OTA Chapter 14: Intervention: Planning, Clinical Reasoning, Implementation, and Review (Early)

Critical questions therapist should focus on that form the core of clinical reasoning. (Eleanor Clarke Slagle lecture by Rogers)

- What is pts. status (evaluative) - What are the available options (theory & techniques) - What ought to be done (ethical aspect)

What could leaving early, not coming on time, or finding excuses to avoid treatment mean, easily accomplishing task, struggling, confused or otherwise unable to engage?

-A need to talk to OT and maybe change plan -need to talk and negotiate/modify

Continuous Quality Improvement or CQI

-Another type of quality management process. -Constant and ongoing assessment vs. retrospective. -more interdisciplinary that QA -looks at outcomes(results) rather than problems -Client centered (versus system centered). -Provides immediate feedback about the results of intervention and can make changes as needed

Goals should....

-Describe clearly what the person will do and what action they will perform. (How they will behave or what they will do when goal is reached). -Follow logically from problems identified by assessment and selected by client and staff as important. The more specific the description of the problem, the easier it is to writ the corresponding goal.

Categories of Interventions

-Health promotion -Prevention -Remediation or restoration (rehabilitation or habilitation) -Maintenance of function -Modification or adaptation or compensation.

Ways to write goals that are difficult to measure:

-Include behavioral indicators (family will report no violent behaviors, cl will describe 1 constructive way coped w/feeling) -develop rating scale (GAS Goal Attainment Scaling)

What does GAS (Goal Attainment Scaling) do?

-Provide the consumer, the team, and the insurance company with a clear understanding of what the person is expected to achieve. -Helps cl set own goals and define their own criteria for success in meeting them.

Activity

-chosen on basis of stated principles in plan - primarily for ability to address the intervention goal through ACTIVITY ANALYSIS! -Activity or engagement in occupation should always be prominent even when verbal therapies used. -Pleasurable, enhance competence, mastery. -Reasonable challenge, just right challenge

Results of re eval can be:

-continue w/plan -change it -dicharge

How can consumers' satisfaction with care be measured?

-exit interviews - most objective and easy - surveys with rating scales

What is it important to maintain when looking for the course of pt's problems?

-maintain a curious and alert perspective. -Don't confine your investigation to what you expect to find. -Don't be too strongly influenced by -Dx or opinions of other staff. -Be open to the person as an individual.

OTA responsibilities

-may provide information or ideas -assists in carrying out the the plan, and shares insights and ideas with the therapist -can contribute to decisions about methods to employ implementation plans and activities -practically, contributes to plan as developing by sharing observations of cl., making suggestions about what pt's needs and is capable of, suggesting int. methods.

How can behavior rating be achieved?

-numerical rating scales like Comprehensive OT evaluation scale.

PICO stands for

-population, patient, problem -intervention -comparison (another intervention, no tx, tx as usual) -outcome (what kind of improvement can be expected)

Intervention Review

-process for determining the effectiveness of the plan -cl involved as possible (cog. level) -May include reevaluation using standardized assessments. -Information obtained provide information about the person's readiness for transition to the next level of care -OT responsible

What 3 areas should be assessed in QA programs for mental health OT (Thien)?

-progress toward goals -pt's satisfaction w/care -behavior rating scores

OT responsibilities

-responsible for intervention planning and management -discusses with and may delegate plan to the OTA -practically, usually determines a general int. goal and major steps and overall int. approach and methods.

4 step process to help pt link activities used w/ their purposes (Peloquin)

1. Explain the purpose of the group or activity. 2. Encourage the pt to think about the purpose and ask him or her to share this view. 3. Discuss the skills used and link them to the activities or tasks performed. 4. Summarize what has transpired.

steps in planning intervention

1. Review the results of the individual assessment. 2. Identify problems and, if possible, their causes. 3. Identify the client's strengths and assess/estimate readiness and motivation for int. 4. Collaborate with cl to set goals (LTG/STG, in order of priority). 5. Identify intervention principles using the practice model. 6. Select methods appropriate to the practice model.

What should be established before the therapist begins to plan intervention?

A relationship with the consumer.

Should you try to persuade a pt. to accept an intervention that you know or suspect will improve their condition?

According to professional ethics, YES. but they have the right to refuse. as long as they are not a danger.

Intervention methods may specify:

Activity to be used Environment in which it will be performed Therapeutic Approach to present activity

What is the surest route to learning the client's strengths and potential?

Be open to the person as an individual.

intervention process includes:

the plan, implementation, and review

How and why is a practice model or theory selected?

Choose one that best explains the cl's problems, as a guide in selecting methods of intervention.

Environment

Conditions under which activity takes place that influence response -ind's home enviro. and perf. contexts and the setting for intervention must be considered.

What are practitioners in short-term settings more concerned with?

Evaluation and helping pt make a transition to the next level of care than with long-term planning.

