receiving β-blockers. The Journal of Heart and Lung Transplantation. 23(12)

Kop, J. (2009) Role of psychological factors in heart transplant candidates. J Heart Lung Transplant. 29(3): 263-268.

Fox, S. (2004). Older Americans and the Internet. Pew Internet Project: March 24, 2004,

presented at presentation at “Older Adults and the Web” event for usability.gov, July 19 & 20, 2004  as cited on http://www.w3.org/TR/wai-age-literature/

Morris, A., Goodman, J. and Brading, H. (2007). Internet use and non-use: views of older adults.

Universal Access in the Information Society, 6(1) pp. 43-57. Pew Research Center. Biennial Media Consumption Survey 2008.  http://people-press.org/reports/pdf/444.pdf

Nilsson, U. (2009). The effect of music intervention in stress response to cardiac surgery in a randomized

clinical trial. Heart and Lung: The Journal of Acute and Critical Care. 38(3)

Rutledge, T., Reis, V., Linke, S., Greenberg, B. and Mills, P. (2006). Depression in heart failure: A meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. Journal of the American College of Cardiology. 48(8):1527-37.

Senf, B., Brandt, H., Dignass, A., Kleinschmidt, R., & Kaiser, J. (2010). Psychosocial distress in acute

cancer patients assessed with an expert rating scale. 18(8) pp. 957-65

Sherwood, A., Blumenthal, J., Trivedi, R., Johnson, K., O’Connor, C., Adamns, K., Dupree, C., Waugh, R., Bensimhon, D., Gaulden, L., Christenson, R., Koch, and Hinderliter, A. (2007). Relationship of depression to death or hospitalization in patients with heart failure. Arch intern Med, 167, 367-373.

Wood, W. (1998). Biological requirements for occupation in primates: an exploratory study and

theoretical analysis. Journal of Occupational Science, August 1998, 5 (2), 66 –81. 

Appendix A — CPT Codes

“CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity.”

 “CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated annually.” 

http://patients.about.com/od/costsconsumerism/a/cptcodes.htm

The following codes and values have been approved for payment to occupational therapists. 

https://catalog.ama-assn.org/Catalog/cpt