Pedretti Ch. 3 - Application of OT Practice Framework to Physical Rehabilitation Flashcards
Occupational therapy process
- Should be conceptualized as a circular process
- Initiated with a referral
- Then Evaluation to determine the client’s needs
Intervention is developed based on the evaluation
–The targeted outcome of the intervention is supported through the client’s health and participation in life through engagement in occupation - All parts are mutually influential
Referral
- Physician or other legally qualified professional requests OT services for the client
- May be oral, but written is usually a necessity
- Guidelines vary
Screening
- OT determines if further evaluation is warranted and if OT services would be helpful for this client
- Generally brief
- Consider prior evaluations, diagnosis, physical condition, reason for referral and information from other professionals
Evaluation
- Refers to the “process of obtaining and interpreting data necessary for intervention”
- Assessment: specific tools or instruments that are used during the evaluation process
- Two parts of the evaluation process:
1. Generation of an occupational profile
Assessments are chosen to help generate
2. Analysis of occupational performance
Synthesis of data collection through a variety of means
Occupational Profile
- Reviews the client’s occupational history and describes the client’s current needs and priorities
- Includes client’s previous roles and contexts for occupational performance
- Initiated through an interview with the client and/or family and record review
Purpose of the Occupational Profile is to answer the following questions:
- Who is the client? – include significant others/ dependents
- Why is the client seeking service?
Needs of individual and significant others - What occupations and activities are successful or are problematic for the client?
- How do contexts and environments influence engagement in occupations and desired outcomes?
- What is the client’s occupational history?
Level of engagement in various occupations and activities along with the value attributed to those - What are the client’s priorities and targeted outcomes?
After completing the Occupational Profile, the OT must decide what additional information is needed
- What additional data are needed to understand the client’s occupational needs including contextual supports and challenges?
- What is the best way to collect this data?
- How will this information support the intervention plan?
- How will this information influence potential outcomes?
Final steps of eval process
Then the OT will evaluate the client’s ability to plan, initiate and complete various occupations
The OT will then analyze the data to determine the specific strengths and weaknesses that impact their occupational performance → impact of contextual factors will be included
The OT will also consider if the client would benefit from a referral to other professionals
Intervention Planning
When selecting an intervention plan the strategies should be linked to the intended outcomes of service.
They should answer the question: “What type (approach/strategy) of intervention will be provided to meet the client’s goals?”
Examples of types of interventions:
1. Prevention of disability
Focused on developing the performance skills and patterns that support continued occupational performance and provides intervention that anticipates potential hazards or challenges to occupational performance
- Contextual issues (environmental barriers) are also addressed
- Ex: patient with balance issues → fall prevention tips
Examples of types of interventions: 2. Health Promotion
Provided to enhance and enrich occupational pursuits
- May be used to help clients who are transitioning in roles or foster occupational performance across contexts
- Ex: promoting a transition of role from worker to retirement → anticipating changes and making choices
Examples of types of interventions: 3. Establish or Restore a Skill or Ability
Aimed at improving child’s skills or abilities, thus allowing greater participation in occupations
- Ex: CVA → restore ADLs and iADLs
Examples of types of interventions: 4. Adapt or Compensate
Modifying the environment, activity demands, client’s performance patterns to support participation in occupations
- Ex: Dyspnea → energy conservation techniques
Examples of types of interventions: 5. Maintain Current Functional Abilities
Approach focuses on clients diagnosed with degenerative disorders and OT services should actively address the need to maintain occupational engagement
- Intervention may focus on activity demands, performance patterns or context for occupational engagement
Through collaborating with the client and significant others, the intervention plan identifies specific focus of the goal but also explicit content of the goal
The plan includes:
Client-centered goals and methods for reaching them – values and goals of the client are primary and those of the therapist are secondary
- Cultural, social and environmental factors are incorporated
- Must identify scope and frequency of intervention and anticipated date of completion → outcomes must be written at the time the plan is developed
- Discharge planning is initiated during the intervention planning process
Clear and measurable goals
Long-term goals or terminal behaviors must reflect a change in occupational performance
Outcomes may be achieved through several means: improved occupational performance, role competence, adaption, prevention and quality of life
Short-term goals or behavioral objectives reflect the incremental stages that must occur to reach this target
Intervention Implementation
OT retains the responsibility to direct, monitor, and supervise the intervention and must ensure the necessary and relevant interventions are provided in an appropriate and safe manner and that documentation is accurate and complete
Methods used to provide interventions include:
- Therapeutic use of self, therapeutic use of occupations and activities, consultation, advocacy and education
The intervention would identify which approach or strategy will be used in combination with the methods
- During the intervention the clinician may shift between methods depending on the needs of the client
Anticipatory Problem Solving – Schultz Krohn
Helping the client anticipate needs and solutions
Developed from model of human occupation and person-environment occupation
