Competency in Tasks of Life Roles

•          Roles are made up of a collection of tasks

•          Tasks identified for the same role may be different for different people

•          Therapist cannot assume which particular tasks are or are not important to a person’s interpretation of a role

** People have different values and therefore must define his/her role by identifying the tasks he/she believes are crucial to satisfactory engagement in a particular task.

Activities and Habits

•          Activities – smaller units of goal-directed behavior that comprise tasks

•          Activities bring together abilities and skills within a functional context

•          Habits – chains of action sequences that are so welled learned that one does not have to pay attention to perform them in normal circumstances and familiar contexts

**OTPF equivalence to habits is performance patterns

•          The OFM identifies six categories of abilities and skills:

**Trait – muscle strength or memory

OTPF terms performance skills; identifies three spheres – motor, process, communication/interaction

•          Ability

Developed Capacities

•          Reveal the organization of first-level capacities into more mature, less reflexive, more voluntary responses

•          Ex: the organization of dexterity skills is normally acquired through maturation

•          In therapy, occupation-as-means is used to develop specific capacities

**Equivalent OTPF is client factors. Ex. The ability of dexterity requires independent use of the fingers, graded release, and pinch which are developed capacities that develop from reflexive grasp and automatic release (first-level capacities).

First-level Capacities

•          These are the functional foundation for movement, cognition, perception, and emotional life based on the integrity of the organic substrate

•          First-level capacities are reflex-based motor responses reflecting organization of primary visual, sensory, and motor systems

**Ex. Babies fascination with human faces – first-level capacity of the socioemotional domain.

Organic Substrates

•          The structural and physiological foundation for movement, cognition, perception, and emotions

•          Includes:

•          CNS organization in the neonate

•          CNS organization that is spared or recovers spontaneously after injury

•          Integrity of the various body systems/organs

•          If organic substrate is not present, therapy cannot generate it

**If it exist, therapy attempts to develop it into first level capacities

•          Environment:

**OFM assumes all context and environment surround and permeate all levels of the occupational functioning hierarchy.

When challenges of the environment exceed the capabilities of a person, that person is said to be disabled.  One may be able to accomplish tasks and complete roles by adaptation of the environment. OT may focus on changing the environment or context rather than on remediating the person’s impaired capacities.

•          Process follows the universal plan for problem solving:

•          OT focuses only on the problems related to the person’s occupational life

•          What a person needs to do, wants to do, and can do are identified

**Discrepancy between what person needs or wants to do and what her or she can do identifies the problem.

Assessment

•          The organization of the OFM indicates that higher level occupational functioning is established on a foundation of abilities and capacities

•          Assessment always follows a top-down approach

•          Roles and tasks a person was responsible for before accident or disease and what he/she is expected to be or wants to be responsible for post-rehab are determined by the therapist

•          There are a variety of assessment tools on the market

**Refer to text for tools

Treatment

•          May focus on:

•          Changing the environment

•          Changing the impaired skills and abilities of the person

•          Teaching compensatory ways to accomplish activities and tasks

•          Starting point acknowledges the problem identified by the client as an immediate concern, but may not actually start there

**Example: Fishing as a goal, may teach adaptive methods, or may start treatment by regaining finger dexterity to enable specific activities (lower level ability)

Occupation as means is used to optimize impaired abilities through remedial therapy in which a change in physiological structure, function, or organization is sought.

•          Remediating one’s abilities to as high a level as possible will enable versatile performance of activities

•          Occupation-as-means are used to optimize motor and CNS impairment and may include:

•          All approaches share the idea of the importance of the need for repetition  

**The effect of context is important: practicing a skill under simplified, non-context-specific conditions is different from participating with an actual object in a context-specific situation.

