Review of Literature

The purpose of this section is to review the literature relevant to the delivery of pediatric primary care and occupational therapy’s contributions to a primary care team. The main sections discuss literature related to well-child care, occupational therapy’s role in pediatric primary care, and integrating occupational therapy into primary care settings. 

Well-Child Care

A well-child visit in pediatric primary care typically includes a clinical examination (i.e. health history, physical examination), screenings (i.e. psychosocial, developmental, dyslipidemia, hypertension, iron deficiency, lead poisoning, vision), anticipatory guidance (i.e. safety, dental care, screen time, sleep, diet and activity), and immunizations (Lipkin & Macias, 2020; Turner, 2018; Vitrikas et al., 2017). The American Academy of Pediatrics (AAP) recommends that primary care providers incorporate health supervision and anticipatory guidance into well-child visits by considering environmental factors and providing guidance on safety, screen time, sleep, diet, and activity to promote health and prevent disease and injury (AAP, 2021; Turner, 2018).  

Despite recommendations for preventative services, primary care providers have identified time constraints as a major challenge when delivering services to their patients and often do not have adequate time in a typical visit to provide preventative services and accomplish all necessary components of well-child care (Halle, et al., 2018; Morelli et al., 2014; Norlin et al., 2011; Halfon et al., 2011; Boyd & Fortin, 2010; Ostbye et al., 2005). Primary care providers also have responsibilities such as obtaining a medical history, physical examination, immunizations, and diagnosing/treating acute and chronic diseases which often takes priority over preventative services (AAP, 2021; Turner, 2018).

Norlin et al. (2011) observed well-child visits over a 10-week period to document characteristics on the delivery of well-child care and compared it with recommendations from Bright Futures, which offers a set of guidelines for health supervision of infants, children, and adolescents which is supported by the American Academy of Pediatrics (AAP, 2021). Norlin et al. (2011) observed 52 pediatric primary care providers (43 pediatricians, 6 nurse practitioners, and 3 physician assistants) during 483 well-child visits of children from birth to 19 years old and documented the total visit duration as well as time spent on each health supervision or anticipatory guidance topics. The average visit duration was 20.3 minutes and was found to be longer for children with special health care needs. The time spent on components of well-child care were broken down as follows: 8.6 minutes for health supervision/anticipatory guidance topics, 4.2 minutes on physical examination, 1.1 minutes of discussion of immunizations, 1.2 minutes on other health-related conditions, 0.8 minutes addressing prescriptions, tests, and referrals, and 4.2 minutes on minor complaints, family history questions, and social conversation. In 76.8% of observed visits, the primary care provider asked at least one open-ended question to elicit parent or patient concerns. The most common concerns raised by parents were related to nutrition/diet, growth, sleep, and toileting. When comparisons were made with the recommendations in Bright Futures, it was determined that the primary care providers addressed only 42% of the health supervision/anticipatory guidance topics that are recommended by Bright Futures (American Academy of Pediatrics, 2021).

Halfon et al. (2011) surveyed 2,068 parents of children aged 4 to 35 months to examine the associations between visit length and content, family centered care and parent satisfaction. Researchers found that 33.6% of parents reported spending less than 10 minutes at their last well-child visit while 47.1% spent between 11 to 20 minutes, and 20.3% spent over 20 minutes. These findings are consistent with the 2019-2020 National Children’s Health Survey in which 82.2% of the sample of children (N=24,954) spent less than 20 minutes with their doctor for preventative services (Data Resource Center for Child & Adolescent Health., 2021). Halfon et al. (2011) found that visits that lasted longer than 20 minutes were more likely to include developmental assessments, questions asked by parents, and higher parent satisfaction with the clinician.

Developmental Screening

The American Academy of Pediatrics (AAP) recommends that developmental surveillance occur at every well-child visit and formal developmental screenings occur at the 9, 18, and 30-month well-child visits (AAP, 2021). Despite recommendations from the AAP, the 2019-2020 National Survey of Children’s Health revealed that 63.1% of children ages 9 through 35 months did not receive a developmental screening, 18.1% of children spent less than 10 minutes with their health care provider during their preventative check-up, and 70% of parents reported not being asked by their child’s doctor if they have concerns about their child’s learning, development, or behavior (Data Resource Center for Child & Adolescent Health., 2021). King et al. (2010) examined how 17 pediatric primary care practices implemented AAP’s developmental surveillance and screening recommendations and found that all practices used parent-completed screening tools and screened over 85% of children at the recommended screening ages by dividing responsibilities among the primary care team. However, during busy periods or times of staff turnover, many practices reported difficulty administering a screen after developmental surveillance suggested a concern. 

