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OT Process and Intervention

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Occupational Therapy Process


The provision of occupational therapy services follows a specific sequence of
steps.

Step in the Process Description Who is Involved Points to Consider
Altruism Patients are referred to occupational therapy by a variety of sources, including family members, caregivers, physicians, health care centers, employers, etc.
–Occupational therapists cannot work with any patient because the patient may have a therapeutic need; patients must be referred.
–The rules and regulations regarding occupational therapy referrals vary from state to state.		 Anyone can refer a patient to occupational therapy, including the patient. Occupational therapy services cannot be provided, however, without an evaluation. A prescription, also called an order, for an evaluation must be issued by the patient’s physician (including medical doctor, doctor of osteopathy, psychiatrist, or other holding a medical degree), nurse practitioner (subject to state law), chiropractor, or dentist.

–Physician’s orders for occupational therapy are required in most states and by most insurance providers.
–An evaluation may be allowed without physician’s orders, but the occupational therapy treatment plan must be approved by the physician.
–Public schools might not require a physician’s order for occupational therapy, depending on the regulations in each state.

 Therapists can also refer to other therapeutic practitioners.
-Visual acuity issues=refer to the optometrist
-Eye disorders= refer to the ophthalmologist
-Not following dietary recommendations=refer to the dietician
-Speech delay=refer to the speech language pathologist
-Gait disorders=refer to the physical therapist.A referral can be very specific such as asking for a neoprene splint or general by asking to test for a developmental delay.
Screening After the referral, the occupational therapist needs to screen the patient in order to determine if an evaluation is needed. A screening is used to obtain preliminary information of the patient’s situation. The occupational therapist oroccupational therapy assistant may complete observation of the patient, checklists, and medical record review.
–The occupational therapist may also use a quick screening tool such as the ACL. 		Occupational therapists should discuss the patient’s status with other health care providers and with the patient’s family before pursuing an evaluation.

Screening usually occurs before a physician’s order is issued.
Before conducting a screening, the OT should summarize the benefits and reasons for administering the type of screening tool.
If the patient does not want to answer the questions from a questionnaire then the OT must acknowledge the view of the caregiver and transition to asking informal interview questions. You cannot document the results of the screening tool if the caregiver does not complete it.
Evaluation
An occupational therapist can use a standardized assessment such as the Peabody Developmental Motor Scales, Functional Independence Measure (FIM), or the Sensory Profile. If a standardized assessment is used, then the therapist needs to follow the assessment word for word and step by step.
-Criterion referenced assessment: the patient’s scores on the assessment are compared to predetermined criteria or standards. The Functional Independence Measure (FIM) is an example of a criterion referenced assessment.
-Norm referenced assessment: the patient’s scores on the assessment are compared to a set of normative data that compares the patient to the population from which the data was gathered. This population is usually comparable in age and gender to the patient. The Peabody Developmental Motor Scales is an example of a norm referenced assessment.		 The occupational therapist completes the evaluation, including administering evaluation tools, scoring the results, and writing the evaluation report.
–The occupational therapy assistant may assist with the evaluation by completing those portions of the assessments that he or she has been trained to administer under the supervision of the occupational therapist.		 Therapists should consider any language or cultural barriers prior to or while conducting an evaluation. For example, if the therapist has an accent that is different from the patient’s and the patient cannot understand verbal directions due to the therapist’s accent, the therapist should arrange for an alternate means of communication, such as written instructions or asking another staff member to act as an interpreter.
Intervention Intervention is provided based on 4 levels. These levels will be discussed in a separate chart. See below. The occupational therapist or occupational therapy assistant may provide intervention. The occupational therapy assistant is supervised by the occupational therapist based on the occupational therapy assistant’s experience, complications that may arise during intervention, and any pertinent rules, regulations and insurance requirements. An occupational therapy aide may not provide occupational therapy intervention. An occupational therapy aide may assist the occupational therapist or occupational therapy assistant in providing portions of the intervention under close supervision. Occupational therapy aides should be trained in providing portions of intervention before assisting therapists with patients.
When designing a program, the OT needs to research relevant literature to support the process of evidence-based decision-making.
Discharge The patient is discharged from occupational therapy services when goals are met, when progress has plateaued, or when the patient’s medical condition changes and the patient is unable to tolerate occupational therapy services.
–Planning for discontinuation of services begins at the evaluation.		 The occupational therapist recommends discharge from occupational therapy services to the referring physician, who approves the dismissal.