•          When one has an impairment that decreases independent functioning the OT helps them find ways to compensate by reorganizing activity patterns or adapting techniques, equipment, or the environment

•          The goal is independence

•          Activities to restore competence focus on:

•          Environmental or contextual modification

•          Teaching physical, cognitive, and emotional adaptation

•          Therapeutic mechanisms of change include:

•          Context:

•          Cultural context:

•          Personal context:

•          Social context: 

**The word context has its roots in the Latin word 

Occupational Function and Context

•          Understanding the context of one’s life and background gives us a better understanding of his/her performance during the OT assessment

•          Occupational function is rooted in context

–        Physical, cultural , social, and personal factors help shape its form (Nelson, 1988)

**Ex. – vietnamese culture lack of eye contact sign of respect

Difficulty picking out clothes – wife had done for 50 years

Assessment and Context

•          Contextual factors may influence OT assessment and treatment in three ways:

•          1 – by helping or hindering performance on traditional OT assessments

•          2 – as facilitators or barriers to function, therefore identified as targets for intervention

•          3 – by allowing the practitioner to search for what clients find meaningful, as goals are set and intervention planned

**1 – skews and muddies the results

Conditional Reasoning

•          Enables the therapist to appreciate the wholeness of the client and his or her situation

•          OT practitioners need an ability to imagine the clients, both as they were before the illness/injury and as they could be in the future 

**To understand the influence of contextual factors in others the therapist must acknowledge and inventory their own.

•          The intrapersonal environment that shapes an individual’s experience

•          Determines a persons unique response to the onset of illness or impairment

•          Contributes to one’s ability to adapt

•          adaptation to illness/injury

**Intrapersonal – relating to the internal aspects of a person, especially emotions

Stable aspects – age, longstanding beliefs         

•          pain

•          mood

•          adaptation to illness/injury

Personal Demographics: Age

•          Age influences one’s occupational functioning in three primary ways:

•          1 – age-related changes in capacities and abilities

•          2 – developmental shifts in goals, values, and priorities

•          3 – the individual’s generation-based worldview      

**Review Table 10-2 in class

Individuals go through “occupational shifts” during the life cycle that lead to major changes in patterns of activity.

Acumen = sharpness of mind

•          Early adulthood:

–        establishing worker roles

–        realigning social roles to adjust to marriage and parenthood

•          Middle adulthood:

–        maintain work and leisure roles

–        may undergo occupational shifts due to caregiving roles

•          Maturity:

–        continue work and leisure roles

–        occupational shifts occur from death of family members, loss of provider status and adjustments in life goals

•          Old age:

Five contemporary generational groups in the United States:

•          G.I. elders (born 1901-1924)

•          Silent mid-lifers (born 1925-1942)

•          Boomer adults (born 1943-1960)

•          Generation Xers (born 1961-1981)

•          Millennials (born 1981-2000)

•          G.I. elders (born 1901-1924)

•          Silent mid-lifers (born 1925-1942)

•          Boomer adults (born 1943-1960)

•          Generation Xers (born 1961-1981)

•          Millennials (born 1981-2000)

Coping Strategies and Beliefs

•          Both influence individuals’ response to catastrophic injury and chronic illness

•          Coping style affects whether one seeks health-related services and extent to which they follow a professional’s advice

•          Two aspects of coping are:

–        Optimism

–        Locus of control

–        Optimism

–        Locus of control

– general belief about one’s ability to control life circumstances and events

**Internal locus of control – individual takes responsibility for change; external – expect other people and factors to determine a particular outcome.

Can review chart on page 293 for to look at specific questions that practitioner may ask patient.

Spirituality

•          The beliefs and practices about the world and one’s place in it that give one inspiration in the meaning of their life

•          It is central to a person’s occupational function

•          Riley, et. al (1998) suggested that spirituality “is clearly too important a variable to be neglected in the rehabilitation process”

•          Influence of culture on one’s experience is hard to state

**Culture is not biologically inherited or determined by geography or ethnicity.

Read definition of ethnicity on page 292.

Many evaluation tools are based on norms developed for a white middle-class population.

•          Cultural rules are learned but are also:

•          Culture

•          Both acute and chronic pain interferes with occupational function and quality of life for many people

•          Contributes to:

•          Pain is a highly personal experience

–        McGill Pain Questionnaire

Mood

•          Depression and anxiety are common mood disorders seen in people who receive OT services

•          These disorders appear to:

–        interfere with attention and concentration during assessment

–        negatively influence outcome

**Certain patterns of behavior may indicate a need for referral to a psychologists or psychiatrist for further assessment and treatment.

