This is an essay reflection about my time spent at Roger C. Peace and the determinants related to the services provided at the facility.

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Public Health Determinants and Trends
Karen Wortham
Clemson University

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“Occupational therapy, huh?” she said, looking over her glasses at me
inquisitively, “Well, I guess you can be a public health scientist and an occupational
therapist. I was an occupational therapist once, you know.” This lady, with the tweed
jacket, the glasses sitting on the bridge of her nose, and her hair pulled back into a bun,
looked the picture of the stereotypical professor. In the spring of 2016, I sat with a
handful of other students in a boardroom across the table from three women. The lady
quoted above was just one of these women who composed the site visit team that would
decide whether my department would become accredited by the Council on Education for
Public Health.
Over lunch, the team asked the students question after question regarding the
types of classes we had taken, what was taught in those classes, and the practical
application of the lessons. Many of the students shared stories about how their internships
exemplified what we were taught in the classroom. Proudly, I now have experienced
what the others in that boardroom were sharing.
During the summer of 2016, I had the privilege serve as the undergraduate intern
at Roger C. Peace Rehabilitation Hospital in the Outpatient Occupational Therapy
Department. My experiences throughout my internship highlighted and demonstrated
many of the theories taught throughout my coursework at Clemson University. As a
Health Science major, understanding these theories and noticing how they play in the real
world is crucial. Through researching published literature and in my own experiences, I
have been able to see how the social and organizational determinants of health affect our
health care system and how the health care professional must maintain professional
demeanor despite frustrating situations.

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1. Social Determinants in Health - Medical systems that promote disease prevention,
and health promotion, not just episodic sick care
In American medicine today, much emphasis is placed on curative, not
preventative, care. As top health threats in America swung from infectious to chronic
diseases, the budget has not kept up with the change. According to the CDC, chronic
diseases are responsible for 70% of deaths, and treatment for those diseases accounts for
86% of health care costs (Centers for Disease Control, 2016). Medical systems that
simply treat episodes for chronic diseases instead of working to prevent them incur more
treatment and cost. While at Roger C. Peace, I saw the impact chronic disease can have
on health care. Much of the need for therapy, type of therapy needed, and variety of
patients seen was due to the emphasis placed on curative rather than preventative care.
The need for therapy was clearly affected by a medical system that treats
episodes of chronic diseases. One of the patients I bonded with while an intern was a
former occupational therapist who had type-II diabetes. She had one leg amputated and
experienced severe neuropathy in her fingers. Despite having the training of an
occupational therapist, she needed therapy because her chronic condition was not
prevented. Once diagnosed with diabetes, her symptoms were not managed well enough
to prevent secondary conditions. The need for the health services at Roger C. Peace was
severely affected by the curative focus and set-up of the US health care system.
Along with the need for therapy, the type of therapy required is dictated by the
heavy emphasis on curative medicine. Indeed, while writing goals for therapy, the
occupational therapists aim to cure patients of recent declines in functioning. During an
evaluation, the therapists I shadowed often used the Barthel Index of Activities of Daily

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Living as a tool for measuring decline and setting long term goals for the patient. The
Barthel contains questions regarding ability to dress, toilet, clean, transfer, and manage
money. At the end of their time at Roger C. Peace, patients hope to have regained their
previous level of functioning. Though therapists play a crucial role in the health care
system, the mindset of a therapist is to “cure” the patient – not prevent initial decline.
The variety of the patients was much determined by the curative mindset of the
health care system as well. For example, I observed therapy sessions with three different
patients diagnosed with strokes. One patient was morbidly obese, inactive, and only in
her thirties. Her stroke was classified as a hemorrhagic middle cerebral artery stroke, and
it affected many of her functional abilites, including her ability to talk, stay alert, dress,
and take medications. While improving quality of life is important for such patients, these
cases may have been prevented. Part of the reason Roger C. Peace exists is because of
this type of patient. In the upstate, it is one of the foremost facilities dedicated to
neurological rehabilitation. The continued incidence of strokes impacts the variety of
patients seen at Roger C. Peace.
Therapists fit into the current medical system because of the number of chronic
diseases and the reimbursement for treating those chronic diseases. They play an
irreplaceable role. Notwithstanding this, the need for therapy, type of therapy, and variety
of patients seen in therapy at Roger C. Peace is highly influenced by this social pressure
and determinant of health: cure rather than prevent.
2. Organizational Behavior and Governance