–In the public schools, the occupational therapist recommends dismissal to the IEP team, who must agree with the recommendation.		 Discharge from occupational therapy services may be dictated by the patient’s insurance company and the limits on the amount of occupational therapy that is allowed by the patient’s policy.
Occupational therapy assistants may give the occupational therapist input regarding the discharge of patients but may not recommend discharge themselves.

Practice Questions About the OT Process

Name the part of the service delivery process that applies to each situation:

  • 1. A manufacturing company consults with an OT about the increased number of back injuries among the employees. The
    company wants all employees in identified jobs to be trained in injury prevention.
  • 2. The OT works with a person following a myocardial infarction in an outpatient clinic three times weekly for
    strengthening to improve work related skills.
  • 3. A 30-year-old woman with a brain stem CVA presents for a wheelchair assessment with her mother. She independently
    uses an augmentative communication device. She has been seated in a manual wheelchair for 5 years and is dependent on
    her aging mother and father for all mobility and activities. During the assessment, the mother informs the OT that she is
    not ready for her daughter to regain independence.
  • 4. An inpatient who has borderline personality disorder has been hospitalized due to an exacerbation of suicidal and self-
    mutilating behavior. An initial evaluation has been completed and it indicates that the patient is functioning at AllenCognitive level V (exploratory actions). The patient reports being overwhelmed by a new personal relationship,
    experiencing job dissatisfaction, and feeling a lack of control in many daily situations.
  • 5. An individual with chronic undifferentiated schizophrenia is referred to a day hospital. The referring psychiatrist notes
    that the patient’s positive symptoms have responded well to a new medication, but the negative symptoms remain.
  • 6. An OT is evaluating a patient who has an ulnar nerve injury at the wrist level of the right dominant extremity.
  • 7. A therapist has just received a referral for a resting hand splint. The therapist is in the process of determining the need
    for an in-depth evaluation.

Answers:
1. Screening
2. Intervention
3. Evaluation
4. Intervention
5. Screening
6. Evaluation
7. Screening

OCCUPATIONAL THERAPY INTERVENTION

The Four Levels of Intervention


Intervention is adjusted based on a patient’s needs, but usually aligns with one of 4 levels

Level Description Examples Photo
Adjunctive This may be the initial step in the intervention process in order to prepare the patient for occupational performance. These methods are often used to prepare the patient for meaningful activities and are often used in the acute care setting. Education, physical agent modalities, and resources are used at this level.
 A customized exercise pamphlet with stretches and strengthening exercise that the patient can do at home 1-2 times every day.
Providing electrotherapeutic agents to improve muscle strength, modulate pain, and relax targeted muscles with other physical agent modalities
Educating the patient on ways to prevent pain by including exercise, diet, sleep, and stress avoidance into their daily life
Teaching relaxation, breathing, mediation, and coping techniques
Providing the patient with community resources, workshops, and associations so the client can have access to a support system
Verifying whether the patient was provided with the right wheelchair for the right purpose
Enabling Activities These are exercises or ways to condition the body in order to get to the patient’s end goal.

-Together the occupational therapist and the patient can work on range of motion, muscle conditioning, schedules, pacing activities, coping strategies, time management, and medication management.