Social Context:

•          Social network –

•          Social networks vary in terms of the following characteristics and the extent of resources or support provided:

–        Reciprocity

–        Intensity

–        Complexity

–        Density

–        Reciprocity

–        Intensity

–        Complexity

•          The four types of social support are:

–        Emotional

–        Instrumental

–        Information

–        Appraisal

–        Emotional

–        Instrumental

–        Information

Caregiver Adaptation: A Dynamic Social Factor

•          A patient’s social network is critical to his/her ability to:

–         adapt to chronic illness and disability

–        influence outcome

•          Caregiver’s support is dictated by their own physical and emotional health

**A man in his 20s or 30s would be better equipped physically to help a disabled family member confined to a W/C than a man in his 70s. A mother who is emotionally stable would be better able to meet the emotional needs of her disabled child than one who suffers from a mood disorder.

Illness Trajectory

•          “The sequence of physiological changes associated with illness or disability and the adaptive work demanded of the patient and family that accompany each phase” (Corbin and Strauss, 1988)

The five phases identified are as follows:

• Acute
• Comeback
• Stable
• Unstable
• Downward

–        Acute phase:

–        Stable phase:

–        Unstable phase:

Patient-Therapist Social Interactions

•          “Part of the way the patient behaves with you is a function of the way you are with the patient” (Gans, 1998)

•          The therapist shapes the interaction during assessment by asking certain questions and omitting others

•          Some OTs may define the client as the problem and themselves as the solution

•          According to Gans the primary source of clinician gratification should come from “the privilege of participating intimately in another person’s life”

**Client as problem/therapist as solution – failure is attributed to the patient and success to the clinician’s efforts

When work no longer feels like a privilege, therapist should figure out why – caseload too heavy, problems in private life, questionable ethical practices of employer

Cultural Context: The Larger Society and Community

•          In European and North American cultures, the status for a complete adult person includes self-sufficiency, activity, and upright posture

•          This affects the likelihood of full participation for persons with disabilities 

•          Adaptive equipment may be rejected due to appearance or acceptability in public

•          Pt and family may try to keep the disability private (due to embarrassment/guilt)

•          OT practitioners need to look closely at their own assumptions about people with disabilities

**Ex. – pt. who didn’t want to wear compression garments

Cultural beliefs may hold person responsible for their disabilities

General Guidelines to Facilitate the Assessment Process

•          Review the assessments of other disciplines

•          Use specific tools to measure contextual factors that are confusing or appear to bias performance

•          Take advantage of informal conversations with patients

•          The influence of contextual factors helps keep us humble and on guard against jumping to the wrong conclusion about assessment findings and our patients

•          Use each and every moment with patients to help understand who they are, where they come from, and how they are interpreting their experience in therapy

•          “Patients who feel cared about and valued make the most gains in therapy” (Gans, 1998) 

Importance of Occupation

}  Occupational engagement contributes to the experience of a life worth living (Hammell, 2004)

}  In the absence of social and productive occupation one may experience a sense of disorganization, depression, and loss of a sense of self-worth (Hoppes, 2005)

 Occupation

Therapeutic Occupation

}  Has meaning for the patient

}  Makes demands on the system needing improvement

}  Fulfills a purpose in the person’s life

}  Requires effort for the patient to accomplish, but is possible for the patient to accomplish

Occupation-As-End

}  The complex activities and tasks that comprise roles

}  The goal is learning the occupation within the customary environment

}  It is equivalent to the OTPFs areas of occupation

}  Its therapeutic effect is achieved from the qualities of purposefulness and meaningfulness

◦       Purposefulness -  organizes behavior

◦       Meaningfulness – motivates performance

}  Focus is on changing the task demands and/or the environment

**See definitions on page 344 – table 12-1

Occupation-As-Means

}  The use of occupation as a treatment to improve a person’s impaired capacities and abilities to enable eventual occupational functioning

}  Occupation functions as the therapeutic change event

}  It is therapeutic when the activity has a goal that makes a challenging demand but has a prospect for success

}  Focus is on changing the person

}  In OT the promotion of participation through meaningfulness is characterized in four ways:

◦       1 – provide enjoyment

◦       2 – offer a choice

◦       3 – offer the end product to keep

◦       4 – enhance the context or make the context more applicable to the person’s life

