Experience has shown that one of the most difficult tasks for the occupation-based OT/hand therapist is to write treatment goals that reflect function yet are measurable enough to denote subtle improvements in targeted client factor areas.
Third-party payers are interested in seeing functional change; physicians and therapists want to see specific change; and all demand that outcomes ultimately enhance the life of the client.
In order to assist with the critical thinking associated with this task, I have created what I call "The Test of Occupation Based Goal Writing." This "test" is basically a three-step process in which the therapist reflects on certain points while creating the treatment plan. Therapists who write occupation-based goals will note that selection of relevant occupation-based tasks is much easier when the expected outcome is performance based.
The first step in writing occupation-based goals is to be able to articulate the difference between client factors and performance areas. Those who are becoming more familiar with the OT Practice Framework (OTPF) will recall the seven performance areas that define the domain of OT. These are: ADL, IADL, Work, Leisure, Play, Education and Social Participation. Client factors are defined as body functions and structures-pieces of the puzzle, yet not definitions of function. These include ROM, strength, endurance, wound status, tone, to name a few.
Long-term goals (LTGs) should always be reflective of performance area outcomes. For example, a client with a wrist fracture may not be able to care for her pets. Pet care is an IADL that can become the LTG: "Client will demonstrate the ability to independently complete all desired IADL within the home upon all attempts."
Short-term goals should always reflect a more specific occupation within the performance area. In the case of pet care: "Client will consistently demonstrate the ability to open cans of cat food for independent pet care."
Step one: After writing a goal (short or long term), ask yourself this question: "Can the outcome of this goal be linked to all performance areas, or is the outcome specific to one performance area?"
Step two: If you answered that your goal is applicable to all performance areas, then it is most likely a client-factor goal; this is not desirable. For example, increasing ROM is a necessary outcome that is part of all performance areas. It is therefore not measurable as an occupation-based performance outcome.
If you answer that your goal is only applicable to one or possibly two performance areas, then it is likely occupation-based. For example, opening cans of pet food is a component of the IADL "pet care." It can be measured based upon the ability of the client to complete or not complete that task. This is a desirable occupation/performance based goal.
Step three: Test the telescope effect, an additional measure of occupation-based goal writing. Ask yourself these questions: "Does the activity that I have chosen specifically address the STG?"; "Upon completion, will the skills achieved in the STG improve the ability of the client to engage in the LTG?" If you answer yes to these questions, then you have been successful. If goals and activities do not flow, try again.
Create activities that can be easily linked to the expected short and long term outcomes. Ensure that the client is well aware of how the activity is going to help them return to the things that are important to them. For example, the homework activity for this client may be to practice opening all types of cans using an electric can opener. An inability to consistently hold the can, place it in the device and push down the lever will result in initial difficulty with this task. Day-to-day repeated practice will create adaptation and improved hand movement; very soon the client will be able to feed the cat.
Appease the need to write client factor outcomes through the addition of "behavioral objectives," a means by which the hand therapist can monitor client factors to note specific body structure changes. Identifying these more rapidly evolving changes in body movement, strength and etc. will satisfy the needs of the physician as well as the therapist in knowing that the day to day use of modalities, exercise and occupationbased activity is effective. An example of a behavioral objective attached to the STG above: "Client will demonstrate full active flexion of MCP joints all digits of affected left hand."
Add the behavioral objective to the telescope test. Will clay pot making and can opening practice work the MCPs of the affected hand? Yes. Will full active MCP flexion enable cat food can opening? Yes. Will cat food can opening create independence in the IADL of pet care? Yes. Is the client aware of this correlation? Yes.
Congratulations, you are a true OT and have created a true occupation-based treatment plan.
Deborah Amini, MEd, OTR/L, CHT, is director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC. Readers may reach her at email@example.com. or through ADVANCE at firstname.lastname@example.org.