Progress toward goals is most easily measured when:

Goals are behaviorally observable and measurable. (like an improvement in standardized test)

When are consumers at risk of falling through the cracks of the system?

In making the transition from one setting to another

How is effectiveness monitored?

Informal observation and formal evaluation

What must be the basis of activity selection if we expect to produce the desired therapeutic effect?

Knowledgeable analysis Trouble making decisions? - activity that gives choices. Trouble following procedures? - activity with lots of rule/restrictions

Difficult initially determining theories and models in mental health due to:

Lack of understanding of causes of mental illness or how or why medications work. Lack of understanding of how mental health undermines a person's function Lack of experience with clients in mental health

Therapeutic Approach

Must consider clients values, learning style and preferences, and motivation for change

What should practitioners looking to strengthen or expand their practice employ?

QA strategies.

Remediation or restoration

aims to restore or establish a skill or ability (UE mobility, ability to cope with stress @ work) -Aims to alter underlying disease process. Interventions given to affect disease process, unsure in psych, i.e. SI.

What are major focuses of psychiatric OT?

Rehabilitation and habilitation

What is important (especially at first) when selecting STGs?

Select specific and objective goals that the pt can achieve relatively quickly to inspire confidence and encourage them to more forward to more challenging.

What happens with an acutely ill pt who is psychotic, out of touch with reality and unable to cooperate and participate in int. planning?

Staff my develop an int. plan on behalf of the pt, sometimes in consultation with members of the pt's family.

What can pt failure to work toward goals that the therapist considers appropriate indicate?

The goals don't reflect the pt's real concerns.

What is often the key to the most effective approach to intervention?

Understanding the causes of the cl's problems

Second Question: What are the available option?

What approaches are available? What outcomes are predicted for each of these? What results can we expect? How much time is needed to reach the objectives using each of these approaches? -Th. searches memory for knowledge and experience that relates while taking into account pt's env. and social context, supports, barriers. -generates internal list of possible interventions.

Possible reasoning questions from the Cog.-Behavioral model:

What are pt's beliefs and assumptions about life? What do they say are the causes of life problems? What errors in thinking are behind cl's beliefs? Develop an intervention plan to challenge and refute erroneous thinking.

First Question: What's the pt's status?

What is the pt's occ. role status? What problems does he/she have? What strengths do they possess? What are they motivated to try? Engagement in occ., perf. skills and patterns, contexts, cl. factors. that are obstacles or supports.

prevention

aims to intervene before dysfunction occurs -at risk populations (supportive activity group for kid of alcoholic parents) -Overlaps with all other areas

Third Question: What ought to be done?

Which options are consistent with this pt's values? Has the pt been informed of the consequences of different treatment options and been allowed to choose among them? Rogers: "Simply because a goal appears technically feasible for the patient does not mean that it should be set as a goal."

Possible reasoning questions from the Cog. Disabilities model:

Which sensory cues are disregarded by pt? To which do they attend? Is the cl. able to follow 2 step directions? Construct an intervention plan to adapt life situation and bring task demand into person range of ability.

Environmental Support

a feature of the environment that encourages and assists the individual to perform a particular behavior (soap dispensing machine, case manager who checks)

Clinical Reasoning

a logical approach to gathering info & using it to generate intervention goals & methods. -How to know which practice model, which evals to administer, which problems to target, which approaches to use. -a complex cognitive and affective process -process of analysis using thinking & feeling -select theories and methods that best apply. -understand and appreciate pt's story and feel for their dilemma

PICO

a model for writing search questions to help locate pertinent articles in the clinical literature

goal

a statement about what the client will achieve

Pragmatic reasoning

about getting things done, thinking through problems that might arise, and finding efficient strategies to take care of details -keeping sticky notes in pockets to leave notes

Maintenance of function

aimed at assisting the person to use his/her remaining capabilities by providing supports -create enviro. that supports/encourages pt. to care for own needs, take charge of own life however they can for as long as they can. -Aim to assist person to use his or her remaining capabilities. -Often focus for chronic or progressive disorders.

Environmental Demand

an expectation for a certain kind of behavior or action that is evoked by something in the environment (flag stimulates salute, parent require As)

Health promotion

applies to all populations, including those w/ no present disablility -aim is to enrich or enhance occupational engagement for all individuals -fall prevention education; homework management

Interactive reasoning

applies to understanding and relating to the patient as an individual -relationship w/ patient, communicating receptivity, & acceptance of their needs/concerns

A practice model or frame of reference is helpful in generating _____ and _____ on which to base ____

assessment questions obtaining data the plan

intervention planning

based on results of the evaluation: the occupational profile & analysis of occupational performance -entails identifying client's strengths & barriers & personal goals, choosing outcomes, & selecting reasonable goals & methods to achieve them

What are ways we can alter demands/supports within environment?

by adding or removing objects or people, by changing the arrangement of the furniture or the lighting, or by other factors.

short-term goals

can be understood as small steps to achieve long-term goals. -considers length of time available for treatment and pt's sense of time and ability to visualize future. -can be accomplished in a few weeks or less.