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In the upstate, Roger C. Peace is one of the largest rehabilitation hospitals.
Composed of four floors of therapists, the teams at Roger C. Peace have to work in
harmony in order to keep high quality, cost effective available therapy services available.
To accomplish these things, the function of interdepartmental communication is crucial to
ensuring that patient care is held at the highest priority. Interdepartmental communication
between floors of the hospital and disciplines of therapy is influenced by organizational
culture, building structure, and insurance policies.
The rehabilitation hospital is divided into departments by floor. The top floor of
the hospital is dedicated to inpatient tramautic brain injury and stroke therapy teams. The
second floor is occupied by the inpatient orthopedic and spinal cord injury therapy teams,
while the ground floor is where the outpatient therapy and acute care therapy departments
are located. In the basement, the home base for the driving rehabilitation program is
situated with evaluation rooms, offices, and driving simulator for practice before the
patients get into a real car. Separated by flights of stairs, maintaining healthy
relationships between these departments is important in order to ensure the best patient
outcomes.
Many of the patients from the second and third floors of the hospital will (after
being discharged from inpatient therapy) come to the first floor for outpatient therapy in
order to continue the rehabilitation process. Indeed, a patient could start and end his or
her rehabilitation journey on the first floor by moving from the acute therapy unit on the
first floor, to the second or third floor (depending on the nature of the patient’s injury),
and then moving back to the first floor for outpatient therapy. Much of the case load for
the outpatient therapists comes from the upper two levels of the hospital. This intrinsic

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interlocking of the services provided on each floor makes the communication between
levels and disciplines of therapy vital.
Interdepartmental relationships and communication was most heavily influenced
by organizational culture during my time at Roger C. Peace. While and intern, I had an
opportunity to observe on the second and third floors, although I spent the vast majority
of my time in the outpatient gym or the driving rehabilitation offices. Each floor had a
different atmosphere. Primarily because of familiarity and personal friendships,
communcation between the first and second floors of the hospital was much greater than
communication between the third and first floors. The inpatient stroke and traumatic
brain injury team, according to my preceptor, tends to operate very independently of the
other floors, putting the outpatient therapists at a disadvantage when they encounter a
patient who has been discharged from the third floor.
Communication between the floors was also influenced by building structure.
Simply by the nature of the building, it was much easier to reach the inpatient spinal cord
and orthopedic injury teams than it was to reach the inpatient stroke and traumatic brain
injury teams. Not only were there more stairs to climb between the floors, but the set up
of the third floor did not enable therapists to be available to other therapists. Unlike the
second floor, the third floor offices for therapists were separate from the main gym space,
meaning that when therapists were working with patients, they were unable to answer
phone calls or emails. In addition, the offices were segregated by discipline. On the
second and first floors, the offices for the therapists were more incorporated into the
treatment areas, and multiple disciplines of therapy shared the same common areas.

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These structural factors were significant in the communication between disciplines and
floors of the hospital.
Finally, interdepartmental relationships at Roger C. Peace were influenced by
insurance policy. If all else fails, the case manager for the outpatient department had to
maintain a communication line with the therapists on the upper floors in order to ensure
that the patient did not max out the therapy caps placed on many plans. During my time
at Roger C. Peace, the case manager often had to track down an inpatient therapist to
verify details about a patient’s case before contacting the insurance company. These
policy-induced communciations did help to link the floors and teams together and create
patient-centered care.
However, the communication and relationships between floors at Roger C. Peace
is not as strong as would be most conducive to care for the patients. A number of changes
could be made to improve communication, but perhaps none more important than
increasing the amount of time the therapists spend together. To do this, I suggest
requiring monthly meetings of the departments to pass the baton of patient care from an
inpatient therapist to an outpatient therapist.
This change in the current organizational practice would make the system more
efficient and effective. Although reading progress notes about a patient can help a
therapist get a good idea of a patient’s injury and abilities, having a conversation with the
therapist that has discharged who patient will help fill in the gaps. In talking with my
preceptor regarding interdepartmental communication, she noted that the recently
improved communication with the inpatient spinal cord and orthopedic injury team made