Empower client to anticipate potential challenges and develop solutions prior to encountering those challenges
Key elements:
- Identify the occupation or activity to be performed
- Features of the environment – contextual and environmental factors; necessary equipment
- Potential safety risks or challenges to engagement
- Develop a plan for these risks and challenges
Foundation of this process is to engage the client in developing solutions for everyday challenges encountered as they engage in occupations/activities
Intervention Review
OTs evaluate the intervention plan on a regular basis → determine if the client’s goals are being met
Review includes a re-evaluation of the client’s status
Critical for showing the effectiveness of the intervention
The intervention may be changed, continued or discontinued based on the results of the re-evaluation
Outcomes
Working with the client, client’s family and the intervention team, the OT/OTA identify the intended outcome of the intervention
Outcomes may be written to reflect a client’s improved occupational performance, a change in the client’s response to an occupational challenge, effective role performance, habits and routines that foster health or prevention of further disability, and client satisfaction in services provided
Overarching outcome of OT intervention
supporting health and participation in life through engagement in occupation
A client is formally discharged when:
A client is formally discharged when they have reached their established goals or achieved maximum benefit from OT services
OT will formally discontinue services and create a discontinuation plan that documents follow-up recommendations and arrangements
Necessary revision of the client’s outcomes and goals occur if it becomes apparent that the desired outcome is not realistic
Clinical Reasoning in the Intervention Process is
Defined as:
Defined as: the process used by OT practitioners to understand the client’s occupational needs, make decisions about intervention services, and as a means to think about what we do
Five forms of clinical reasoning
- Procedural
- Interactive
- Conditional
- Narrative
- Pragmatic
- Procedural Reasoning
- Getting things done, “what has to happen next”
- Medical form of problem solving
- Emphasis is placed on client factors and bodily functions and structures
- Critical pathway: form of decision making tree based on a series of yes/no questions that can direct client interventions
- -Developed to support best practice when there is substantial information about a client’s course of recovery
- Used to develop critical pathways and is driven by the client’s diagnosis and potential outcomes anticipated for individuals with this outcome
- Interactive Reasoning
- Concerned with the interchanges between the client and therapist
- Therapist uses this kind of reasoning to engage with, understand and motivate the client
- Understanding the disability from the client’s POV is fundamental
- Used during the evaluation to further explore the client’s occupational needs
- During the intervention it is used to access the effectiveness of the intervention
- Conditional Reasoning
- Concerned with the contexts in which interventions occur, the contexts in which the client performs occupations and the ways the various factors might affect the outcomes and direction of therapy
- Using “what if?” – imagining possible scenarios for the client
- Integrate the client’s current status with the hoped for future
- Recognizes that the process of intervention often necessitates a reappraisal of outcomes
- Reappraisal should be encouraged to help the client refine goals and outcomes
- Narrative Reasoning
- Uses story making as a way to understand the client’s experience
- The client’s experience reveals themes that permeate the client’s understanding and that will affect the enactment and outcomes of therapeutic reasoning
- Also used by therapist to plan the intervention session; and what will happen for the client as a result of therapy
- Therapeutic use of self is critical
- Where context and occupational performance intersect
- -Cultural and social contexts
- Pragmatic Reasoning
- Extends beyond the interaction between the client and therapist
- Integrates several variables: demands of the intervention setting, therapist’s competence, client’s social and financial resources, and the client’s potential discharge environment
Clinical Reasoning in Context
- Therapist must balance the needs of the client with the practical realities of healthcare reimbursement and documentation
- -Needs to know: anticipated or requirement date of discharge; scope of services that will be reimbursed
OT must document service accurately and effectively
Therapist is guided by client’s goals and preferences – Client Centered
- Requires client or family involvement and collaboration at all stages
- Must be able to communicate with people of all backgrounds
- Cultural and social factors
Client-Centered Practice
- Involving clients in identifying their own goals and in decision making about their own care and intervention
- Begins when the therapist first meets the client
- Occupation based assessment tool: COPM (Canadian Occupational Performance Measure)
Client-Centered Practice is Guided by the Following Principles:
- Language reflects client as a person first and condition second
- Client is offered choices and supported in directing the OT process
- Intervention is provided in an accessible, flexible manner to meet the client’s needs
- Contextually appropriate and relevant
- Clear respect for differences and diversity
Theory
According to Reed, theories attempt to do the following:
- Define and explain relationships between concepts or ideas related to the phenomenon of interest
- Explain how these relationships predict behavior or events
- Suggest ways that the phenomenon can be changed or controlled
Theory is tested across settings for ____.
Theory is tested across settings for confirmation of concepts and relationships
From an OT perspective: theories provide the profession with ___.
From an OT perspective: theories provide the profession with a means to examine occupation and occupational performance and understand the relationship between engagement in occupations and participation in context
Mary Reilly’s theory of occupational behavior was designed to explain what?
