OT ROLE IN PATIENTS WITH HEART FAILURE

Statistics of number of people with heart failure 5.7 million people have heart failure with 670,000 incident cases each year (Go et al., 2013). Congestive heart failure (CHF) is the most frequent diagnosis for hospital admissions and readmissions (Miniño, Murphy, Xu, & Kochanek, 2011). 25% of patients with heart failure are readmitted in 30 days (Desai & Stevenson, 2012). Evidence suggests that many hospital readmissions are related to low functional status and reduced physiological capacity (Arbaje et al., 2008).

Definition of heart failure

“Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body’s needs for blood and oxygen. This results in fatigue and shortness of breath and some people have coughing. Everyday activities such as walking, climbing stairs or carrying groceries can become very difficult” (American Heart Association, 2017). 

For an occupational therapist (OT), patients with heart failure are becoming a part of the everyday patient population in the acute care, subacute rehab, inpatient rehab, home health and outpatient settings. This is a population of patients that OT can greatly impact. OT’s role in treatment for patients with heart failure include occupation centered goals, caregiver involvement, facilitation of social participation, and increasing a patient’s quality of life.

The occupational therapy framework outlines and guides an occupational therapist by providing the following information: client factors to consider, performance skills and patterns to address, activity and occupational demands, context and environmental factors that impact independence in occupations and types of interventions to maximize occupational outcomes.

Patients with CHF are typically on multiple medications when being discharged from the hospital. Most patients have multiple co-morbidities outside of CHF, which could be macular degeneration, dementia, and diabetes. These co-morbidities impact a patient’s vision, cognition and performance factors. 

Occupational Profile

Norma is an 85 y/o female with CHF, diabetes, mild macular degeneration and beginning stages of dementia. She lives on the third flood in an independent living facility (ILF). Her spouse recently passed away. Her daughter lives locally and checks on her mom about three days per week. Norma is forgetful and has difficulty reading medication labels. Norma has been independent her entire life, raised three children, and is retired from work as a bookkeeper. Appearance is very important to Norma. She goes to the in-house salon weekly at the ILF, which is located on the first floor. She likes to participate in activities at her facility including bridge. Her daughter takes her to dinner every Saturday evening. Norma reported over the past two weeks she has been getting short of breath and not going to her salon appointments or bridge games due to fatigue. Norma says her shoes have not recently been fitting and she has not left her apartment. Norma told her doctor and about the recent shortness of breath and fatigue. Her doctor admitted her to the hospital.

Health Management and Maintenance

Once admitted to the hospital, an occupational therapy evaluation and treatment was ordered by the admitting doctor. The Occupational Therapist performed an evaluation, obtained Norma’s occupational profile, and addressed her basic activities of daily living (ADLs). The hospital was planning on discharging Norma on the day of admission with multiple new medications. One instrumental activity of daily living (IADL) to address during this session is health management and maintenance with focus on medication routines to reduce her risk of readmission to the hospital. The OT educated the patient on use of a journal & pen (low tech) to monitor medication intake. Due to Norma’s low vision, visual compensatory techniques were considered. Norma was educated on use of high/low contrast font on medication labels and increased font size to better read labels. The use of a medication pill box to separate medication by AM/PM and by day of the week were recommended to prevent Norma from forgetting her medication schedule and to prevent her from taking too many pills at a given time. Setting a phone alarm when medication time occurs is another technique to maintain an accurate medication schedule. The OT discussed these techniques with Norma with Norma’s daughter present to facilitate carryover of education.

Norma and her daughter were educated that hypertension can lead to heart failure and/or stroke. They were educated on importance of reporting symptoms to the doctor and to take medication as prescribed. Norma was also educated on monitoring edema in lower extremities to prevent risk of CHF exacerbation. If her shoes do not fit, this is a good indication to report this symptom to her doctor. 

Norma was educated to monitor vital signs with use of blood pressure cuff and pulse oximeter. She can maintain a journal (low tech) or ‘notes’ via typing or by voice command on phone (high-tech) to promote communication to doctor when going to doctor’s appointments. Norma opted to use her smart phone voice notes to record this data.

Safety and Emergency Maintenance

Norma was educated to program an “in case of emergency” contact in her phone and to maintain her phone in pocket of clothing always to prevent risk of injury and readmission to hospital when at home alone. The occupational therapist educated Norma and her daughter on increasing font size on phone to better see phone numbers.

Meal Preparation and Cleanup

Like many other CHF patients, Norma tells the OT she prepares microwaveable meals because she becomes too fatigued and cannot stand at the stove, sink, and counter long enough to prepare her meals. The occupational therapist educated Norma on environmental modification and energy conservation techniques in the home to maximize independence and fatigue leading to falls.

Energy conservation techniques include: 

• Placement of chairs throughout home to sit down, take rest breaks and conserve energy
• Performing IADLs seated instead of standing, i.e. sit during meal preparation
• Utilization of a four-wheeled walker during home establishment and management to transport a load of laundry from washer and dryer to another room to sort and fold
• Use of a shower chair and hand held showerhead to conserve energy during bathing
• Placement of frequently used food and plates, bowls, cups in same location to avoid patient from walking back and forth, preventing risk of potential fall if patient becomes too fatigued

OT role in preventing readmissions to hospital 

Higher hospital spending in Occupational Therapy is associated with lower readmission rates. Common medical conditions that result in hospital readmission are heart failure, pneumonia, and acute myocardial infarction. Regression results for the associations between category-level spending and readmission showed OT to be the ONLY category where spending with a statistically significant negative association with all three readmission measures. The average spending on OT per patient across hospitals is relatively low ($12-20) and the clear majority of patients did not receive OT services (72-79%). Increased spending for OT is a feasible option for hospitals (Rogers, Bai, Lavin, & Anderson, 2016)

Summary

In summary, there are many factors to consider when creating an OT plan of care for patients with CHF. OT can have a profound impact on the independence and safety in occupational independence with this patient population. Gathering pertinent information from the occupational profile is vital to best serve these patients to meet their needs. OT intervention can decrease risk of further potential decline and injury to prevent risk of readmission to the hospital.

References