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a significant impact on how she approached patients during an initial evaluation. This
testimonial shows the importance and function of interdepartmental relationships.
Typically, there is a slight lag in time between a patient’s discharge from inpatient
therapy and initial evaluation in outpatient therapy. This lag would provide a window for
the therapists to be able to ask questions and make suggestions regarding patients referred
to outpatient therapy. Conveniently, all levels of Roger C. Peace have roughly the same
lunch hour, which would provide a common time the therapists would be able to meet.
Indeed, the acute care therapy and outpatient therapy departments already use a similar
model of meetings in order to discuss shared patients and experiences. Extending this
model to all floors of the hospital will improve the function of interdepartmental
relationships.
Interdepartmental relationships and communication is a function that is crucial to
cost effiecient, available, and high quality services provided by Roger C. Peace
Rehabilitation Hospital. Changing organizational practice to include meetings for the
departments would improve continuity of care for the patients and make patient care a
centralized focus of all three floors of the facility. As one of the foremost rehabilitation
facilities in the upstate of South Carolina, Roger C. Peace should take strides to ensure
the optimal care and work towards the best outcomes for its patients.
3. Concentration Specific Questions – Preprofessional Health Studies
During my time at Roger C. Peace Rehabilitation Hospital, I had the pleasure of
working with several therapists who exemplified professionalism. All of the outpatient
therapists that I encountered had excellent professional demeanors around patients, but

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perhaps none more so than Ashley Cunningham. It was during my observation time with
Ashley that I saw a therapist professionally handle the most uncomfortable situation I
witnessed.
Ashley is an occupational therapist on the outpatient spinal cord rehabilitation
team. One of his patients was an African-American woman in her mid twenties with a
mid-thoracic, incomplete spinal cord injury. With limited function beneath the level of
injury, she had minimal sensation in her lower back, hips, and legs. As a consequence,
bowel and bladder management and other hygiene tasks became more difficult. During
the second therapy session, the patient’s menstrual cycle began without her knowledge
due to her loss of sensation. It was not until the midpoint of the exercises on the therapy
mat that the pool of blood caught her attention.
Needless to say, the patient was mortified and instantly burst into embarrassed
tears. Ashley handled the situation excellently. He first followed standard precautions and
put on gloves while talking and comforting the patient, assuring her that this was normal
and did not upset him. Secondly, he helped the patient to her wheelchair and asked her
what she would like to do. When the patient responded that she would like to go home,
he simply helped her to find the restroom and escorted her out of the therapy gym. As he
passed, he calmly gave me instructions for cleaning the mat.
I believe this situation exemplifies how Ashley maintained professional demeanor
despite a startling and uncomfortable discovery. He maintained a mature, caring affect to
the patient and did not allow the awkwardness of the situation to change how he treated
her. Instead, he took responsibility for cleaning up and making the patient feel

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comfortable again. Allowing compassion to rule the moment, Ashley communicated a
caring heart to the patient, wanting to do whatever would make her feel best.
I learned from this situation how to maintain professional demeanor under
pressure. Ashley showed me how to ignore extenuating circumstances and keep patient
care as the highest priority. In addition to this, I learned from my internship how to put
difficult news into firm yet gentle words. Prior to my internship, I always felt guilty and
responsible when a patient did not improve as much as hoped. From my preceptor,
Nathalie Drouin, and Ashley Cunningham, I learned how to tell a patient bad news in a
way that exuded professionalism and compassion. I hope to remember how Ashley
handled this difficult situation when I encounter difficult situations in the future.

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References
Centers for Disease Control. (2016). “Chronic disease prevention and health promotion”.
Retrieved July 23, 2016 from http://www.cdc.gov/chronicdisease/