One way I have found to stay focused on occupation, meet Medicare requirements and stay true to OT when writing plans of care is to double-check the goals I have written to make certain that they are truly functional goals.
Functional goals are not simply goals that reflect changes in strength, range of motion or edema. They are goals that are written to specifically address one of the seven performance areas as described in the Occupational Therapy Practice Framework (OTPF). In other words, functional treatment goals (also known as long-term goals) will describe the ability of the client to ultimately engage in the specified performance area.
Just to review, the performance areas are: activities of daily living, instrumental activities of daily living, work, play, leisure, education and social participation. Imbedded within these seven areas are the many sub-components, including occupations such as bathing, dressing, attending school, feeding pets, typing, volunteering and meeting friends for lunch.
As any occupational therapist understands, injury or disease can interfere with the ability of the individual to fully participate in any one, if not all, of these areas. Hand pathology, either through injury, surgery or disease, is certainly no different. For example, a crush injury to the hand can cause long-term pain that will diminish interest in completing self-care tasks. The need to wear a dynamic extension splint can cause a senior citizen to be embarrassed and therefore opt to stay home in solitude instead of being active with friends. A traumatic amputation of the thumb can make it impossible for a high school student to keep up with classmates during note-taking. These are all functional implications of hand injury.
Despite the obvious link to hand health and full function, I continue to witness treatment goals in the hand therapy setting that are focused on components of function, which are described in the OTPF as client factors. Although client factors are one important area to treat in hand therapy, it is functional ability that should concern the OT practitioner in the end, not simply the ability of fingers to bend or squeeze.
There are several reasons why I challenge all hand therapy practitioners to reflect on their goal-writing style to ensure that they are writing function-based goals. First, Medicare (as an example of a third-party payer) is concerned with the functional gains made by clients in the performance areas described above. Medicare is not interested in things like decreased pain or edema because these entities are not specifically tied to any changes in the client's ability to independently function. Medicare is concerned with the ability of the client to stay healthy and vital through the ability to volunteer, wash and dress himself and participate in meaningful and relevant activities with others. In other words, Medicare promotes occupation-based treatment and functional goal writing.
Second, function-based goals keep the focus where it needs to be kept?in day-to-day treatment planning. A therapist is much more likely to ask a client how dressing is progressing when a dressing goal is present, versus asking that question when the goal states that client will place nine pegs in a nine-hole pegboard within 25 seconds.
Third, function-based goals speak to the profession of OT and keep us true to who we are; this is very important in current-day practice, where we are constantly being asked what makes us different and unique from other professions.
Fourth, what happens when a client has maxed out insurance coverage but has not reached that initially established grip-strength goal? How sad it is to write that an arbitrary pound of force was not obtained when, in fact, the client did improve significantly in his ability to engage in some or all of the performance areas. The OT could have taken pride in the functional achievements of the client and the client could have seen the benefits that the profession of OT brought him.
We must remember that some people will never return to their pre-injury state in regard to what their hands can do. Regardless of that, we must always help to get them back to their pre-injury functional level. Even if the hand is not working as it did, adaptations/modifications and alternate techniques can return someone to his life.
As with all treatment goals, function-based goals require the basics of good goal writing. Goals should be measurable, have a subject, a desired action and a date of completion. Many sources are available on the market that provide instruction on how to write a good goal. Some sources give many examples of functionally written goals; others do not. The following are two examples of function-based goals that may appear in a hand therapy chart:
Client will consistently demonstrate the ability to take notes in high school classes at rate of speed comparable to peers using prosthetic device by 10-10-07.
Client will independently dress upper and lower extremities, within a self-reported satisfactory amount of time, including all fastenings/closures, within four weeks.
Debbie Amini, MEd, OTR/L, CHT, is director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC. A 1983 graduate of Quinnipiac University, Hamden, CT, she has been a clinical hand therapist for 19 years. Readers may reach her at 910-362-7096, by e-mail at firstname.lastname@example.org or through ADVANCE at email@example.com.