Natalie Leland PhD, OTR/L, BCG, FAOTA
Assistant Professor, joint appointment with the USC Davis School of Gerontology
Room: CHP 133
Phone: (323) 442-1307
Natalie Leland is an outstanding researcher in gerontology with a focus improving post-acute care services for older adults. Dr. Leland received her BS degree in Occupational Therapy from the University of New Hampshire and her MS and PhD degrees in Gerontology from the University of Massachusetts Boston. She completed a postdoctoral fellowship at the Center for Gerontology and Health Care Research at Brown University. Dr. Leland has extensive geriatric clinical experience in a variety of rehabilitation settings.
She has joint faculty appointments in the USC Chan Division of Occupational Science and Occupational Therapy and the USC Davis School of Gerontology. Dr. Leland holds leadership positions both within occupational therapy and within the broader discipline of gerontology. She was President of the Rhode Island Occupational Therapy Association, currently serves on the Board for Advanced and Specialty Certification (BASC) for the American Occupational Therapy Association (AOTA) and is on the Emerging Scholar and Professional Organization (ESPO) Executive Committee for the Gerontological Society of America (GSA). She was named to the AOTA Roster of Fellows in 2012.
Dr. Leland's recent scholarship includes the American Occupational Therapy Association's newly released "Occupational Therapy Practice Guidelines for Productive Aging for Community-Dwelling Older Adults" and trends in access and outcomes of post-acute care for patients post-hip fracture surgery. She has received international attention for her work on falls among new-admitted nursing home patients. She is expert in the use of large administrative datasets, longitudinal data analysis and geographic variation in rehabilitation services. Dr. Leland has received funding from the Agency for Healthcare Research and Quality (AHRQ) as a T32 Postdoctoral Research Fellow and Rehabilitation Research Career Development (RRDC) Program (#5T32HS000011, P.I. Vincent Mor, PhD), and from the National Center for Medical Rehabilitation Research (NICHD) as a K12 Rehabilitation Research Career Development Program Scholar (K12 HD055929, P.I. Kenneth Ottenbacher, PhD, OTR).
Dr. Leland's research is focused on understanding and improving post-acute care quality for older adults and with a particular interest in how occupational therapy can contribute to fall prevention. Dr. Leland is an expert in secondary data analysis and evaluating the impact of health services on quality of care for older adults in post-acute settings.
Doctor of Philosophy (PhD) in Gerontology
University Massachusetts Boston
Master of Science (MS) in Gerontology
University Massachusetts Boston
Bachelor of Science (BS) in Occupational Therapy
University of New Hampshire
Leland, N. E., Elliott, S. J., & Johnson, K. J. (2012). Occupational therapy practice guidelines for productive aging for community-dwelling older adults. Bethesda, MD: AOTA Press. Link to full text Abstract →
GUIDELINE OBJECTIVES: To help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, to understand the contribution of occupational therapy in treating community-living older adults to facilitate productive aging.
To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations to assist in understanding the role of occupational therapy services in the community.
Martinez, J., & Leland, N. (2015). Language discordance and patient-centered care in occupational therapy: A case study. OTJR: Occupation, Participation and Health, Advance online publication. doi:10.1177/1539449215575265. Link to full text Abstract →
The accumulative burden of a growing non-English speaking minority population and health disparities in the United States demonstrate the urgency of examining occupational therapy practices and defining care that is timely, effective, safe, and patient-centered. In this context, we investigate an occupational therapy episode of care from the perspectives of patient, caregiver, and primary occupational therapy care provider. Treatment sessions were observed and one-on-one semistructured interviews were conducted with the participants. Several themes describing areas of concern in communication and care delivery emerged, including expectations for care, the therapy relationship, professional identity, and pragmatic constraints. The use of untrained interpreters compromised treatment effectiveness and safety. This case highlights potential areas of concern in therapy when working with a diverse patient population. Abundant opportunities exist for occupational therapy to situate itself as an equitable, responsive, valuable, and essential service.
Mallinson, T., & Leland, N. E. (2015). The need for uniform quality reporting across post-acute care rehabilitation settings: An examination of accidental falls. Journal of the American Geriatrics Society, 63, 195-197. doi:10.1111/jgs.13221. Link to full text Abstract →
To the Editor: A fall during post-acute care (PAC) rehabilitation can limit an individual's ability to make functional gains and safely return home, two of the primary goals of rehabilitation services. Public reporting of falls, which are a Medicare "Never Event," is not mandated in all PAC rehabilitation settings. Consequently, little is known about the similarities or differences in the occurrence of this adverse event and its risk factors in these settings. Thus, stakeholders do not have important information necessary to make informed decisions about PAC service use. This study used a unique dataset to examine variations in accidental falls and risk factors between individuals in PAC receiving rehabilitation services in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home health agencies (HHAs).