Morelli et al. (2014) conducted focus groups with eight parents of children under the age of five regarding perceptions of developmental screening and found that parents felt their parental knowledge and concerns were undervalued by pediatricians and that they desired the opportunity to provide more input regarding their child’s development. Of the 1,002 parents who completed a survey, 99% reported no difficulty completing developmental screens and 98% felt it covered important areas of their child’s development. However, focus groups with the 22 pediatric primary care providers revealed that physicians preferred using their clinical judgements over screening tools and felt that parents lacked knowledge of child development and therefore did not rely on parental concerns.

Referrals to Early Intervention 

Part C of the Individuals with Disabilities Education Act (IDEA) establishes early intervention services, which may include occupational therapy, for children under three years of age with developmental delays. A physician referral is not required for a child to be evaluated for early intervention services, however, developmental surveillance and screening conducted within pediatric primary care settings may warrant a referral from a physician. Studies have shown that many pediatric primary care providers do not adequately refer eligible children for early intervention (McManus et al., 2020; King et al., 2010).

McManus et al. (2020) retrospectively identified gaps in early intervention referrals, access, and service use among 14,710 children under 35 months of age with developmental delays or developmental disabilities who attended a well-child visit at primary care clinics over a two year period. Of the 14,710 children with a developmental delay or disability, only 18.7% were referred to early intervention. Most notably, black non-hispanic children were less likely than white non-hispanic children to be referred to early intervention. 

King et al. (2010) found that among the 17 pediatric primary care practices examined, most providers reported difficulties submitting referrals to medical subspecialists and local early intervention programs during busy periods and staff turnover. The providers reported only referring 61% of children who failed developmental screenings. Tracking referrals was another difficulty reported and many families did not follow through with recommended referrals (King et al., 2010). A referral to health care providers at an outside source can often inflate health care costs, cause a delay in receiving services, and fragmentation of healthcare delivery (Dahl-Popolizio et al., 2017; Muir, 2012). An onsite occupational therapy practitioner integrated into the primary care team would decrease fragmentation of care and increase access to occupational therapy services, lessening the burden of tracking referrals for physicians. 

Occupational Therapy’s Role in Pediatric Primary Care 

The American Occupational Therapy Association (2020b) states that occupational therapy’s role in pediatric primary care includes providing developmental assessments, identifying early intervention needs, and linking families with support services, resources, and community-based care for children facing challenges to their occupational performance and participation. 

Brenner et al. (2020) surveyed 95 pediatric primary care providers to explore their perceptions on the involvement of occupational therapy practitioners during well-child visits and found that 78% of PCP’s would be receptive to OT’s involvement during well-child visits to help with developmental screening and provide preventive and developmental education to parents and caregivers. Few reports of occupational therapy practitioners’ provision of  services in pediatric primary care settings have been noted in the literature (Bauer, 2022; Foxhoven, 2020; Zachry & Flick, 2018). Occupational therapy faculty and students from Tennessee served children in a pediatric primary care practice and found that OTPs were needed for providing developmental screening (Zachry & Flick, 2018). Two occupational therapy doctoral projects (Foxhoven, 2020; Bauer, 2022) focused on collaborating with pediatric primary care providers to support caregivers of children in promoting healthy child development. Foxhoven (2020) collaborated with pediatricians on well-child visits to assist with developmental screening and parental education on child development and found that the PCPs became receptive to the inclusion of OT on their pediatric primary care team. Bauer (2022) conducted a mixed-methods research study to evaluate the needs of pediatric PCPs and caregivers of children in order to develop programming to address those needs. A program that consisted of six five-minute videos addressing common family routines and child development topics of concern was created for patients and providers at the primary care clinic served. 

Several studies (Mirza et al., 2020; Pyatak, et al., 2019; Garvey, et al., 2015; Richardson et al., 2010; Jackson et al., 1998) support the use of occupational therapy interventions in primary care for chronic disease management. However, according to the 2019-2020 National Survey of Children’s Health, 68.7% of children ages 0-17 had health conditions that moderately or greatly affected their daily activities and 37.9% had at least one lifelong health condition (Data Resource Center for Child & Adolescent Health, 2021). Although occupational therapy interventions for chronic disease management in the pediatric primary care setting have not been formally researched, studies examining OT interventions for adult primary care patients (Mirza et al., 2020; Pyatak, et al., 2019; Garvey, et al., 2015; Richardson et al., 2010; Jackson et al., 1998) provides strong evidence for occupational therapy’s role on an interprofessional primary care team. 