Mary Reilly’s theory of occupational behavior was designed to explain the importance of occupation and the relationship between occupation and health
Model of Human Occupation (MOHO)
Engagement of occupational performance is understood as a product of three interrelated subsystems
- Volitional subsystem: refers to the client’s values, interests and personal causation – thoughts and feelings, including occupational forces
- Habituation subsystem: habits and roles that are critical to a sense of self
- Performance Capacity subsystem: reflects the client’s lived experience of the body
- -Refers to the client’s previous experience, changes, and expectations of performance capacity
Ecology of Human Performance (EHP)
Intended to serve as a mechanism for understanding human performance across professions
Important is the interaction of the person, the task (activity demands), and the context
- These three factors influence each other and the person and task are linked to the context
- Occupational performance is intertwined and the product of these three variables
- Equal importance is placed on each variable
Ecology of Human Performance (EHP) – client centered model
Client centered model – each person is viewed as unique and complex; includes past experiences, skills, needs and attributes
Ecology of Human Performance (EHP) – five intervention strategies
- Establish/restore: focused on improving person’s abilities; includes context for performance
- Alter: intervention alters contextual factors to foster occupational performance
- Adapt/modify: task or context is adapted to support performance
- Prevent: intervention may address the person, the context, or task to prevent potential problems from occurring
- Create: intervention addresses all three variables of the person, task, and context and is designed to develop or create opportunities for occupational performance
Person-Environmental Occupation Model (PEO)
Shares characteristics with EHP; occupational performance is seen as the intersection between person, environment and occupation
Client centered; but equal emphasis is placed on environment and occupation when designing intervention
Defines the person as a dynamic and changing being with skills and abilities to meet roles over the course of time
Further differentiates the progression from an activity, a small portion of a task, a task that is a clear step toward an occupation, and the occupation itself evolves over time
Frames of Reference (FOR)
Purpose: help the clinician to link theory to intervention strategies and to apply clinical reasoning to the chosen intervention methods
Tends to have a more narrow approach to occupational performance when compared to models of practice
Offers a way to structure intervention and think about intervention progressions
Should be well fitted to meet the client’s goals and hoped-for outcomes
A clinician may blend intervention strategies for multiple FORs to meet the client’s needs
Biomechanical
Kinematics and kinesiology are foundations
Analyzing the movement required to engage in the occupation
Principles of physics, the force, leverage, and torque required to perform a task are assessed → basis for intervention
The outcome must reflect engagement in occupation
Rehabilitation
Focuses on the client’s ability to return to the fullest physical, mental, social, vocational and economic functioning as possible
Emphasis is placed on client’s abilities and using current abilities coupled with technology or equipment to accomplish occupational performance
Compensatory intervention strategies are employed
Focus of the intervention is often engagement in occupation through alternative means
Clinician must always link intervention to the client’s occupational performance
Sensorimotor
Several FORs are included in this grouping
- Proprioceptive Neuromuscular Facilitation (PNF)
- Neurodevelopmental Treatment (NDT)
- These approaches share a common foundation of viewing a client who has suffered from CNS insult to upper motor neurons as having poorly regulated control of lower motor neurons
- Various techniques are employed to promote reorganization of the sensory and motor cortices of the brain
- Basic premise: client receives systematic sensory information, his or her brain will reorganize and return of motor function will be obtained
Meeting the Client’s Needs
As a therapist applies theories, models, or FORs to meet the client’s needs, a series of potential questions should be posed:
- Does the theory, model of practice, or frame of reference help with understanding and interpreting the evaluation data while considering the client’s expressed needs?
- Does the theory, model of practice, or frame of reference provide a good fit for the type of intervention that will meet the client’s needs?
- What evidence is available that the theory, model of practice, or frame of reference can efficiently produce the results requested by the client?
Teamwork within the Occupational Therapy Profession – Two levels of practitioners: OT and OTA
OT ability to provide occupational therapy services independently
- Should seek supervision and mentoring to foster professional growth
OTA must receive supervision from an OT to deliver occupational therapy services
OT – OTA Relationships
Appropriate role of the OTA is complementary to that of the OT
Many variations in the use of OTAs exist across settings
AOTA has identified critical factors to consider in the delegation of delivery of occupational therapy services
- Factors include the severity and complexity of the client’s conditions and needs, the competency of the practitioner, type of intervention selected to meet the identified outcomes and requirements of the practice setting
Occupational Therapy Aides
Must work only under direction and close supervision of an OT practitioner (OT or OTA)
Provides supportive services – do not provide skilled occupational therapy services
Teamwork with Other Professionals
Many healthcare professional collaborate in the care of persons with physical disabilities
Relationships are determined by the context of care or setting
Advantages: better integration of services, fewer healthcare providers, cost reducing
Disadvantages: erosion of professional identity, risk to consumers of harm at the hands of less skilled providers and ceding control of individual professions to outside parties such as insurers
Many factors affect the relationships among professionals across disciplines
Intervention setting, reimbursement restrictions, licensure laws, other jurisdictional elements and the training and experience of others involved
Each discipline has a certain scope of practice, but there might be some overlap
Cross Training
training of a single rehabilitation worker to provide services that would ordinarily be rendered by several different professions
Multiskilling
used synonymously with cross training; acquisition by a single healthcare worker of many different skills
Ethics
OT practitioners should anticipate that they will frequently encounter ethical distress
Plan of action:
- Reviewing AOTA guidelines
- Seeking guidance from institutional ethics and review boards
- Approaching and engaging colleagues, peers, and the community to identify and debate ethical questions and formalize resolutions