 Practicing exercise techniques such as stretching and
strengthening with an elastic band or with other types of adaptive equipment, such as a reaching stick, in order for the patient to do his or her morning grooming routine.
The patient can write in a daily journal to document performance, accidents, injuries, and emotions
Purposeful Activities
These activities have a relevant goal and are meaningful to the patient.
The performance of purposeful activities includes compensatory strategies and adaptations to facilitate a patient’s involvement in activities.
–Compensatory strategies: Techniques that allow patients to do things in a different way.
Compensatory strategies do not usually involve equipment, technology, or modifications to the environment.
–Adaptations: Adaptations include the use of adaptive equipment, assistive technology, and environmental modifications to compensate for a patient’s limitations. 		Practicing gardening techniques with adaptive equipment in the therapy clinic to work toward a goal of returning to gardening at home.
Work tabletop practice activities, practice boards, simulators, driving simulators, and hooks for mastering dressing along with methods that stimulate the activity.
Equipment such as wheelchairs, communication devices, environmental control objects, and other ambulatory aids.
Practicing feeding, dressing, mobility, communication, art, sports, with the therapist in the clinic or hospital.
Practicing combing hair with a universal cuff
Compensatory strategies examples:
A woman with a diagnosis of COPD sits at the kitchen table to chop vegetables for dinner rather than standing at the counter to conserve energy.
A woman with a diagnosis of left above elbow amputation holds a jar of pickles between his knees and uses his remaining hand to open the jar.
A woman with a diagnosis of rheumatoid arthritis keeps her commonly used dishes on the kitchen countertop instead of the upper cupboards due to her limited shoulder range of motion.
Examples of Adaptations: A teenage boy with a diagnosis of advanced muscular dystrophy uses a head pointer to type on a computer keyboard since he cannot use his hands to type.
A woman with a diagnosis of Parkinson’s Disease has a walk-in shower installed in her bathroom as she is unable to lift her legs to step over the side of her bathtub.
A man with a diagnosis of glaucoma uses a talking clock to help him tell the time.
Occupation-Based Activity
Interventions at this level include client centered activities and goals. The therapist’s involvement begins to decrease as the client performs ADLs, IADLs, play, and leisure to his or her own maximum capacity. 		A patient cooks eggs for her kids in their home. A patient plays softball in the community with a friend.

Intervention Approaches

5 Intervention Approaches


Table reference: Pendleton, Heidi McHugh. Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti)) (p. 125). Elsevier Health Sciences. Kindle Edition.
The unique role of the OT is to contribute to the patient’s care plan and the rehabilitation process, by establishing a method that assists the patient to reach a state of physical, mental, and social wellbeing, to identify and attain their aspirations, to satisfy their personal needs, and to change or cope with their environment.
Each patient’s intervention plan is formulated using selected theories, frames of reference, practice models, and evidence. This process is directed by the patient’s goals, values, beliefs, and occupational needs, and is based on the patient’s goals and priorities. Establishment of the intervention plan is a collaborative effort between the therapist and the patient or, if the patient is unable to collaborate, the patient’s family or caregivers.
Summary of Intervention Approaches
1. Health promotion and wellness to enable or enhance performance in everyday life activities.
2. Establishment, remediation, or restoration of a skill or ability that has not yet developed or is impaired.
3. Maintenance and enhancement of capabilities without which performance in everyday life activities would decline.
4. Compensation, modification, or adaptation of activity or environment to enhance performance.
5. Prevention of barriers to performance, including disability prevention.

Focus on the Intervention Approach of Modification, Adaptation and Compensation

In a remediation approach, intervention is targeted towards improving performance components, with the assumption that such improvements will lead to enhanced occupational performance.
If a patient’s previous abilities cannot be restored, utilizing an adaptive or compensatory approach can promote participation in occupations. This approach focuses on the patient’s remaining abilities and aims to improve function by compensating for deficits in performance components. Ultimately, optimal occupational performance is achieved through successful adaptation.
OTs view individuals to be independent whether they perform the component activities by themselves, perform the occupation in an adapted or modified environment, use various devices or alternative strategies. The OT facilitates the achievement of occupational performance goals by finding ways to revise the current context or activity demands to
support performance.
Including:
• Modifying or adapting tasks, activities and environments
• Using assistive devices to maximize function and compensate for lost function
• Using compensatory strategies

Adaptations

In simple terms, an adaptation makes performing an activity easier. An adaptation is a change in the structure, function, or form of the activity to promote a better adjustment to the environment in which the patient lives. Adaptation may involve changing the tool or the technique used to complete a task. It is important to note that, although adapting may involve making changes to an activity to make the task possible for a patient according to their abilities, adaptation does not change the outcome of the activity. The manner of how the activity is accomplished, is purposefully altered to make it achievable for the patient.
Adaptations may require:
– Restructuring of the physical environment to assist occupational performance.
– Changing the technique used to perform an activity.
– Modifying or substituting objects used in performing an activity to make it easier to complete.
– Using adaptive equipment, assistive technology, and environmental modifications to compensate.