Leland, N. E., Gozalo, P., Bynum, J., Mor, V., Christian, T. J., & Teno, J. M. (2015). What happens to patients when they fracture their hip during a skilled nursing facility stay?. Journal of the American Medical Directors Association, Advance online publication. pii:S1525-8610(15)00250-9. doi:10.1016/j.jamda.2015.03.026. Link to full text Abstract →
OBJECTIVES: To characterize outcomes of patients experiencing a fall and subsequent hip fracture while in a nursing home receiving skilled nursing facility (SNF) services.
DESIGN: Observational study.
PARTICIPANTS: Short-stay fee-for-service Medicare beneficiaries who experienced their first hip fracture during an SNF stay.
MEASUREMENTS: Outcomes measured in the 90 days after the hip fracture hospitalization included community discharge (with a stay in the community <30 days), successful community discharge (in the community =30 days), death, and institutionalization.
RESULTS: Between 1999 and 2007, 27,305 hip fractures occurred among short-stay nursing home patients receiving SNF care. After surgical repair of the hip fracture, 83.9% of these patients were discharged from the hospital back to an SNF, with most (99%) returning to the facility where the hip fracture occurred. In the first 90 days after hospitalization, 24.1% of patients died, 7.3% were discharged to the community but remained fewer than 30 days, 14.0% achieved successful community discharge, and 54.6% were still in a health care institution with almost 46.4% having transitioned to long-term care.
CONCLUSION: SNF care aims to maximize the short-stay patient's independence and facilitate a safe community transition. However, experiencing a fall and hip fracture during the SNF stay was a sentinel event that limited the achievement of this goal. There is an urgent need to ensure the integration of fall prevention into the patient's plan of care. Further, falls among SNF patients may serve as indicator of quality, which consumers and payers can use to make informed health care decisions.
Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010p1-6901090010p7. doi:10.5014/ajot.2015.691001. Link to full text
Mallinson, T., Schepens Niemiec, S. L., Carlson, M., Leland, N., Vigen, C., Blanchard, J., & Clark, F. (2014). Development and validation of the activity significance personal evaluation (ASPEn) scale. Australian Occupational Therapy Journal, 61, 384-393. doi:10.1111/1440-1630.12155. Link to full text Abstract →
BACKGROUND/AIM: Engagement in desired occupations can promote health and wellbeing in older adults. Assessments of engagement often measure frequency, amount or importance of specific activities. This study aimed to develop a scale to measure older adults' evaluation of the extent to which their everyday activities are contributing to their health and wellness.
METHODS: Eighteen items, each scored with a seven-point rating scale, were initially developed by content experts, covering perceptions of how daily activities contribute to physical and mental health, as well as satisfaction and activity participation in the last six months. Rasch analysis methods were used to refine the scale using the pencil and paper responses of 460 community-living older adults.
RESULTS: Initial Rasch analysis indicated three unlabelled rating scale categories were seldom used, reducing measurement precision. Five items were conceptually different by misfit statistics and principal component analysis. Subsequently, those items were removed and the number of rating scale steps reduced to 4. The remaining 13-item, 4-step scale, termed the Activity Significance Personal Evaluation (ASPEn), formed a unidimensional hierarchy with good fit statistics and targeting. Person separation reliability (2.7) and internal consistency (.91) indicated the tool is appropriate for individual person measurement. Relative validity indicated equivalence between Rasch measures and total raw scores.
CONCLUSIONS: ASPEn is a brief, easily administered assessment of older adults' perception of the contribution of everyday activities to personal health and wellness. ASPEn may facilitate occupational therapy practice by enabling clinicians to assess change in meaning of an older adult's activity over time.
Leland, N. E., Marcione, N., Schepens Niemiec, S. L., Kelkar, K., & Fogelberg, D. (2014). What is occupational therapy’s role in addressing sleep problems among older adults?. OTJR: Occupation, Participation and Health, 34, 141-149. doi:10.3928/15394492-20140513-01. Link to full text Abstract →
Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Association’s Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, and multicomponent interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.
Tyler, D. A., Feng, Z., Leland, N. E., Gozalo, P., Intrator, O., & Mor, V. (2013). Trends in postacute care and staffing in US nursing homes, 2001-2010. Journal of the American Medical Directors Association, 14, 817-840. doi:10.1016/j.jamda.2013.05.013. Link to full text Abstract →
OBJECTIVE: The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010.
