An efficient health-care system includes services for people with chronic and episodic conditions within primary care (Aggarwal & Hutchison, 2012). Services delivered within primary care and primary health care contexts allow practitioners to offer timely interventions in regards to prevention, self-management and health promotion (McColl & Dickenson, 2009). Due to its role as the entry point to health services, primary health care is a privileged setting to address a broad spectrum of needs and coordinate different health and community services (Canadian Working Group on HIV and Rehabilitation [CWGHR] & Wellesley Institute, 2012).

As such, primary health care service delivery allows for a forward thinking approach that can delay or prevent avoidable treatments and reduce the risk of emergency or crisis situations, and hospital admissions (CWGHR & Wellesley Institute, 2012; Tran, 2004). Finally, primary health care services are usually offered over an extended period of time, which can help foster the development of trust between practitioners and their clients. This kind of relationship can facilitate the disclosure of sensitive issues such as substance use and psychological difficulties (CWGHR, 2009) and provide opportunities to find long-term management strategies, which are essential when working with people with chronic and episodic conditions.

An example of a chronic condition: human immunodeficiency virus
The advent of antiretroviral therapy has tremendously increased the life expectancy of people living with human immunodeficiency virus (HIV) to the point that this condition is now considered a chronic and episodic condition (World Health Organization, 2002). However, compared to the general population, people living with HIV are at greater risk of developing other chronic conditions such as renal failure, diabetes and cardiovascular diseases, and are developing those conditions at an earlier age than people not infected by HIV (Guaraldi et al., 2011). Consequently, they face several challenges in performing daily occupations (see Table 1).

One of the most prominent challenges for people living with HIV is linked to episodic disability (Tran, Thomas, Cameron, & Bone, 2007), which is the experience of uncontrolled and unpredictable limitations in performing productive, self-care and leisure activities. These occupational challenges are thus likely to prevent someone from fully engaging in significant life roles.

Table 1. Challenges experienced by people living with HIV

Body function

• weakened immune system
• fatigue, decreased strength and endurance
• neuropathic pain and peripheral neuropathy
• impairments in executive functions, episodic memory, attention, working memory, and language
• decreased information processing speed

Activity and participation

• restrictions in ability to perform self-care, work or school, and leisure activities
• requirement to manage a rigorous medication regime and its associated side effects, as well as to manage a schedule
  of several medical obligations and appointments
• imposed restrictions due to an unpredictable health status
• suboptimal participation in meaningful life roles

Environmental and personal factors

• fear of disclosure
• social stigma, discrimination and/or rejection
• difficulty with access to specialized health care, particularly outside urban areas
• poverty

Occupational therapy service delivery to HIVpositive clients in primary health care
The Nine Circles Community Health Centre is a prime example of an interprofessional primary health care setting that recently integrated occupational therapy services. This not-for-profit organization provides coordinated medical and social support services for those living with and affected by HIV and acquired immunodeficiency syndrome (AIDS) (Nine Circles Community Health Centre, 2013).

In 2009, the centre conducted a client survey. Clients indicated that they wanted services to help them address issues related to successful aging, increasing independence, and returning to work and school. To assist in addressing client concerns, the coordinator of the clinic worked with the Canadian Working Group on HIV and Rehabilitation, the national advocacy association that is focused on improving rehabilitation services for people living with HIV.

This organization quickly identified that Nine Circles CHC was in need of the expertise of an occupational therapist, a professional with knowledge in helping people perform activities they need to do or want to do. Dawn James was then hired as the first occupational therapist to work with the Nine Circles CHC team of professionals, including physicians, nurses, social workers, health educators, mental health therapists, a pharmacist, a dietician and a health promotion coordinator.

