Research Proposal and Program Plan
for Grant Submission
C onnecting O ccupational en gagement an d E veryday C ommunity T echnology
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
Mission and Vision Statement
Development of Project
Possible Funding Sources
Appendix A – CPT Codes
Appendix B – iPad Apps for Occupational Therapy
Appendix C – Sensitizing Research: Cardiac Patients
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.
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.
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
“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.
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 ).
Access email, connect with family, friends, patients with similar conditions, blog, learn more about their health, play games, etc.
iPads Access the internet, patient education, games, building life skills, cognitive training, addressing motor and coordination impairments, explore different iPad Apps*
for entertainment, productivity, leisure interests, and creative expressions
Kindle Read books, access internet, play games
Portable DVD Player
Watch movies, listen to CDs, tune out distracting ICU noise and alarms with disposable headphones
Record milestones, create movies, legacy building for patients with chronic illness
Gaming Console (Nintendo Wii and Xbox Kinect) Practice balance, movement, weight shifting, motor control, physical exercise, socialize, increase tolerance for standing and ambulatory level activities
*For a list of iPad Apps and possible applications please see Appendix (B )
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 Has laptop in room
Owns laptop and phone 2 (7%)
Phone with internet capabilities
(ie. smartphone or iPhone)
Using wireless internet services 4 (14%)
Uses phone only for texting or calling
No phone or laptop 13(45%)
Identified as not appropriate for program
(ie. severity of illness, somnolent, cognition issues, vision problems, discharge likely within 24 hours)
Identified as candidates for program (ie. referral by therapist, demonstrated interest or need)
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.)
Average Daily Census
Common cases and conditions
4 ICU – heart transplantation, VAD, heart failure, cardiomyopathy
5 No – Cardiothoracic; s/p transplant; CF
6 So – s/p Liver, kidney transplant
7 ICU – Autoimmune diseases; neuro
8 W – oncology, allogeneic stem cell tx
8 E – oncology
9 E/W – oncology, AML
*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.
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.
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.
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
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.
Waiting for Heart Transplantation
George, 60 year old male with cardiomyopathy waiting for a heart transplant Laptop
Portable DVD player with headphones
-listening to music
George is a retired construction worker. For leisure pursuits during his pretransplant phase, he enjoyed projects where he could work with his hands such as building a birdhouse and tiling a mosaic with his occupational therapist.
George regularly watched movies and recorded sitcoms his family brought in on a portable DVD player. With his headphones, he was able to reduce distractions and ICU noise and stressors. George also used this DVD player to listen to relaxing classical music as a method of stress management.
The portable DVD player was a better option for George than a laptop because it was simpler to use. He did not use the laptop regularly stating unfamiliarity with its operations and low vision issues. George has diabetic retinopathy of both eyes that affects his vision. However, on the weekends, with his daughters’ assistance, George would use Skype to call in family members from the Philippines which he reported was significant for his emotional and spiritual wellbeing as these family members would pray together with him for his recovery.
Edmondo, 55 year old male waiting for a heart transplant Laptop
-Anagrams Edmondo was an active sportsman prior to his hospital admission. He volunteered as an umpire for Little League and is a third degree black belt in Tae Kwon Do. Edmondo has five grandkids and enjoys being a grandfather and father as well as a popular uncle.
Edmondo uses a webcam and laptop to connect with family over Skype. At first, he only had a few family members registered with the service. However, he has found that this is an effective way to contact and socialize with others while in the hospital and stated “I’m getting some of my other nieces and nephews on here so I can talk to them.”
Edmondo was proud to report his family had created a support group on Facebook called “Team [Edmondo]”. The support group is not just for him, but for a child with the same name also needing a heart transplant. He felt this was very apropos and is glad that him and his family has the opportunity to help out the community and contribute to a cause even while he is in the hospital.
In addition to doing woodwork with Occupational Therapy, Edmondo plays with his Nintendo DS as a form of leisure. He stated, it “keeps my mind active.”
Lilly, 54 year old female with cardiomyopathy, waiting for a heart transplant à VAD placement Laptop
-listening to music Lilly is a primary caregiver of a 4 year-old child and is a retired health insurance biller and had worked as a record manager many years ago.
She was open to using the iPad, but the laptop was a better fit for her since she could watch movies and listen to CDs on it.
Lilly expressed high anxiety about her condition and treatments. She endured several months waiting for a heart and experiencing episodes of respiratory distress that required reintubation. After one particular setback she remarked, “I feel so helpless. This reminds me of when I was a child and my parents were fighting and I couldn’t do anything about it. I thought when you grew up, you would have control over your life”. When asked if there was a need for stress management, she responded, “Do I ever!”
Lilly worked with OT Lifestyle Redesign® to examine and modify habits and routines for health promotion.
Lilly identified watching movies as a relaxing occupation and began weekly movie nights with an Occupational Therapist. Having a more normalized routine and something she could look forward to helped ease some of her anxiety. It also helped her regain a sense of control and was also able to get her mind of her worries.