Implementation of Therapeutic Occupation in Practice: Occupation-As-End

}  During the therapeutic encounter, the therapist:

◦       Ensures that task is within the patient’s capabilities

◦       Organizes the subtasks to be learned so the person will succeed

◦       Provides clear instructions

◦       Provides feedback to promote a successful outcome

◦       Structures the practice to ensure improved performance and learning

◦       Makes adaptations as necessary

Implementation of Therapeutic Occupation in Practice: Occupation-As-Means

}  During the therapeutic encounter, the therapist:

◦       Determines the patient’s interests

◦       Selects occupations that reflect those interests

◦       Analyses the occupations to determine which would be appropriate to achieve the patient’s goals

◦       Allows the patient to choose from among several occupations offered

◦       Instructs patient in correct performance of the activity to derive the most therapeutic benefit

◦       Grades the occupation to increase challenges as the patient improves

Clinical Reasoning

•          “The thinking process by which OTs collect   and use information to make decisions about care of an individual client” (p.41).

•          It is an ongoing process

•          Scientific reasoning

•          Narrative Reasoning

•          Pragmatic Reasoning

•          Ethical Reasoning

Scientific Reasoning

•          Logical thinking about client’s problems and course of action

•          Scientific reasoning occurs when using assessment tools and is dependent on the reliability and validity of these tools

•          Use of the patient’s medical and occupational diagnoses and research evidence are used to guide treatment planning

Narrative Reasoning

•          Thinking in story form

•          “Placing client’s functioning in the context of his/her background and broader experience” (p. 45).

•          Used to help understand the meaning of disability in one’s life to help link his/her goals and values to the therapy process

•          “Thinking about logistics and practical aspects of delivering services to clients within a given setting or organization”

•          This type reasoning is employed when considering:

**Logistics – the planning and implementation of a complex task.

Your organization may have certain assessment tools that are used, along with a specific documentation forms, etc.

•          Optimistic thinking about what should be done on behalf of a specific client

•          Used when combining:

•          research evidence

•          appraisal of competence

Summary of What Clinical Reasoning is

•          A dynamic process

•          Influenced by client and therapist characteristics, experience, and background

•          Settings in which OT works also shape clinical reasoning

•          Assessment tools and methods are influenced by physical, financial, and personnel resources

•          “EBP minimizes influence of personal and environmental biases in clinical reasoning”

**Therapist at different stages in their lives may arrive at different assessment conclusions and develop different treatment plans because of different life experiences 

Encourage students to read the examples in Table 3-1 to gain a better understanding of the process of clinical reasoning

Method of EBP is made up of seven steps:

•          Write an answerable clinical question

•          Gather best evidence to answer the question

•          Evaluate the validity and clinical usefulness of the evidence gathered

•          Synthesize the findings

•          Communicate with stakeholders about evidence as it relates to assessment or treatment

•          Apply findings to practice

•          Monitor, evaluate, and document results

EBP helps OT's???

Clinical Documentation

•          Provides a chronological record of a patient’s status and condition related to occupational functioning and outlines the course of intervention (AOTA, 2004)

•          Reflects the practitioner’s reasoning

•          Serves as basis for judging appropriateness, effectiveness, and necessity of intervention

•          The means by which we communicate our treatment to other health professionals and third-party payers

•          Documentation is one of the most important skills an OTA can develop

**Clinical documentation chronicles clinical reasoning about occupational therapy.

Many OT practitioners will tell you what they dislike most about their job is documentation.

The OTPF is helpful in structuring a documentation system and uses language designed for OT practice, such as areas of occupational performance (ADL, education, work, leisure).

Language and the correct use of terminology are crucial in documentation.

Four Principle Purposes for Documentation (AOTA, 1995)

•          Facilitate effective intervention

•          Justify reimbursement

•          Stand as a legal document

•          Provide communication among healthcare professionals, client, and family

•          Documentation has legal, ethical, and financial ramifications

**Documentation is the only evidence of professional decision making and clinical reasoning and the only method that ensures that something has actually taken place when reviewed by reimbursement agencies and accrediting bodies.

Documentation is the means by which we communicate treatment to other health care personnel and third-party payers.