Examples of Adaptations:
• Applying Velcro to replace shoelaces
• Listening to music to filter out certain stimuli while working
• Putting different textured surfaces onto individual keys to aid in finding the correct one
• Adapting working conditions- physical space and lighting to maximize productivity
• Adjusting the height of the table to improve posture
• Assistive devices such as basic a long-handled sponge for bathing.
• Adapting a wheelchair for a respiratory unit
• Recommending environmental adaptations to assist with physical, perceptual, and cognitive functioning, such as labeling cupboards and drawers, or using lighting to improve vision and/or attention to task

Providing assistive devices is an important element of OT intervention to support the patient’s performance and increase their participation in their occupations. Assistive devices are classified as adaptive equipment as the patient requires the assistance of an external device (assistive device or aid) to be independent in their occupations. i.e.: The patient is Modified Independent. If the assistive technology acquired does not match the skills and abilities of the patient, the OT then adapts them accordingly.

Modifications

Types of Environmental Modifications
1. Changes to the Physical Environment
• Modify the layout (remove a door to make the opening wider)
• Provide adaptive equipment (a tub bench)
• Architectural modifications (provide a ramp, bathroom modifications)
2. Modification of the Occupation (modify behavior)
• Education about how to use the environment in a different way (always turn on lights before entering a room for an individual who has low vision)
• Use everyday items to achieve goals (always carry a mobile phone to call for help if needed)
Examples of Modifications
• In a work environment, the OT can modify the way that the worker performs the work or modify the work environment to allow the worker to perform optimally.
• Home Modifications: The main goal of home modifications is maximizing safety and independence in the home. This involves reviewing aspects of the home that may require modification to facilitate performance and making changes to adapt living spaces to increase usage, safety, security, and independence. It includes recommendations for alterations, adjustments, or additions to the home environment through the use of specialized, customized, off-the-shelf, or universally designed technologies; low- or high-tech equipment, furnishings; and other features that affect the layout and structure of the home. Common home modifications include increasing lighting with nightlights or increased light bulb wattage, replacing faucets and door knobs with levers, installing non-skid materials in bathing areas and on stairs, adding handrails or grab bars, widening doorways, and adding ramps.
• To make a bathroom accessible for a patient in a wheelchair, the bathroom can be modified to allow independence with BADLs.
• A patient who has been diagnosed with a progressive disease will experience a decline in their ability to function independently. As the disease progresses, there is a greater need for environmental support such as durable medical equipment, modifications to the home, and adaptive equipment.
• Recommending modifying a patient’s diet in terms of changing the texture if they have difficulty swallowing thin liquids.

Compensation

Determining new ways of accomplishing an activity. Finding strategies/techniques or using specially adapted tools that
work around the patient’s limitations. In comparison to adaptation which involves altering the setting or demands of a task
to facilitate performance. Compensatory strategies do not usually involve equipment, technology, or modifications to the
environment.
Examples of Compensatory Techniques/Strategies
• Teaching a patient who presents with muscle weakness in their shoulders how to use a compensatory technique of propping their elbows and bringing their hand to their mouth when eating.
• Fatigue management or energy conservation techniques for COPD
• Teaching hemi-dressing techniques (dressing affected side of body first, using adaptive dressing aids such as a button hook)
• Techniques for completing tasks with functional use of one hand (for example, using a dycem mat to stabilize a mixing bowl while breaking an egg into the bowl with one hand)
• Using a daily planner or reminder functions on mobile phones to compensate for poor memory
• Shopping during quieter supermarket hours to manage social anxiety
• A patient with COPD sits at the kitchen table to chop vegetables for dinner rather than standing at the counter to conserve energy.
• A patient with a left above elbow amputation holds a jar of pickles between his knees and uses his right hand to open the jar.
SUMMARY

Adaptation = Add
Modification = Change
Compensation = Use what the patient has available/use the strengths the patient already
possesses

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