10- FOXcast OT: Pamela Toto at #AOTA18

Jimmy: This is FOXcast OT, a podcast for clinicians made by clinicians. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org.

Welcome to FOXcast OT! I’m your host, Jimmy McKay, in the, well, the expo hall here at AOTA, 2018 and I’m joined with:

Pam: Pam Toto.

Jimmy: Pam, from?

Pam: The University of Pittsburgh.

Jimmy: Yeah, and she’s got a big button that says…

Pam: I love Pitt OT!

Jimmy: Very, very shy – very subtle.

Pam: I also love Pitt football, Pitt basketball… my family, I guess.

Jimmy: Well say hi to them as well – they’ll probably listen to it.

Pam: Hi Jim, hi Piper, hi Drake.

Jimmy: So this is a podcast by clinicians, for clinicians, discussing pretty much, you know, whatever’s on your mind!

Pam: Sure.

Jimmy: We met yesterday.

Pam: Right.

Jimmy: Because that’s what happens at conferences – you run into people you haven’t met yet or you’ve know for years in the lobby, in the hallway, and you have these great conversations and you, terribly shy, but you know, I really had to pull the words out of you…

Pam: Right.

Jimmy: And I was like – gotta come on the show.

Pam: Right.

Jimmy: So what I want to talk about?

Pam: The future of how we can help older adults to be able to age well.

Jimmy: Oooh – well you’re at the FOX Rehabilitation booth. So we love everything you just said.

Pam: Exactly.

Jimmy: So where do you want to start?

Pam: Ever since I became aware of FOX Rehab, and I haven’t worked for FOX, so for you all of you listening I’m not a FOX employee…

Jimmy: No bias.

Pam: No bias! But I think you guys had the idea right. When people age they want to live in their own homes and they want to participate in their own communities for as long as they can, and they’re not really always interested in quantity of life, but they’re interested in quality of life.

Jimmy: Absolutely.

Pam: So the clients who we see, they want to, despite their chronic conditions, despite their frailty, despite their limitations, they want to be able to age in place to the extent of their ability. Occupational Therapists play a critical role. Our training allows us to look at the the person, the environment, and the occupation, and we are skilled to actually intervene in any of those three. Right? So we can make a person stronger if they want to and they’re frail. We can make their environment more adaptable, or we can teach them a new way to do their occupation – so now they sit and cook instead of stand and cook. I think that Occupational Therapists are underutilized in that role and we’ve always been stuck in traditional models because that’s where it’s the easiest to get reimbursed and we sort of follow that system. So, I would like to see Occupational Therapy expand to more of preventative models, or primary care models, or if you want to call it secondary care models. I think that we could have a role in long-term service and support. So when people enter a system they start to have trouble and we put them into an Area Agency on Aging or a long-term services support program, and those are usually run by nurses or social workers who are great at their jobs…

Jimmy: Great at making you medically stable or medically well.

Pam: Right.

Jimmy: Not functional.

Pam: But they also solve the problem by putting in a service that does for you. So they are do-for services. Yes that person no longer has that disability because we’ve eliminated the occupation. Well, we know that even if it’s just physical activity – so being able to get in and out of your shower yourself, getting a shower is physical activity. So even if you don’t believe what we believe as Occupational Therapists – that the whole point of living is to have purpose to your day, even the menial tasks that we don’t like to do – even at the very limit, making your peanut butter and jelly sandwich, getting your mail, vacuuming your floor are all still physical activity that we know actually increases your health.

Jimmy: And when those go away, that’s a big deal!

Pam: So what we’ve done at the University of Pittsburgh is we’ve done a lot of pilot programs of helping people in the community at an earlier stage.

Jimmy: Talk about that

Pam: We piloted a program where we infused Occupational Therapy into a long-term, a great long-term service and support program, that includes nursing and some physician oversight and social work. So our first step was: what is our role. We found out that they do a great self report of ADLs, IADLs, leisure. We also found that they find funding, and they find handymans, and secure and make environmental changes. They actually provide all the equipment that typically an OT or even a PT may recommend. So these folks already have a lot of those things, so you start by scratching your head and you say “oh it seems like they’re doing some of the things that we can do.”.

But what we realized was that what was missing was this, this encouragement, or this coaching, or sort of the behavioral approach to helping people do more for themselves. A lot of older adults don’t even know – like they actually expected decline. So they don’t know and they lose…

Jimmy: Society has told them that that’s what’s expected of them.

Pam: Exactly, Exactly.

Jimmy: And we know differently.

Pam: Right. So people lose their occupations, unless they have a catastrophic illness or something major, especially with chronic disease, they lose their occupations over time. So maybe they get a shower every day and then it’s difficult so they get a shower three times a week, and then they say “well if I just do it once a week it’s OK,” and then before you know it you’re talking to them and you say, I say “do you have difficulty in bathing” and they go “No.” And then I find out they’ve been sponge bathing for six months. So I could say, do you like sponge bathing and they say, if they say yes then that’s their choice. But if they say heck no…

Jimmy: That’s where you say yeah, well let’s figure out how to do that.

Pam: I say “did you know that you could do this again yourself?” So I think that we have a role getting in earlier. And I think that historically Occupational Therapy/Physical Therapy has always been posted acute.

Jimmy: Right. It’s always been reactionary.

Pam: Right.

Jimmy: So we were talking before we turned the microphones on, and I’ve now learned about you – I should always have the microphones on when you walk into the room… We were talking about how we’re going to be paid in the future. This is across all the therapy disciplines. Money is always the bottom of it. I know it’s like a dirty phrase, but I like to, you know, pay rent and buy cornflakes.

Pam: Amen!

Jimmy: And then how are we going to be doing it – it’s going to be outcomes based.