DESIGN: We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities.
SETTING: All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims.
MEASUREMENTS: We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff.
RESULTS: In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities.
CONCLUSIONS: There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.
Teno, J. M., Gozalo, P. L., Bynum, J. P., Leland, N. E., Miller, S. C., Morden, N. E., Scupp, T., Goodman, D. C., & Mor, V. (2013). Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. Journal of the American Medical Association, 309, 470-477. doi:10.1001/jama.2012.207624. Link to full text Abstract →
IMPORTANCE: A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care.
OBJECTIVE: To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009.
DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270 202), 2005 (n = 291 819), or 2009 (n = 286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life.
MAIN OUTCOME MEASURES: Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life).
RESULTS: Our random 20% sample included 848 303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%).
CONCLUSION AND RELEVANCE: Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.
Leland, N. E., & Elliott, S. J. (2012). Special issue on productive aging: Evidence and opportunities for occupational therapy practitioners. American Journal of Occupational Therapy, 66, 263-265. doi:10.5014/ajot.2010.005165. Link to full text
Elliott, S. J., Ivanescu, A., Leland, N. E., Fogo, J., Painter, J. A., & Trujillo, L. G. (2012). Feasibility of interdisciplinary community-based fall risk screening. American Journal of Occupational Therapy, 66, 161-168. doi:10.5014/ajot.2012.002444. Link to full text Abstract →
OBJECTIVE: This pilot study examined the feasibility of (1) conducting interdisciplinary fall risk screens at a community-wide adult fall prevention event and (2) collecting preliminary follow-up data from people screened at the event about balance confidence and home and activity modifications made after receiving educational information at the event.
METHOD: We conducted a pilot study with pre– and post-testing (4-mo follow-up) with 35 community-dwelling adults ≥55 yr old.
RESULTS: Approximately half the participants were at risk for falls. Most participants who anticipated making environmental or activity changes to reduce fall risk initiated changes (n = 8/11; 72.7%) during the 4-mo follow-up period. We found no significant difference in participants’ balance confidence between baseline (median = 62.81) and follow-up (median = 64.06) as measured by the Activities-specific Balance Confidence scale.
CONCLUSION: Conducting interdisciplinary fall risk screens at an adult fall prevention event is feasible and can facilitate environmental and behavior changes to reduce fall risk.
Leland, N. E., Gozalo, P., Teno, J., & Mor, V. (2012). Falls in newly admitted nursing home residents: A national study. Journal of the American Geriatrics Society, 60, 939-945. doi:10.1111/j.1532-5415.2012.03931.x. Link to full text Abstract →
OBJECTIVES: To examine the relationship between nursing home (NH) organizational characteristics and falls in newly admitted NH residents.
DESIGN: Observational cross-sectional study from January 1, 2006, to December 31, 2006.
SETTING: NHs in the United States in 2006.
PARTICIPANTS: Individuals (n = 230,730) admitted to a NH in 2006 without a prior NH stay and with a follow-up Minimum Data Set (MDS) assessment completed 30 days or more after admission.
MEASUREMENTS: The relationship between experiencing a fall noted on the MDS assessment and NH characteristics (e.g., staffing, profit and chain status, religious affiliation, hospital-based facility status, number of beds, presence of a special care unit, funding) was examined, adjusting for NH resident characteristics.
RESULTS: Twenty-one percent of this cohort (n = 47,750) had experienced at least one fall in the NH at the time of the MDS assessment, which was completed for newly admitted NH residents who had at least a 30-day stay. NHs with higher certified nursing assistant (CNA) staffing had lower rates of falls (adjusted odds ratio = 0.97, 95% confidence interval = 0.95–0.99).
CONCLUSION: For newly admitted NH residents, NHs with higher CNA staffing had a lower fall rate. In an effort to maximize fall prevention efforts, further research is needed to understand the relationship between CNA staffing and falls in this NH population.
Leland, N. E., Teno, J. M., Gozalo, P., Bynum, J., & Mor, V. (2012). Decision making and outcomes of a hospice patient hospitalized with a hip fracture. Journal of Pain and Symptom Management, 44, 458-465. doi:10.1016/j.jpainsymman.2011.09.011. Link to full text Abstract →
CONTEXT: Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making.
OBJECTIVES: To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services.
METHODS: This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival.
RESULTS: Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001).
CONCLUSION: Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.