Confidentiality

•          This is crucial when discussing documentation

•          The OT Code of Ethics protects information about a client from being shared with anyone outside the treatment team

•          HIPAA offers legal ramifications if patient confidentiality is broken

•          You as an OTA must work hard to ensure patient confidentiality is protected at all times

**Breech of confidentiality may include: bringing notes home that identify the patient, talking about a patient in the elevator, sharing interesting stories that would identify the patient with family and friends.

HIPAA – Health Insurance Portability & Accountability Act

HIPAA

•          Source-oriented medical records

•          Integrated medical records in chronological order

•          Problem-oriented medical records

•          Source-oriented medical records–

•          Integrated medical records in chronological order –

•          Problem-oriented medical records

– organized according to four components:

•          Database

•          Complete list of problems

•          Plans for each problem

•          Progress notes

•          SOAP notes

S

O

A

Narrative Notes

•          Allows more flexibility than a SOAP note

•          Does not have structure

•          Information of all data is provided in a smooth, flowing, descriptive note

       General outline:

•       Begins with objective information

•          Followed by interpretive information

•          Concludes with review of objectives met and plans for next session

•          Daily contact notes

•          Evaluation summaries

•          Weekly or monthly progress notes

•          Discharge/Outcome summaries

•          Formats for these reports include:

** See Fig. 3-1 computerized medical record of daily progress note

Regardless of format, practitioner must be clear about their target audience – who will read the note?; what do they need or want to know about the OT work with this patient?

A single note should meet a number of stakeholders’ information needs.

Who is the reading audience of your documentation?

•          Members of the treatment team want to know how best to collaborate

•          The third-party payer: wants to decide whether to pay for services

•          The accrediting agency (for ex: JCAHO): want to determine whether quality services are provided at your facility (Joint Commission on Accreditation of Healthcare Organizations)

•          The legal system: wants evidence in malpractice litigation

•          The patient and significant others: want to understand the care 

**Review Example of progress note on page 49

•          Evaluations

•          Direct intervention, such as:

•          Training in techniques or strategies

•          Task modification

•          Selection or construction of equipment or orthotics

•          Instruction to patient or caregiver about maintenance programs

•          Reviewing information relevant to a prospective patient to determine the need for further evaluation and intervention (Moyers, 1999)

•          Information is gathered by the therapist through:

**MD’s referral is a prerequisite to beginning services covered by third-party payers

          Relevant documents in the patient’s medical record are reviewed for information such as:

•          Other team members’ assessments

•          Diagnosis

•          Severity of illness/disorder

•          Patient’s age/sex

•          Personal and social background

          Introduction (Interview) to patient/significant others

•          To ensure appropriateness of referral

•          Obtain agreement to participate

•          May occur during first few minutes of initial assessment (outpatient/homecare) or be a brief encounter (in hospital room) with assessment to take place later

**DX: R UE Lymphedema secondary to breast CA

Treatment diagnosis: Recurrent cellulitus of RUE, limited functional use due to severe edema

Onset: December 14, 2007. Evaluation and treatment as indicated assess for compression garments as appropriate.

Screening may suggest that referral to OT is not appropriate or patient may not want to participate. Clinician records orders were received, screen performed and explanation as to why further assessment and tx appear unwarranted.

Assessing Occupational Function:
The Four Elements

**Synthesize – combine various components into new whole

Interview

•          Client’s needs and goals in context of his or her life are identified by clinician using a structured interview

•          This is a critical step and must be completed

•          Helps establish client-centered performance and in turn results in enhanced outcomes and cost reduction

Observe Function

•          OT observes patient performing an activity described as important and problematic

•          Formulates hypotheses regarding underlying impairments/deficits that interfere with function

**Ex.: Diagnosis CVA, difficulty locating garments due to L neglect

Evaluate with Selected Tools and Methods

•          Used to verify and quantify the existence of impairments or inefficiencies

•          Only those client factors, impairment, or inefficiencies suspected of limiting occupation function are evaluated

**Not going to do a wide array of testing to identify all possible deficits.  Underlying OCD, pt. has been functioning with this deficit for years, not a treatment issue.

