Occupational Therapy Process: Evaluation, Intervention, and Outcomes

Occupational Therapy Process: Evaluation, Intervention, and Outcomes

The occupational therapy process is the interaction between two active agents, the practitioner and the client, involved in a course of action. The interaction is not something done to the client, rather the interaction engages with the client.

The occupational therapy process can be divided into three components. The first component, the evaluation process, includes referral, screening, developing an occupational profile, and analyzing occupational performance. The intervention process is the second component, and it includes intervention planning, implementation, and review. The third component is the outcomes process, which includes measurement of outcomes and decision-making related to the future direction of intervention.

EVALUATION PROCESS

The purpose of the evaluation process is twofold: (1) to find out what the client wants and needs; and (2) to identify those factors that support or hinder occupational performance.

The OT bases the evaluation procedures on the client's age, diagnosis, developmental level, education, socioeconomic status, cultural background, and functional abilities in this section, the steps to the evaluation process are reviewed, and the various methods used to gather information are described.

REFERRAL

The occupational therapy process is initiated when a referral, a request for service for a particular client or a change in the degree and direction of service, is made. Referrals may come from a physician, another professional, or the person himself or herself.

The model of practice helps organize the practitioner's thinking. From the model of practice, the practitioner selects a frame of reference and chooses assessment instruments consistent with the frame of reference.

OCCUPATIONAL PROFILE

The goal of this step in the process is to gather information on the client so that an occupational profile can be developed.

An occupational profile provides the practitioner with a history of the client's functioning and background information with which to design intervention. The following questions from the Occupational Therapy practice framework (OTPF) help the practitioner develop the occupational therapy profile:

• Who is the client (individual, caregiver, group, population)?
• Why is the client seeking service, and what are the client's current concerns relative to engaging in occupations and daily life activities?
• What areas of occupation are successful, and what areas are causing problems or risks?
• What is the client's occupational history (i.e., life experiences, values, interests, previous patterns of engagement in occupations and in daily life activities, the meanings associated with them)?
• What are the client's priorities and desired targeted outcomes?

OCCUPATIONAL PERFORMANCE ANALYSIS

From the information gathered during the occupational profile (e.g. client's needs, problems, and priorities), the practitioner makes decisions regarding the analysis of occupational performance.

Occupational performance analysis entails analyzing all aspects of the occupation to determine the client factors, patterns, contexts, skills, and behaviors required to be successful.

SCREENING

Through screening, the OT practitioner gathers preliminary information about the client and determines whether further evaluation and occupational therapy intervention are warranted.

Screening typically involves a review of the client's records, the use of a brief screening test, an interview with the client or caregiver, observation of the client, and/or a discussion of the client with the referral source.

Evaluation is seen as a critical decision-making role requiring a depth of understanding of many factors; as a result, the final responsibility of evaluation rests with the OT.

The evaluation requires that the OT gather accurate and useful information to identify the needs and problems of the client to plan intervention. The techniques used during the evaluation process can be classified into three basic procedures: (1) interview, (2) skilled observation, and (3) formal evaluation procedures.

INTERVIEW

The interview is the primary mechanism for gathering information for the occupational profile. Interviewing the client and his or her significant others provides more data.

Initial Contact

At the point of initial contact, the skilled interviewer spends the first few minutes of the interview putting the subject at ease. Often, a person is worried and anxious at a therapy interview.

The practitioner begins the interview by introducing him or herself and informing the client about the clinic, the program, and standard procedures.

Information Gathering

After an informative discussion about the center or the therapy process, the OT practitioner begins to gather information about the client.

Closure

Effectively putting closure on the interview is also a learned skill. The OT practitioner must remain aware of the time so that the necessary details are covered.

DEVELOPING OBSERVATION SKILLS

Observation is the means of gathering information about a person or an environment by watching and noticing. Observation may occur through a structured series of steps introduced by the OT practitioner, or it may be intentionally left unstructured to see what takes place.

Practicing observation with a goal in mind helps to further develop the skills. If the long-range goal is to describe a person's appearance as completely as possible, then gather the information systematically.

The next level of observation skill development is to employ thought and discrimination before making the observation to gather information about what is needed.

A structured observation involves watching the client perform a predetermined activity. OT practitioners frequently use structured observation to gain knowledge of what the person can or cannot do in relation to the demands of the task.

FORMAL ASSESSMENT PROCEDURES

Formal assessment procedures help determine the existing performance level of the client. Formal assessment procedures include test tools, instruments, or strategies that provide specific guidelines for what is to be examined, how it is to be examined, how data are to be communicated, and how the information is to be applied in clinical problem-solving.