Pam: Exactly.

Jimmy: How could you measure it and how do you talk about it, how do you present it.

Pam: Exactly. So I think it’s twofold. Unfortunately, the easiest path is to always work in your health system and to do whatever your health system tells you. Like, one of my least favorite things in the world is when I, I’ve worked for agencies and they say we’re going to use the Timed Up and Go to determine falls risk. Well, the Timed Up and Go is a great community screen, but if you work in a skilled nursing facility you could actually not do the TUG and you could also predict that 100 percent of the people in the home – it’s not sensitive enough.

Jimmy: Right.

Pam: So as a clinician I think that we need to be more empowered to know, understand, and use the best evidence based tools and interventions – that’s number one. And number two is we have to be able to talk about it, and we have to be able to look at the outcomes. A lot of times we’re also, we’re often removed – we do our paperwork, we see our client, we have no idea what what outcomes our system is measuring. And so what happens sometimes is the system is looking at an outcome that doesn’t reflect the skilled service and the intervention that we provided.

Pam: I remember many many years ago I worked in skilled nursing facilities and they were trialing the FIM – the Functional Independence Measure – and the speech therapists were in nuts over it because they were taking people from a feeding tube and putting them to like maybe a regular diet or a mechanical soft but they were still being fed. So on a FIM it looks like there’s no change in feeding. They started as a dependent, they end as a dependent. Meanwhile, the service was rich, meaningful, and improved the person’s health.

Jimmy: So the test was not sensitive enough.

Pam: Right. And the test was wrong. If you want to be a clinician – be a great clinician and be aware. But we also need clinicians in management roles and in decision in leadership roles.

Jimmy: So you’re in the board room when the decisions are being made

Pam: Yeah, and which outcomes to measure. And I don’t think that we’re always confident enough. Like, sometimes we do get asked. We’re afraid that we’re going to pick the wrong outcome, like “oh, they’re finally asking me which one do I choose.” A lot of great rehab happens. Unfortunately, the systems that we’ve had in place for a long time aren’t necessarily measuring the value of those services. And we, as clinicians (because I agree with you – we live in a capitalist society: I don’t work for free) – we have to not be afraid to talk about money.

Jimmy: Instead of saying money, I focus on value.

Pam: Ok, right!

Jimmy: What will I bring and what does that cost. Let’s divide one by the other and I can show you what I gave to you.

Pam: Right! There are some statistics, and I can’t tell you the reference, but if we could prevent people from going to a nursing home by one month the cost savings would be phenomenal! So we’re not trying to save the world, we’re not trying to help grandma run a marathon. We’re trying to help grandma live well, continue to go to church, babysit the grandchildren once a while, go to Eat’N Park. Sorry – hi guys, I’m from Pittsburgh Pennsylvania: Eat’N Park’s a staple in our town. Go to Eat’N Park with your daughter, prune your rose bushes, do your own laundry.

Jimmy: Be you.

Pam: Be you, right.

Jimmy: We have a tradition here on FOXcast is the FOXtale.

Pam: OK.

Jimmy: Are you ready?

Pam: Yeah!

Jimmy: So why did you choose Occupational Therapy – why this profession for you.

Pam: Oh, great question. So, um, since I was 8 years old I wanted to work with older adults and I didn’t know that there are really that many professions. I grew up in a small town, I worked in a bingo.

Jimmy: Were you the caller?

Pam: No, I was the card changer

Jimmy: Ok, a very important role in Bingo.

Pam: You know, the Bingo winner caller.

Jimmy: Right.

Pam: I even had like a little group of older adults who had some limitations, I didn’t know this at the time, who would like follow me from table to table because our stations moved. And so I always wanted to work with older adults and I thought I had to be a geriatrician to be able to help older adults live well. In my freshman year I’m at the University of Pittsburgh as a premed major – the dormitory advisor, the R.A., was leaving to go and do her level two fieldwork. And I had to turn my keys in and she didn’t like me because she thought I was a little loud.

Jimmy: OK.

Pam: Are you suprised?

Jimmy: I don’t even know why she would say that. No idea.

Pam: So, um, I was kind of cavalier. I thought that Occupational Therapists found jobs for people and I actually made that comment. And I remember that she said “No, you see this phone?” And I’m a little old, so I think she had a dial phone. She said “Like what if like someone had arthritis and they couldn’t dial these numbers, like how would they be able to do it?” She says “I help people figure out how to do the things that they need to do.” All of her examples were older adults, and so I was like -wow!

Jimmy: Light bulb moment.

Pam: Right. I thought, I was paying for college myself – I wasn’t sure I could afford medical school anyway. And I thought, boy I could get there quicker and help older adults and do more for themselves. Never looked back!

Jimmy: Get there quicker, which was to help older adults.

Pam: Right!

Jimmy: And now you get to decide how that is.

Pam: Right.

Jimmy: Glad you’re here!

Pam: I love being here. I’ve been coming every year since 1995 to AOTA.

Jimmy: Yeah.

Pam: Except for 1999, sorry Indianapolis.

Jimmy: One year off.

Pam: I had a baby.

Jimmy: Pam, I appreciate you coming by and coming on the show. I have a feeling this is not going to be the last time we’ll have you on the program.

Pam: I would love to be on your show again and I want to just say: University of Pittsburgh Graduate Kelsey Trainer Swope, one of our alumni – so proud that you have her with your team.

Jimmy: Yeah, that’s one of our Mentor Services grand pubahs.

Pam: Hail to Pitt.

Jimmy: Yeah, thanks. Thanks again – appreciate your time.

Thanks for listening to FOXcast OT, a clinically excellent podcast. It’s brought to you by FOX Rehabilitation. Listen to other episodes or read articles and position papers at foxrehab.org.