Leland, N. E., Elliott, S. J., O’Malley, L., & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence and future directions. American Journal of Occupational Therapy, 66, 149-160. doi:10.5014/ajot.2012.002733. Link to full text Abstract →
Falls are a serious public health concern among older adults in the United States. Although many fall prevention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear. This article presents a scoping review of current published research documenting the role of occupational therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in environmental modifications, exercise, and multifactorial and multicomponent interventions. Although research documenting the efficacy of occupational therapy interventions is identified as part of the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008), we identified little or no such research examining interventions to modify behaviors (e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage medications. Although occupational therapy is represented in the fall prevention research, the evidence for the profession’s role in many areas is still lacking.
Tyler, D. A., Leland, N. E., Lepore, M., & Miller, S. C. (2011). Effect of increased nursing home hospice use on nursing assistant staffing. Journal of Palliative Medicine, 14(11), 1-4. doi:10.1089/jpm.2011.0080. Link to full text Abstract →
BACKGROUND: Since 1999, there has been a significant increase in hospice providers and hospice use in nursing homes. A 1997 Office of Inspector General (OIG) report warned of possible kickbacks, monetary and otherwise, that might be paid by hospices to nursing homes in exchange for referrals. One possible kickback mentioned in the report was nursing homes receiving additional staff hours at no cost, which could lead to decreases in nursing home staffing. The purpose of this study was to determine if changes in nursing home hospice volume were related to changes in certified nursing assistant (CNA) staffing.
METHODS: The study included free-standing nursing homes with at least 3 years of observation between 1999 and 2006, no fewer than five deaths in any year, and between 30 and 500 beds (n=10,759). We examined the longitudinal relationship between changing hospice volume and CNA minutes per resident day (MPRD), utilizing nursing home fixed-effects regression analysis and adjusting for resident case mix and changing organizational characteristics.
RESULTS: The introduction of hospice services in a nursing home did not result in statistically significant changes in CNA staffing. Instead, increases in hospice volume resulted in small increases in CNA staffing. Specifically, the addition of 1000 hospice days, in a given year, resulted in an additional 0.79 (95% confidence interval [CI] 0.373–1.211) CNA MPRD.
CONCLUSIONS: The proposition that nursing homes may be decreasing their staffing as a result of receiving additional hospice staff was not supported by this study and, in fact, nursing homes were found to only slightly increase CNA staffing with increasing hospice volume.
PURPOSE OF THE STUDY: To determine whether reported falls at baseline are associated with an older adult’s decision to make a residential adjustment (RA) and the type of adjustment made in the subsequent 2 years.
DESIGN AND METHODS: Observations (n = 25,036) were from the Health and Retirement Study, a nationally representative sample of community-living older adults, 65 years of age and older. At baseline, fall history (no fall, 1 fall no injury, 2 or more falls no injury, or 1 or more falls with an injury) and factors potentially associated with RA were used to predict the initiation of an RA (i.e., moving, home modifications, increased use of adaptive equipment, family support, or personal care assistance) during the subsequent 2 years.
RESULTS: Compared with those with no history of falls, individuals with a history of falls had higher odds of making any RA. Among those making an RA, individuals with an injurious fall were more likely than those with no history of a fall to start using adaptive equipment or increase their use of personal care assistance.
IMPLICATIONS: The higher initiation of RAs among fallers may indicate proactive steps to prevent future falls and may be influenced by interactions with the health care system. To optimize fall prevention efforts, older adults would benefit from education and interventions addressing optimal use of RAs before falls occur.
Steinman, B. A., Nguyen, A. Q., Pynoos, J., & Leland, N. E. (2011). Falls-prevention interventions for persons who are blind or visually impaired. INSIGHT: Research and Practice in Visual Impairment and Blindness, 4(2), 83-91. Abstract →
The purpose of this article is to describe four main areas of falls-prevention intervention for older adults who are blind or visually impaired. When integrated into multifactorial programs, interventions pertaining to education, medical assessment, exercise and physical activity, and environmental assessment and modification have been shown to be effective in falls reduction. These areas of intervention are discussed with respect to specific concerns of older adults who are blind or visually impaired. In describing these areas of intervention, the increasing need for cross-disciplinary falls-prevention programs designed specifically for older persons with vision loss, as well as research demonstrating the efficacy of multidisciplinary programs designed for this group, are emphasized.
Lee, I., & Leland, N. E. (2013). Fall prevention for community-living older adults [Research update]. OT Practice, 18(16), 19;22. Link to full text