Evaluating Occupational Performance
To Determine Intervention
By Jill Diffendal
Talk of returning to occupation-based practice is in no short supply in the profession. But when therapists ask how they can achieve this, answers seem to be few and far between. Keeping occupation as the basis of practice needs to be done from the minute a patient walks in your door. Starting with an occupation-centered assessment is the first and perhaps most important step.
Assessments OTs are accustomed to using measure all kinds of things. Some evaluate motor control; others are concerned with
cognitive ability. Most, however, deal with performance components and rate the success or failure of intervention based on improvements in specific deficiency areas. But this focus on impairments strays from the OT philosophy of treating the whole person and enabling him or her to return to valued occupations.
"If the focus of occupational therapy is on the ability of people to do occupations within the environments in which they live, then the assessments by which we measure the success of our intervention need to reflect that," says Mary Law, PhD, OT(C). Dr. Law is a professor at the School of Rehabilitation Science and co-director of CanChild, the center for childhood disability research at McMaster University in Hamilton, Ontario.
Dr. Law was involved in creating the Canadian Occupational Performance Measure (COPM). She and her group wanted to create a measure for all areas of OT for clients of all ages and diagnoses that would truly reflect the concerns of the patient.
The COPM actually reflects a client's self-perception of his or her occupational performance, by which the patient can identify specific problems associated with various daily activities. The COPM uses a standard scoring method, but the occupational performance problems identified by each client are individual to the person. First published in 1991, the COPM has been translated into 11 languages and is used in 25 countries.
According to Wendy Coster, PhD, OTR/L, occupation-based assessment is important to OT . "Unless we have tools that are congruent with this 'whole-person-in-context' approach, we cannot gather information in a way that supports meaningful, occupation-based intervention. We fall back on instruments that were designed to 'diagnose' disorder or delay, and that often gives a distorted picture of what the (patient) can actually do."
Dr. Coster, associate professor and chair of the department of occupational therapy at Sargent College of Health and Rehabilitation Sciences at Boston University, worked to create the School Function Assessment (SFA), a tool to measure a child's abilities to fulfill his or her roles in a school environment. One of the few pediatric occupation-based assessments, the SFA was designed to "focus first on the extent to which students with disabilities are achieving meaningful participation in their school programs-- including their ability to undertake the tasks and activities that are part of the everyday expectations of 'being a student' in elementary school," she explained.
Occupation-centered assessments such as the COPM and the SFA reflect why the client is receiving OT services. OTs main goal is not to increase range of motion or hand grip strength, but to help a client to be able to go swimming or comb her hair. "If you are not using an occupation-based assessment, then both the client and the therapist don't have an accurate sense of whether intervention is going to make a difference in their daily life," Dr. Law explains.
Research has shown that there is no direct relationship between changes in impairments and changes in occupational performance. "We may focus on the impairments that are the most obvious on the tests," says Dr. Coster, "but they may not be the factors most limiting the child's engagement in meaningful occupations in school."
Some therapists avoid such occupation-centered assessments because they take more time, and in today's professional environment time is a luxury. Yet these assessments can provide what therapists most need in current practice. The assessment itself may take a little longer, but it can save time in the long run because OT intervention is much more focused. It also can provide information and data about whether or not intervention has been effective.
Reimbursers often expect information on impairments, but therapists must remember what exactly it is that they provide to clients. The goal of OT is to help a client to do the occupations that he or she wants to do. With assessments that show improvements in occupational performance, reimbursers have evidence that occupation-based therapy really works.
Therapists are often unaware of all measures that are available, and once they find an assessment, they cannot be sure of its effectiveness or reliability. For this reason, Law and some of her colleagues are currently creating educational software for outcomes measurements to be published this year. The conceptual framework comes from the World Health Organization's International Classification of Impairments, Disabilities and Handicaps (1980).
OTs are asked questions pertaining to a specific client: what they want to measure, what they want to have an impact on, as well as factors such as age and where the assessment will be done. The software has a database of tools, each of which has been critically reviewed by the researchers. The program will tell the OT which assessments can be used, their reliability and where they can be obtained. The researchers found the software twice as effective and twice as fast as searching in a library.
"There is a great tendency to try to assess everything, which leads to assessments which aren't necessary," Dr. Law observed. "If our use of assessments is more focused and more purposeful in the sense of first identifying occupational performance issues and then identifying the reasons why the person is having problems with those issues, then it saves time and will enable us to measure out outcomes better." As Dr. Law tells her students, "You'll never go wrong if you start and end with occupational performance." *
Jill Diffendal is an ADVANCE editorial assistant.