Facility-level and racial disparities in access to inpatient psychiatric occupational therapy services in the Veterans Health Administration

Abstract: Importance: Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown. Objective: To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics. Design: Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics. Setting: VHA inpatient psychiatric setting. Participants: Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844). Ooutcomes and Measures: Occupational therapy utilization. Results: Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality. Conclusions and Relevance: Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.