Health care is changing, there is no doubt about it. I received my copy of American Journal of Occupational Therapy [AJOT] today. One of the first articles in this issue referred to P4 Medicine and Pediatric Occupational Therapy. According to this article (AJOT 2013), the occupational therapy profession will need to survive the increasing scrutiny of regulators and funders to continue to provide services within these new and already existing models of care. As we know, there have been those “Ah Ha” moments when you, an OT, find out that physical therapists [PTs] have been working on Activities of Daily Living with patients. My local hospital considers itself a “Stroke Center” and guess what? There is not an occupational therapist on the staff! We really do need to step up and create a standardization of documentation that demonstrates our vast body of knowledge under the Occupation Therapy Framework: Domain and Process, showing what we do using our best critical thinking, clinical reasoning and clinical judgement.
Whether or not you have purchased or read my book, “Using Rubrics to Monitor Outcomes in Occupational Therapy,” our own professional organization is calling for us to collect and analyze good clinical data so that we will not become shark bait for professions that can potentially swallow us whole [PT and Psychology]. I know that moving toward clinical data collection is difficult for some and others adapt to it easily. Adapt we must, clearly and efficiently.
In my opinion, evaluation or summative data, needs to be standardized by our profession. We must set up a system of data collection that evaluates the patient’s current status. The FIM certainly attempts to follow this model but, in my opinion, we need to do better. Even G-Codes, do not provide enough data collection, G-codes appear to be summative data as it is typically not meant to be modified in such a way to collect information on a patient’s progress with a therapist. Formative data, collected during therapy sessions, collects data on a patient’s progress with a therapist and is modified to meet the needs of the patient. One of my most recent blogs referred to using rubrics in all practice areas, it explored the use of a rubric developed from a handout provided to patients in a rehab setting. So the rubric matched the handout which is the initial expectation of a therapist providing care. So if we consider that a patient with a CVA, a.k.a. stroke, may have difficulty with hand function, we should then be adapting this assessment or summative rubric to collect and monitor treatment provided to the patient. Once the rubric has been modified to address the patient’s hand function, it then collects formative data. The modifications made to the rubric are based on our critical thinking, clinical reasoning and clinical judgement skills. Our ability to make the appropriate modifications and develop the structure to collect clinical data is a tool by which we may be judged.
Several of the articles in this journal also suggested implications for further research. Using a standardized rubric, each of the participants can be assessed and re-assessed throughout the study. Assessment of the treatment modality can be assessed using a standard rubic that follows a protocol developed for that modality by a facility. Again, let’s look at the one-handed method of putting on socks assuming that the patient wants to put his socks on independently. The typical adult will receive a score of 3 in all criteria [that is typically the acceptable norm for all rubrics]. A score of 4 in all areas indicates that the patient does not have any problems and can perform the task in 5/5 trials. For arguments sake, let’s say that the patient scores 1 in the criteria for dynamic sitting. You would modify the assessment rubric to focus in on dynamic sitting balance. Using a newly developed patient centered rubric following the protocol set by the rehab center, you work on dynamic sitting until the patient scores 3-4 for that criterion. Then the patient is reassessed using the standard protocol for putting on socks using one hand. This continues until the patient is successful [achieving a score of 3 for all criteria]. Each time, you are collecting clinical data. Each time, you are working toward the patient centered goal of putting on socks independently. This rubric [or modified rubric] can be shared and discussed with a secondary therapist [rater], the patient and possibly his family. This method of collecting clinical data, involves the patient in his goal progress [and possibly family], meeting the needs desired by the patient, and can eventually lead to a perspective on the patient’s function and participation in self-care tasks.
There is one more important point to consider. The graphic shows an arrow with the year 2015 highlighted pointing to a box that states, “Eligible providers paid according to the quality of care.” Something to think about.
Eleanor Cawley, MS, OT 