Referrals to Onsite Primary Care Occupational Therapy 

Andrea et al. (2021) surveyed 16 occupational therapy practitioners who worked in primary care settings, three of whom reportedly worked in pediatric primary care. Three methods for patient referral to OT services were described by these 16 participants: 1) physician referral (N=11), 2) other health care professional referral (N=8), or 3) chart review/risk assessment (N=4). These three referral methods are consistent with the literature surrounding occupational therapy interventions in primary care (Garvey et al., 2015; Mirza et al., 2020; Murphy et al., 2017; Synovec et al., 2020).

To determine the feasibility of incorporating an occupational therapy-led chronic disease management program into primary care practices, Garvey et al. (2015) used recruitment strategies for the study to replicate how it would occur in clinical practice. Primary care providers referred patients to the OT program who met the inclusionary criteria. Since primary care providers had to make the referrals to the occupational therapy led program, it was necessary for them to be previously educated about the inclusionary criteria and who would benefit from OT services (Garvey et al., 2015). This recruitment/referral process demonstrated the reliance on primary care providers’ prior knowledge of occupational therapy’s scope of practice in order to make proper referrals for services that would benefit their patients. 

Mirza et al. (2020) also used referrals from PCPs as the recruitment procedure for a two-group randomized control trial that determined feasibility of implementing an occupation-based program in the primary care setting for adults with chronic illness. In addition to PCP referrals, patients were also identified as eligible for these OT services based on the clinic’s electronic medical records (EMRs), which reflects one of the referral methods found by Andrea et al. (2021) in which chart reviews/risk assessments were used. Mirza et al. (2020) found that, despite PCPs overall receptiveness of providing OT services at their clinic, they still had concerns regarding the screening and referral process. Specifically, PCPs expressed a need for more clarity on what qualifies a patient for occupational therapy and the types of procedures needed to easily connect patients with the OT. 

Murphy et al. (2017) described how occupational therapy met the needs of medically underserved populations when integrated into four Federally Qualified Health Centers. Occupational therapy supplemented the physician's care by participating in client visits and team meetings, administering developmental screenings, and providing mental health, prevention, and health and wellness services. A patient received OT services if they were either referred by the PCP or deemed “at risk” based on chart reviews. When a need for OT was identified, such as in children at risk for developmental disabilities, the OTP immediately intervened to meet that need. 

Tools for Referral to Primary Care Occupational Therapy 

Two referral tools (Grosser & Tadman, 2021; Roselli, 2019) made specifically for occupational therapy referrals in the primary care settings exist, however neither of them are intended for use within pediatric primary care. Roselli (2019) created the “Occupational Participation Assessment for Primary Care (OPAPC)” which was made to explore the potential role of occupational therapy for adults within a primary care setting by screening patients for occupational limitations. There were 150 adult primary care patients who completed the self-report screener and results indicated a need for occupational therapy for adults in that primary care setting. Grosser & Tadman (2021) created the “Primary Care Provider Screening Tools for Adults with Chronic Conditions (PCP-STACC),” which aims to help PCP’s identify if patients have any barriers to performance in daily activities and would benefit from seeing an occupational therapist. This tool is meant to be used in primary care settings for adults over the age of 18 with chronic conditions. Although the development of this tool was guided by literature and theory, it was not implemented in a primary care setting, nor researched on its ease of use or effectiveness. Additionally, occupational therapy practitioners and primary care providers were not consulted throughout the development of the referral tool. 

Integrating Occupational Therapy into Primary Care Settings

Seven occupational therapists who provided OT services in primary care were interviewed to understand their experiences and recommendations for integrating into primary care (Rouch et al., 2022). Recommendations for gaining entry into the practice involved confidence in articulating OTs distinct value in primary care as well as building relationships with all stakeholders in the practice including physicians, medical assistants, front desk staff, and clinic staff. The culture of the organization played a significant role in the success of team-based care. For example, when the organization’s culture was more collaborative and patient-centered, occupational therapy integrated into the organization’s culture more easily. The occupational therapists also reported barriers they faced, including space, resources, and the staff’s understanding of their role. Specifically, the lack of understanding of OT’s role contributed to few or inappropriate referrals. 

Smith et al. (2020) and Valasek & Halle (2018) outlined the necessary steps for integrating occupational therapy into established primary care settings and developing tailored program proposals. For instance, when a primary care practice has expressed interest in the potential collaboration with an occupational therapist, it was recommended that a needs assessment be conducted to identify the unique needs for that site in order to define OT’s distinct role within that specific practice. Information such as the roles of key stakeholders, the organization’s philosophy, services provided, PCPs knowledge of OT, and the patient’s needs are all important aspects to consider when integrating in a primary care setting. A survey was recommended to gather quantitative data regarding PCP’s knowledge of OT, in order to indicate the level of necessity and potential topics for PCP education. 