Adrian, 60 year old male with heart failure waiting for heart transplant iPhone
-talking to family members Adrian had worked as a jewelry maker and is primarily Armenian speaking. His main social support is his immediate family and he uses the phone to call his working age son and daughter. He also uses the phone to keep in contact with his wife who sends him pictures of his beloved Terrier dog Sasha. Being in the hospital ICU for over 2 months, Adrian copes by having established a regular routine, two walks a day, once in the morning, once in the afternoon with a nurse assisting. He also has a daily visit from a family member in the afternoon and will sit in his chair to watch television and eat his meals.
As for leisure interests, Adrian occasionally plays games and watches movies on his iPhone. Adrian is a skilled chess player and plays chess online with competitors.
Denying any boredom he stated, “I’m good. I can do everything here,” pointing at his iPhone.
Jeremy, 54 year old male with cardiomyopathy waiting for heart transplant iPad
“Jeremy was an extremely active man who enjoyed working and playing outdoors, exercising, and spending time with his family. He worked in construction and owned his own business since he was in his teens. Waiting for a heart, Jeremy had to adjust to being confined not only indoors, but in the ICU. Jeremy stayed active by walking upwards of 50 laps around the ICU unit and doing exercises in his room. In order to regain a sense of control and avoid depression, Jeremy developed a daily routine and used an iPad to pursue leisure interests and connect to friends and family. He updated loved ones with entries on CarePages and a newly created email account, watched YouTube videos on toy-making and woodworking, and listened to music on Internet Radio websites such as Pandora.” – contributed by Phuong Nguyen, OTR/L
Melanie, 33 year old female with CF, s/p lung transplant with rejection Laptop
-Music Melanie was a popular and inspirational role model to many people. She befriended many patients on the unit and would make visits to other patients in neighboring rooms. She had many friends and was also very involved with her church community.
Melanie used CarePages as a way to update her many friends (700+) and family about her ongoing treatments and send out prayer requests. Melanie and her husband used CarePages as a regular blog. Having just married a few months before her admission into the hospital, they would celebrate milestones such as monthly anniversaries and commemorate it with pictures on CarePages for friends to see. Her husband reported that CarePages was a useful tool since it made it easier for them to contact concerned loved ones all at once without the stress of having to make a number of phone calls in times he felt was necessary to spend with his wife.
Melanie and her husband also used the iPod to select music to dance to, an occupation they both enjoyed.
Tiffany, 21 year old female with CF, s/p lung transplant, admitted for abdominal pain Laptop
-Music Tiffany has a history of depression and because of her condition has had frequent hospitalizations. Her family lives about 2 hours away (driving distance) and she currently lives alone. She works with a nonprofit in LA bringing musicians and artists to children’s hospitals.
At initial OT evaluation, Tiffany presented with a flat affect and decreased interest in out of bed activities. Nurses reported her sleeping most of the day and spent the rest of the day watching TV in bed. She was soft spoken and could only identify one-two interests and activities of interest. She stated “it’s hard thinking about what I like to do because so much of it I haven’t been able to do for a very long time… like jewelry making, I haven’t done that in years”. She attempted to participate filling out the Modified Interest Checklist during the evaluation, but was unable to complete it. She reported a low level of concentration and stated “I can’t focus right now”.
Tiffany used the laptop for Skype and Facebook. On Skype, she was able to keep in touch with a few close friends and family. On Facebook, she was able to connect with a CF support group and build meaningful relationships with a few people in the group. Tiffany reported that this was very important in her stay in the hospital (about one month). She was able to receive support and encouragement from people who understood her condition. Members of her CF support group also encouraged her to maintain her medication regimen which she reported was difficult for her to do on her own given the side effects.
As she began working with Occupational Therapy, her close friends also tried to keep her accountable in occupational engagement for psychosocial and emotional wellbeing, giving her reminders to go for a walk, get out of the room and do some other activities. She reported this accountability and encouragement from the therapist and her friends was “good for [her] emotional health”.
Ricky, 35 year old male with AML, admitted for allogeneic stem cell transplantation Playstation
-Email Receiving oncologic treatments, as a precaution, Ricky has to remain in isolative protection. His wife is able to visit him in the hospital wearing appropriate protective gown, gloves and mask. However, his two small children are not allowed to visit at this time.
Ricky occasionally plays video games on Playstation and uses his laptop and Skype to keep in contact with his two children. Nurses have reported that Ricky presents with a more positive mood and is fairing well in his treatments compared to his counterparts who do not have access to such activities.
Other Critical Illness
Ramon, 38 year old male with heart failure Laptop
-news Ramon was admitted into the hospital after experiencing an episode of myocardial infarction. He is a highly educated individual with 3 graduate degrees and worked several jobs as a computer engineer and software developer. He had a wife who was expecting their first newborn child. Ramon owned a laptop, but was unable to bring it into the hospital since his wife was currently using it to communicate with family members overseas and finding out information about caring for their expecting child.
After several setbacks in and out of the ICU, Ramon was observed to become more discouraged and was reluctant to participate in therapy sessions. Nurses described him as difficult to get out of bed. The OT department laptop was used as a motivational tool for increased participation in therapy. Ramon began using the laptop 30 minutes a day to read international news. His participation in therapy increased and he enjoyed collaborating with the OT on ideas of what laptops have the best utility and analyzed the costs.
After discharge from the hospital, Ramon is now heading a sta