Seems like in your example of occupation that the UE is left out of the
equation, although through some improvement it can lead to improvements
in the patient's personal goals of occupation. Just because there is
no function in the flaccid UE does not mean there will not be any
improvement 6 months down the road, especially with intentional focus
on the issue. I can make the UE treatment focus on occupation just
like you state, but it will take much longer. Instead of writing
patient will improve AROM by 30 degrees in order to assist with self
feeding I can simply write patient will reach for a glass of water from
table using his involved arm. The problem is it might take 6 months to
a year to achieve this occupationally written goal, but it only might
take 2-3 months to show 30 degrees of progress if the patient has good
rehab potential in arm function. The structure of insurance
re-imbursement is set up on showing immediate progress, otherwise we
are told to DC a patient or set more achievable goals. Even though we
as neuro OTs might wright goals that focus on body impairments, it does
not mean that we are not looking at occupation. It only means that we
want to continue to work with the patient that has the potential of
using their arm in occuation again, but unfortunately we need to be
able to document improvements relatively quickly for insurance to foot
the bill. This sytem of billing does not match up with the natural
progression of improvement in a patient's arm after a stroke.The road
to recovery for a stroke patient's flaccid arm is a long and painful
one, in which sometimes the road does not lead to a positive outcome.
How can we justify seeing them for an entire year, and then finally one
day we state that the patient is not appropriate for OT any longer.
There needs to be incremental steps along the way to occupation showing
that the patient is making progress towards that goals that we
predicted would eventually be achievable. And let me tell you, when
that area of occupatiion is finally achieved after such time and effort
from the therapist and patient, there is not greater feeling in OT. I
wish we could see them for an entire year, following one occuaptionally
based goal and not having to worry about the measurements of tone,
strength, ROM, coordination, but with the system that we bill under
now, we have to follow the rules.
Your examples of training in sit to stands, balance retraining,
functional transfers are on the mark of occupation. However these
areas of impairment are often easier to demonstrate improvements in
occupation simply showing the assist level of improvement (patient
inproved from a total assist to a supervision when toileting). These
areas of occupation are more certainly easier to treat in the timeframe
we are given to show progress. The area of impairment involving the
flaccid UE is much more complex and difficult to show immediate
progress. It is impossible to write goals that focus on occupation
because it would be impossilbe to show incremental progress on the
actual occupation when the patient wants to incorporate he flaccid arm
into occuaption again. If the patient is a total assistance with
reaching for a glass of water using the hemi arm, it would be
impossible to demonstrate in a months time that the patient is at a
maximal assistance, moderate, or minimal assistance for the task while
using the hemi arm. The assist levels do not quantify the small
incremental improvement. I can certainly document that the patient is
using their arm more duing occupation through the use of activity
journals, or subjective surveys that the patient fills out based on
their perceptions, but it is near impossible to visually recognize that
a patient improved from a total assistance to a maximal assist with the
reaching task, because of the limitations of the assist level scales.
It is much more quantifiable to use standardized scales that focus on
body impairments like the dynamomenter, goniometer, Motor Assessement
scales, Wolf Activity Scales, Modified Ashworth Scale, and the like to
show these small incremental scales of progress required for changes in
the patient's occupational goals.
Chris Nahrwold MS, OTR.
-----Original Message-----
From: Ron Carson <[email protected]>
To: [email protected] <[email protected]>
Sent: Sat, 21 Feb 2009 5:19 am
Subject: Re: [OTlist] Occupation as THE goal: Does it matter
Chris, after thinking about your question, I conclude that the best I
can offer is a hypothetical situation. So, here goes....
Take my patient today. A CVA patient. He has a flaccid UE with no
functional use. He requires assist for sit/stand and ambulates with a
quad cane with supervision.
IF the goal is improving the occupation of self-care to the
supervision/setup level, treatment might look like this:
Therapeutic activity to include: sit/stand and transfer
training. Balance training without UE support. Hemi dressing
techniques training
IF the goal is improving UE ROM to increase ability to perform self-care
with supervision/setup, the treatment might look like this:
Therapeutic exercise to the affected UE. Self-care training in
hemi-dressing.
=================================================================
For the record, the patient verbalized mixed goals. Of course he said he
wants to get his arm working but he also wants to reduce the strain on
his wife by increasing his ability to sit/stand without assistance from
her.
Look forward to feedback and comments from you and EVERYONE else! In my
opinion, the issues and topics being discussed are too important to not
be involved! <smile>
Ron
----- Original Message -----
From: [email protected] <[email protected]>
Sent: Monday, February 16, 2009
To: [email protected] <[email protected]>
Subj: [OTlist] Occupation as THE goal: Does it matter
cac> Ron,
cac> Great outline.? Can you next explain how the treatment will differ?
cac> Chris
cac> -----Original Message-----
cac> From: Ron Carson <[email protected]>
cac> To: [email protected]
cac> Sent: Mon, 16 Feb 2009 7:52 am
cac> Subject: [OTlist] Occupation as THE goal: Does it matter
cac> Hello All:
cac> What follows are thoughts and opinion about using occupation as
*THE*
cac> goal for OT treatment.
cac> Here's is the premise for my arguments:
cac> (1) When occupation is *THE* goal, outcome statements may be
written in
cac> concise occupation-based outcomes. For example:
cac> Patient will safely and independently ambulate to/from
toilet
cac> with RW and perform all hygiene without assistive
equipment.
cac> Patient will transfer from w/c to bed using slide
board
cac> transfers
cac> Patient will dress self using adaptive equipment as
necessary
cac> (2) Conversely, when occupation is not *THE* goal, outcomes
may be
cac> written so that occupation is a desired outcome but is
based on
cac> improving underlying impairment(s). For example:
cac> Patient will increase UE elbow ROM to 115 degree active
flexion
cac> to all for donning/doffing of shirt
cac> Patient will increase standing endurance/balance to
allow them
cac> to safely and independently carry out toileting hygiene.
cac>
--------------------------------------------------------------------
cac> Some argue there is little difference in the above approaches.
However,
cac> I believe these approaches frame patient problems very
differently. This
cac> is important because how we frame a problem drives our treatment.
cac> The first example clearly identifies that occupation is the goal.
There
cac> is no expressed concern for underlying factors impairing
occupation.
cac> However, and this if often overlooked, it is IMPLIED that all
factors
cac> impairing the goal will be treated within the therapist's
abilities.
cac> This is true because occupation includes the following factors:
cac> Physical, emotional, mental environmental, behavioral,
social
cac> Thus, as OT's and within our scope of practice,
occupation-based
cac> outcomes address all factors impairing the desire occupations.
cac> While the second example does include occupation as an
outcome, only
cac> factors addressed in the goals are included for treatment. This
severely
cac> limits treatment and
cac> in my opinion indicates that remediation of
cac> underlying impairments is the real goal. The implication is
that if
cac> underlying impairments are remediated, occupation will improve.
However,
cac> is inconsistent with OT theory because occupation is ALWAYS
more than
cac> physical. In my opinion, the second example is much more
like a PT
cac> rather than an OT goal!
cac> In closing, writing occupation-based goals is important for us
and for
cac> the patient. These goals allow us to focus on occupation's many
elements
cac> and complexity to best enable our patients.
cac> Thanks,
cac> Ron
cac> --
cac> Ron Carson MHS, OT
cac> www.OTnow.com
cac> --
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cac> Archive?
cac> www.mail-archive.com/[email protected]
cac> --
cac> Options?
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cac> Archive?
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