Role of OT in assessing functional cognition

Occupational therapy practitioners have a key role in assessing functional cognition and ensuring that Medicare beneficiaries in post-acute care settings receive the right care in the right setting. Occupational therapists use everyday task performance to identify cognitive impairment and inform the plan of care.

Approximately 30% of occupational therapists and 60% of occupational therapy assistants are employed in Medicare-reimbursed post-acute care settings affected by the Improving Post-Acute Care Transformation Act of 2014 (IMPACT Act).

The Centers for Medicare & Medicaid Services (CMS) has stated that the intent of the measures and standardized data required by the IMPACT Act is to use an individual’s health assessment data and goals and preferences in real time, as well as longitudinally, to facilitate coordinated care and improved outcomes. AOTA was pleased that Congress recognized the importance of collecting data on cognitive status in the IMPACT Act because cognitive impairments have a significant relationship to Medicare resource use, length of stay, and patients’ long-term outcomes. This Fact Sheet provides an overview of the critical role of occupational therapy in assessing functional cognition, and ensuring that Medicare beneficiaries in post-acute care settings receive quality care in the most appropriate setting, using only the necessary Medicare resources.

What is functional cognition?

Functional cognition is how an individual utilizes and integrates his or her thinking and processing skills to accomplish everyday activities in clinical and community living environments.

Why is it important to assess functional cognition?

Health care providers need to determine whether and how a client safely and effectively participates in essential ADLs, such as personal hygiene behaviors and dressing, and IADLs, such as medication management, to guide post-acute care transition placement, discharge decisions, and client/caregiver training. To assess these factors, occupational therapists use performance based testing (PBT), which utilizes everyday activities that have high potential to engage clients in a relatively brief amount of time. PBT is also used to inform the post-discharge level of functioning, including self-care and personally valued roles, routines, and activities. The assessment of functional cognition assists occupational therapists to establish the necessary environmental and personal care supports for the individual to function in both treatment and discharge environments.

Why are occupational therapists central to cognitive assessment?

Occupational therapists are experts in measuring functional cognition, which encompasses assessment of everyday task performance (e.g., self-care, household management, childcare, workplace tasks). Occupational therapists specialize in identifying performance-based cognitive impairments, which range from subtle to obvious. Occupational therapists treat cognitive impairments because they have the potential to compromise the safety and long-term well-being of patients, especially those who are elderly. Early identification of performance-based cognitive impairments allows for the timely implementation of an occupational therapy care plan. The plan can include implementing the supports necessary to prevent harmful events that commonly happen during routine, everyday activities for patients with cognitive impairments; for example, falls due to problematic sequencing during bathing or dressing activities. The occupational therapy care plan also promotes optimal recovery, stabilization, and success in post-acute care and discharge settings. The purpose of occupational therapy is to enable compensatory activities and to improve function when possible. For Medicare beneficiaries, early detection by occupational therapists of performance-based cognitive impairments also facilitates the selection of the most appropriate care setting, with an eye toward client-centered discharge options and effective, efficient caregiver identification, support, and training.

What methods of testing do occupational therapists use?

To assess clients' ability to perform tasks, occupational therapists determine how or whether they initiate a real-world task; avoid and/or correct errors, sequences, and execute tasks steps; and demonstrate intrapersonal skill and good time management. Additionally, therapists evaluate clients’ awareness of attention to environmental stimuli throughout the activity. By evaluating individuals’ cognitive strengths and limitations in the context of performing everyday life activities, occupational therapists can help individuals identify strategies to compensate for cognitive loss when possible and to adapt the environment to improve their independence in participating in ADLs and IADLs.

Why is the occupational therapy assessment of functional cognition necessary?

Assessing functional cognition is necessary to identify cognitive impairments that challenge a patient’s ability to accomplish real-world tasks. The many everyday tasks that must be performed for optimal and independent living include managing medication, ensuring home safety, cooking, maintaining healthy lifestyle behaviors, and facilitating positive social interactions. Traditional neuropsychological evaluative measures were developed to localize individual cognitive abilities, such as selective attention, verbal memory, inhibition, and processing. In contrast, PBT reports how a person interacts with the environment to accomplish an activity. Occupational therapists use everyday activities, because tasks with familiar contextual clues have high potential to engage clients. Functional cognition is used to plan for post-discharge level of functioning, including self-care and personally valued roles, routines, and activities. The occupational therapy assessment contributes to identifying appropriate levels of care and appropriate resources to reduce caregiver burden, and it contributes to reduced hospital readmissions and increased safety at discharge.

How can outcome data inform health care policy and reimbursement?

AOTA has been working with a technical panel of occupational therapy members who are experts in functional cognition and performance based cognitive assessment. The research and resulting data available through these AOTA member experts can assist CMS in considering how to best capture functional cognition and related cognitive impairments for patients being treated in post-acute care settings, consistent with the objectives of the IMPACT Act.