Outcomes

changes brought about by OT intervention -Core of ANY OT intervention should be engagement in occupation -Ideally should be selected at eval phase -OT responsible -OTA must be aware and report on them to OT

Who should be included in the first steps of int. planning? (identification of problems, strengths, and motivation and setting of int. priorities)

client anf family Other clinical personnel working w/cl -Have best chance of success because everyone will work toward them.

Continuity of care necessitates that:

clinicians anticipate how the cl will respond to transition -obtain permission to speak directly with OT or provider in next setting. -follow up after transition via phone calls to cl and provider

Procedural reasoning

concerns the disability and the options for intervention -thoughts about long-term implications from schizophrenia, (diminished functioning & possible interventions- sensory int., psychosocial club)

insight based intervention

encouraging client to reflect on their own experience and identify issues that interfere with achieving goals`

rehabilitation

focuses on restoring the person's ability to function after the disease process has been medically treated -Focuses on restoring ability to function. -Habilitation: never developed abilities, focus on skills

All goals should address:

functional occupation-centered outcomes.

Relevant

if goal reflects the individual's life situation & future goals

Conditional reasoning

includes the larger context, the "what if" brainstorming of events that might change the current condition and the need for the patient to participate -creating mental scenarios of if a given approach were tried -what might the pt;s life have been like before -to see a future vision of what's possible

intervention is built on:

info from eval

Narrative reasoning

is telling a story that will capture the interest and spark confidence in the patient -sharing the vision, cultivating hope -creation of a context in which boring tasks have meaning in terms of future life story. -link present task concretely with a future vision of pt's life.

What is the purpose of environmental manipulation?

is to stimulate clients to perform activities, to engage in occupations, to develop skills, to acquire habits, and to enhance their sense of personal causation by providing opportunities for success.

residual disability

loss of function as a result of the disease

Informal observations

made almost automatically, as practitioner takes notes on the client's reaction to intervention -pt's behaviors and remarks provide clues -too easy/difficult?

Formal reevaluation

measuring the progress of an individual by re administering assessments used in original evaluation -responsibility of OT, OTA can contribute -improvements since initial show tx effectiveness but other factors can also account for it.

practice model

organizes our thinking in planning interventions

How can you pts with limited ability to verbalize concerns be guided to participate in planning?

present them with limited choices to make a selection (which goal or area to tackle first)

Reasoning Tracks

procedural interactive conditional narrative pragmatic

long-term goal

states the functional outcome or destination of the intervention, ultimate aim. -to get a job -to have my own apartment

What is an obstacle to implementing QA in psychiatric settings?

subjective nature of mental disorders and difficulty of measuring improvements in mental health.

objective

term used in psychiatric rehab model when referring to short-term goals

What does involving the pt in planning intervention to the extent capable ensure?

that the cl understands and agrees with the plan, a first step in securing motivation to work on goals.

OT intervention

the "process and skilled actions taken by the OT practitioner in collaboration with the client to facilitate engagement in occupation related to health and participation.

Clinical reasoning is continually focused and refined by:

the client's contributions. -They tell you what's wrong and help define the problem.

prognosis

the degree to which we can predict recovery from disability and the ability to resume a normal life

intervention implementation

the enactment of the methods and activities outlined in the intervention plan

priority for goals

the importance or urgency of the goal

What is the number of goals attempted at one time based on?

the pt's ability to divide their energies effectively among the different goals and on the amount of effort needed to reach a particular goal.

Quality assurance

the systematic approach to the evaluation of patient care that enables the identification, assessment, and resolution of problems in order to improve health care benefits for patients -way of measuring how well we are doing so we can improve -looks at entire program to identify problems in pt care and resolve them. System, not ind.

purpose of reviewing the evaluation

to obtain the answers to the second & third steps and to learn as much as you can about the client's problems(barriers), strengths(and supports and resources), and readiness or motivation for change

habilitation

used to distinguish intervention for clients (ID) who have never developed functional abilities because they became ill at a young age

RUMBA criteria

used to evaluate goal statements: Relevant Understandable Measurable Behavioral Achievable

Measurable

when goal contains one or more criteria for success in quantifiable terms rather than qualitative and estimated day of completion. MEASURE How often, how long, level of accuracy, # of times, level of assist needed. TIME FRAME. by specific date, by end of specific unit of time, after a specified # of sessions, by a known milestone (discharge)

Behavioral

when goal focuses on what the client must DO to accomplish the goal

Achievable

when goal is something that the person is able to accomplish in a reasonably short period as defined by cl and th.

Understandable

when goal is stated in plain language and observable terms. Avoid jargon. Pt, family can understand.

Begin the goal statement....

with verbs such as Rehab: to develop, to restore, to improve Maintenance: to maintain ability to Prevention: to prevent deterioration of ability to