        Practitioner:

•          Studies assessment findings

•          Draws conclusions related to patient’s competence and quality of occupational function

          Basis of the hypothesis for treatment:

•          Strengths and weaknesses

•          Underlying causes or explanation for performance problems

•          Potential barriers and enablers to improved functioning

          Hypothesis:

•          reflects practitioner’s understanding of the patient’s problems

•          guides the selection of the treatment approach

**Hypothesis may change as treatment gets underway.

Documentation Requirements

•          Record Keeping and Notes:

•          Typically notes are taken regarding patient performance during the assessment

•          May go directly into medical record

•          Worksheets are also used (typed or handwritten summary produced for MR)

**Assessment and plans may be completed after one evaluation session, or span multiple sessions.

•          Estimate Outcomes and Set Collaborative Goals

-      Long-and Short-Term Goals

-          Collaborating with clients to set goals

•          Determining the Optimal Treatment Approaches

•          Required Documentation: Evaluation Note

**Clinical reasoning is used to estimate outcomes, set goals, and select treatment approaches and methods

•          Outcome

Global outcomes include resumption of self-maintenance, self-advancement, and self-enhancement roles.

•          Goal

•          Long-term goals:

•          reflect what is to be achieved by the time the patient is discharged

•          relate to expectation of the patient’s functional skills and/or resumption of roles

•          Short-term goals

•          These goals are based on either:

•          Expected improvements specific to client factors or impairments that ultimately contribute to improved function

•          Patient’s improved ability to perform portions of the functional task

**Discharge may be from treatment or to the next level of care on the continuum.

OT goals are always linked to a predicted outcome and typically complement the work of other disciplines.

Collaborating with Clients to Set Goals

•          Collaborative goal setting between clients and therapists presents benefits and challenges to both patients and therapists

•          Patients who establish functional as opposed to general goals have higher discharge scores on the FIM

**Newly disabled patients have difficulty anticipating future functioning tasks and skills not needed in their current setting

** Discharge planning should begin the moment the patient is admitted. Having a vision of the outcome from the start will allow treatment to be focused from the very beginning.

         Remedial Therapy

•          Plan -  to restore an impaired ability, expecting improvement to cause a change in the patient’s activities, tasks, and roles

•          Approach - addresses body structures and functions which compromise client factors

•          Often emphasized with patients in the early stages of recovery and rehabilitation

•          remedial approach does not result in full restoration of abilities

•          patient wants to maximize independence while working toward restoration of fundamental abilities

•          Entails three possible therapy actions:

1.         Changing the context

2.          Reestablishing habits and routines

3.          Acquiring compensatory skills and strategies

•          Focus is on changing factors that are external to the patient in order to improve occupational function

•          May include:

Reestablishing Habits and Routines

•          Following a disabling injury or illness habits and routines are disrupted

•          Patients need assistance to either reestablish existing routines or to create new ones

•          Motivation (or at least compliance) helps patients carry out steps to reestablish habits and routines

Compensatory Skills and Strategies

•          OTs teach patient new skills and strategies that allow them to compensate for permanent or temporary impairments

•          Generally takes longer to affect occupational function than other approaches (i.e. changing elements of the physical context)

**Example: one handed shoe tying, or dressing techniques.  Use tenodesis to help with grasp and release when performing functional tasks.

Required Documentation: Evaluation Note: 

Evaluation note is added to the medical record when assessment and treatment planning are complete.

•          Assessment/Reassessment

•          Protection of patient privacy (dressing training)

•          Easily distracted patients

•          Group Treatment

•          Patients engaged in parallel activities

•          May be grouped according to similar goals, diagnoses, education needs, etc.

•          Who Delivers Treatment: 

•          Required Documentation: Daily Contact Note: 

Monitoring Progress

•          Patient’s response to intervention and progress toward goals is continuously monitored

•          Patient status relative to goals is formally reassessed at regular intervals

•          Required Documentation: Weekly and/or Monthly Progress Notes

•          Home Program

    must be provided to patient and included in medical record

•          Referrals: Same as above

•          Discharge Summary: Provides an overview of services provided, outcomes, and recommendations

Each time an OT practitioner documents intervention plans and assessments, it is a reflection of the ___________.