A test is said to have validity if research testing shows it to be a true measure of what it claims to measure. Test reliability is a measure of how accurately the scores obtained from the test reflect the true performance of the client. There are several different types of reliability with which the OT practitioner must be familiar. Test-retest reliability is an indicator of the consistency of the result of a given test from one administration to another. Interrater reliability is an indicator of the likelihood that test scores will be the same no matter who is the examiner. OT practitioners can place more confidence in instruments that have high validity and reliability.

A standardized test is one that has gone through a rigorous process of scientific inquiry to determine its reliability and validity. Each standardized test has a carefully established protocol for administering the test.

Standardized test may be based on normative data, often called norms, collected from a representative sample that can then be used by the examiner to make comparisons with his or her subjects.

OT practitioners also use non-standardized tests for measuring function. Non-standardized test have guidelines for administering and scoring but may not have established normative data, or reliability and validity.

OT practitioners administering a test instrument must be properly prepared. Before administering a test, the OT practitioner must become familiar with the procedures and know the correct way to administer items, score the test, and interpret the data.

INTERVENTION PROCESS

The aim of occupational therapy is to enable the person with a disability to function more independently in his or her environment. This requires problem-solving methods to improve occupational performance.

INTERVENTION PLANNING: PROBLEM IDENTIFICATION, SOLUTION DEVELOPMENT, AND PLAN OF ACTION

The intervention plan is based on an analysis of the information accumulated during the evaluation. The initial step in developing the intervention plan is problem identification.

Solution development is the process of identifying alternatives form intervention and forming goals and objectives. Selecting a model of practice and frame of reference from which the OT practitioner operates is an important component of solution development. Several frames of reference are used in occupational therapy practice.

Based on the problems and the identified frame of reference along with input received from the client, the practitioner determines a plan of action for intervention (expected outcomes). The first step in developing a plan of action is the creation of long- and short-term goals that address the problems identified. These goals are prioritized according to the needs of the client. Next, intervention methods that will help the client achieve the goals are determined. This involves a consideration of the tools or equipment needed, any special positioning where the activity will take place, how it will be structured and graded and whether it to be performed in a group or individually. The intervention methods are based on the selected frame of reference. The practitioner uses his or her knowledge of the disability and the intervention to predict which methods will likely achieve the desired results as stated n the goals.

IMPLEMENTATION OF THE PLAN

Intervention involves working with the client through therapy to reach client goals. Five intervention approaches are used in occupational therapy: create/promote; establish restore; maintain; modify; and prevent.

Create/promote: The OT practitioner organizes an afternoon and writing group for school-aged children. The practitioner recommends the group the children in his or her caseload who have difficulty with handwriting.

Establish, restore: The OT practitioner works with Galen, a 67-year-old man who has lost use of his right side since is cerebral vascular accident. The clinician works to help Galen return to his typical morning routine.

Maintain: After performing a home visit, the OT practitioner makes recommendations so 90-year-old Harry can stay at home.

Modify; the OT practitioner provides 35-year-old Karen, who has cerebral palsy, with adapted feeding equipment so that she can feed herself.

Prevent: The OT practitioner explains proper lifting techniques to a group of workers at the blanket factory with the goal of preventing injuries.

The interaction between the practitioner and client is an essential element of therapy, and it requires informed decision-making. A therapeutic relationship should always have the interest of the client as its central concern.

INTERVENTION REVIEW

As intervention is implemented, the OT practitioner re-evaluates the client's progress in therapy.

The OT practitioner assesses the client during each treatment session by monitoring the impact of intervention and evaluating whether the activity has the desired therapeutic effect.

TRANSITION SERVICES

Transition services are the coordination or facilitation of services for the purpose of preparing the client for a change. Transition services may involve a change to a new functional level, life stage, program, or environment.

DISCONTINUATION OF SERVICES

The last step of the intervention process is the discontinuation of the client from occupational therapy services. The client is discharged from occupational therapy when he or she has reached the goals delineated in the intervention plan, when he or she has realized the maximum benefit of occupational therapy services, or when he or she does not wish to continue services. The discharge plan is developed and implemented to address the resources and supports that may be required upon discharge. The discharge plan includes recommendations for continued services (including occupational therapy, if necessary), equipment recommendations, and any therapy the client is required to follow after discharge. In addition, the plan may include training family members and caregivers.

OUTCOMES PROCESS

OT practitioners use outcome measures to determine whether goals have been met and to make decision regarding future intervention. Outcome measures provide objective feedback to the client and practitioner. Thus selecting measures that are valid, reliable, and appropriately sensitive to change is important. OT practitioners are interested in selecting measures early and using measures that may predict future outcomes.

OT practitioners are also interested in measuring occupational performance, client satisfaction, adaptation, quality or life, role competence, prevention, and health and wellness.