La priorisation des demandes en ergothérapie dans les programmes de soutien à domicile

Referrals to home care occupational therapy services in the province of Quebec are prioritized according to urgency. However, this practice is not standardized and its impact on access to care is uncertain. This thesis, consisting of two related studies, investigates referral prioritization processes for occupational therapy services in home care.  The first study aims to describe in detail the processes that are used to prioritize referrals and to examine the associations between these processes and the the wait for services. We conducted a survey with the person who manages the occupational therapy waiting list in 55 home care programmes. Referral prioritization criteria vary between programmes, but there is a general tendency for problems related to safety and activities inside the home to receive high priority whereas problems related to quality of life and activities outside the home are not prioritized. Priority levels are highly associated with wait times; urgent referrals wait for a median of 2 days and low priority referrals wait for a median of 18 months. Programmes that have guaranteed maximum wait times have significantly shorter waiting lists than programmes that do not use any strategies to allocate services to low priority clients.  The second study aims to compare the opinions of home care occupational therapists, elderly people and persons with disabilities on the relative importance of the main criteria that are used to prioritize referrals. A survey consisting of fictional referral prioritization tasks revealed a significant difference between the priorities of the three groups of respondents. Occupational therapists (n=241) strongly prioritize persons who have fallen whereas elderly people (n=226) and persons with disabilities (n=247) mainly prioritize people who are unable to exit the home. Qualitative interviews with a subgroup of 30 participants revealed that occupational therapists prioritize issues related to home safety due to institutional constraints and lack of resources, but experience ethical tensions in doing so. Elderly people and persons with disabilities prioritize other issues such as independence, dignity, inclusion, participation and freedom. They call for referral prioritization criteria that reflect a broader view of health and healthcare.  The findings from this thesis highlight the need to improve referral prioritization processes in home care occupational therapy and suggest possible avenues to do so. For example, it would be beneficial to use strategies to allocate services to low priority clients, to consult the target clientele on referral prioritization criteria and to adopt a broader view of occupational therapy interventions, beyond home safety. By considering the various issues and challenges underlying referral prioritization for home care occupational therapists and their clientele, we can target solutions to improve equitable service allocation of home care occupational therapy.

Keyphrases: Occupational therapy, Waiting lists, Prioritization, Home care, Access to care, Community rehabilitation, Elderly, Physically disabled, Loss of independence