Primary health care is a setting that is well-suited for occupational therapists to adopt a preventive and forward thinking approach in supporting clients’ optimal participation in daily activities, throughout their life span and despite fluctuating capacities (Tran, 2004). The ultimate goal of these interventions is to enable people to live meaningful and productive lives. See Table 2 for examples of common occupational therapy interventions for people with chronic and episodic conditions. Ms. James’ previous training and work experience in health promotion and in running lifestyle change programs, such as smoking cessation, were tremendous assets in developing the occupational therapy role at Nine Circles. She quickly established strong alliances with her interprofessional team and with various community resources in order to offer and advance services in areas such as mental health, justice, housing, substance use, and lifestyle changes.

In her daily practice, she addresses the broad spectrum of needs of her clients, including difficulties in the areas of sleep, pain, cognition, goal setting, work-related issues, mobility, home management, community mobility, self-care, medication side effects, coping with a chronic and episodic condition, etc. Despite her busy schedule, she has developed new programs like a flexibility-stretching group, a plain language medical information session, and an ‘exer-gaming’ physical training program. These programs aim to help clients achieve their goals related to activities of daily living, physical activity, and socialization with other persons living with HIV.

Ms. James also has a strong commitment to stay current in her occupational therapy evidence-based knowledge and she reads as much as possible on her field of practice. Since finding a mentor in her specific area of practice is a real challenge, she initiated a special interest group for occupational therapists who work with marginalized and vulnerable populations. This local group meets in person approximately six times a year and discusses issues such as coping with vicarious trauma, counseling clients with substance addictions, housing, and food insecurity. They help each other advance their clinical reasoning and problem-solving skills. This network has been very helpful in Ms. James’ efforts to expand and optimize the occupational therapy interventions at Nine Circles.

Ms. James has also joined the Canadian Working Group on HIV and Rehabilitation and has linked with other rehabilitation professionals working in HIV care across the country.

Table 2. Examples of occupational therapy interventions for people
with chronic and episodic conditions

Through assessment, counseling, facilitating experiential learning opportunities, adaptation or support, an occupational therapist may address:

• optimal participation in self-care, employment, leisure, social and community activities
• safety adaptations of home, work or leisure settings
• community mobility
• ergonomics and return to work and school
• prevention of injuries and falls
• energy conservation
• pain and fatigue management
• stress reduction techniques
• health promotion and lifestyle changes
• acquiring coping skills and adjusting to the impact of the chronic and episodic health condition
• increasing self-esteem and feelings of empowerment
• linking clients and family with caregiver assistance and support

A concrete example: Accessing the food bank
Many of Nine Circles CHC’s clients face food insecurity. To help alleviate this problem, the clinic offers a weekly food bank. Unfortunately, many clients are also living with mental health issues, addictions, mobility challenges and episodic illnesses that prevent them from attending the food bank and transporting the food to their home.

Tapping into her occupational therapy expertise and problem-solving skills, Ms. James proposed several solutions. She referred some clients to other community-based food programs that better fit their needs (e.g., closer to their home). She educated clients on how to manage their activity limitations effectively or circumvent personal and social barriers. For example, for clients with anxiety disorders who are particularly anxious in a crowded environment, she suggested visiting the food bank when it is not busy and the food bank staff can provide additional support. Finally, she suggested adaptive equipment that helped her clients to independently transport the food packages (e.g., a trolley for transporting food that can be taken on a public bus).

Conclusion
Occupational therapists’ expertise allows them to offer concrete solutions to optimize their clients’ performance and engagement in daily occupations, contributing to improved well-being (Howey, Angelucci, Jonhston, & Townsend, 2009). These university-trained professionals are part of the interprofessional solution to improve primary health care services for clients living with HIV, a chronic and episodic health condition (Canadian Association of Occupational Therapists, 2006). They offer comprehensive and personalized health-promoting services that not only contribute to improved client health and well-being but have also been shown to be cost-effective (Clark et al., 2001; Rexe, McGibbon Lammi, & von Zweck, 2013).

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This article was originally published in Occupational Therapy Now, Volume 15.5. It is reproduced here in partnership with the Canadian Association of Occupational Therapists. It is re-published here with permission.