Education for Primary Care Providers 

A limited understanding of occupational therapy’s scope of practice and role in primary care is one of the most significant barriers to the integration of OT into primary care (Rouch et al., 2022; Andreae et al., 2021; Halle et al., 2018; Dahl-Popolizio et al., 2017a; Donnelly et al., 2013). However, educating primary care providers on the role of occupational therapy has been shown to be effective in increasing the support and receptiveness to the inclusion of OT on a primary care team (Andreae et al., 2021; Halle et al., 2018; Dahl-Popolizio et al., 2017a; Donnelly et al., 2013).

Dahl-Popolizio et al. (2017a) surveyed 34 primary care providers including 17 medical doctors, four doctors of osteopathic medicine, nine nurse practitioners, and four physician assistants with seven questions focusing on whether their interprofessional primary care team could benefit from an OT on the team. All 34 participants read a brief educational paragraph about occupational therapy prior to completing the survey. Quantitative analysis showed that 79% of PCPs could envision patients in their practice that would benefit from the skill set of an OT, and 91% of PCPs were open to working with an OT as a member of their interprofessional primary care team. Qualitative analysis, which included only nine PCPs, revealed that eight of them were supportive of OT in primary care; one PCP was unsupportive of hiring an OT, but would contract with them. Although the majority of PCPs were supportive of OTPs in primary care, four out of the eight “supportive PCPs'' described concerns such as the uncertainty of what OTs can do in primary care and defining roles between the healthcare team.They suggested the need for further education regarding the role of OT in the primary care setting. Two participants who identified as pediatric primary care providers indicated support for OT in primary care, but shared that most of their pediatric patients already obtain OT services from outside sources.

Pediatric primary care providers’ understanding of the role of OT in primary care has received less attention in the literature, with only one study (Brenner et al., 2020) focusing solely on pediatric primary care providers. Brenner et al. (2020) found that 82.1% of pediatric primary care providers (N=95) reported familiarity with occupational therapy’s scope of practice. These findings contradict previous findings in the literature in which adult primary care providers typically did not fully understand OT’s scope of practice (Andreae et al., 2021; Halle et al., 2018; Dahl-Popolizio et al., 2017a; Donnelly et al., 2013). While the findings of Brenner et al. (2020) conflict with previous literature, Brenner et al. (2020) collected quantitative data in which participants responded on a Likert scale as “disagree, somewhat disagree, neutral, somewhat agree, agree.” Therefore, there was no qualitative data that would confirm these clinicians accurately understood occupational therapy’s scope of practice. A comparison cannot be made because there are currently no other quantitative or qualitative studies that focus specifically on pediatric primary care providers’ understanding of occupational therapy’s scope of practice.

In addition to direct education for PCPs about OT’s role, co-location has also been found to be beneficial for indirectly educating primary care teams on the role of occupational therapy (Pyatak et al., 2019; Donnelly et al., 2013). Co-location refers to OTPs and PCPs treating clients in the same location. Pyatak et al. (2019) found that, when implementing Lifestyle Redesign® in a primary care clinic for adults with diabetes, colocation allowed for informal education to PCPs on OT’s role throughout the duration of the study and helped providers gain a deeper understanding of OT’s scope of practice. Similarly, Donnelly et al. (2013) found that out of the four primary care clinics in Canada that were examined, only one clinic had an OT onsite with the physicians, while the other three clinics had OTPs working in nearby buildings. The lack of colocation was identified as a main barrier in the integration of occupational therapy.

Andreae et al. (2021) found that incorporating OT students into primary care settings was beneficial for educating primary care providers on the distinct value of OT. Andreae et al. (2021) conducted a mixed-methods study to explore how occupational therapy students are used in the primary care setting in fieldwork and capstone experiences. Due to the limited number of occupational therapists who work in the primary care setting, only 16 OT’s participated in this study. Results showed that 69% of participants identified PCP’s “narrow or unclear vision of the value of OT” as a main barrier to OT in primary care. However, OT students were viewed as useful for providing interventions, screening and evaluating for OT services, and most notably, educating the interprofessional team about the value of OT.

Donnelly et al. (2013) found that educating primary care providers about occupational therapy’s scope of practice was an important element in the successful integration of OT into four primary care teams in Canada. Using a multiple case study design, Donnelly et al. (2013) conducted in-depth interviews and questionnaires with occupational therapists working at four different primary care teams. Occupational therapists at each of the four practices educated physicians and team members about OT’s scope of practice and role in primary care through presentations, educational rounds, meet and greets, brochures, and information letters. Team members identified that having a good understanding of occupational therapy increased the rate of appropriate referrals.