Chris and others, What follows is a long reply to a message that Chris N. wrote awhile back. I generally don't like the format that I used, but I don't want to take the time to make a more "formal" looking message.
Thanks, Ron -- Ron Carson MHS, OT www.OTnow.com ----- Original Message ----- From: cmnahrw...@aol.com <cmnahrw...@aol.com> Sent: Saturday, February 21, 2009 To: OTlist@OTnow.com <OTlist@OTnow.com> Subj: [OTlist] Occupation as THE goal: Does it matter cac> Seems like in your example of occupation that the UE is left out of the cac> equation, although through some improvement it can lead to improvements cac> in the patient's personal goals of occupation. Then I guess a PT improving UE function is also helping the patient engage in occupation, right? Also, there is nothing supporting the concept that improving the UE can lead to improvement in occupation. Your statement is strictly hypothetical. Improving UE function may or may not lead to improved occupation. And if it doesn't then there's been no improvement in occupation, so what has been done? cac> Just because there is no function in the flaccid UE does not mean cac> there will not be any improvement 6 months down the road, cac> especially with intentional focus on the issue. Any goal that takes 6 months is not a reasonable goal. cac> I can make the UE cac> treatment focus on occupation just like you state, but it will take cac> much longer. Instead of writing patient will improve AROM by 30 cac> degrees in order to assist with self feeding I can simply write cac> patient will reach for a glass of water from table using his cac> involved arm. Reaching for a glass of water is not occupation. You are contriving occupation to fit your treatment agenda. cac> The problem is it might take 6 months to a year to cac> achieve this occupationally written goal, but it only might take cac> 2-3 months to show 30 degrees of progress if the patient has good cac> rehab potential in arm function. I consider rehab of arm function to be PT, regardless if it's a PT or OT doing the rehab. I have a patient who has spent countless hours doing mindless exercises on his flaccid UE. It hasn't helped ANY and his previous OT wasted a lot of valuable time acting like a PT and working on his arm. In my opinion, the PT should have addressed the mans' arm and the OT should have been working on improving his occupational performance. cac> The structure of insurance cac> re-imbursement is set up on showing immediate progress, otherwise cac> we are told to DC a patient or set more achievable goals. There is nothing in Medicare guidelines requiring immediate progress. Progress is REQUIRED, and should be, but there is no specific requirement that it be immediate. Goals must be achievable in a reasonable period of time, but that time is not spelled out. cac> Even though we as neuro OTs might wright goals that focus on body cac> impairments, it does not mean that we are not looking at cac> occupation. Focusing on body impairment does not exclude occupation, it simply places it in hind-sight. And honestly, PT does the same thing. Of course, they call it function, not occupation. cac> It only means that we want to continue to work with the cac> patient that has the potential of using their arm in occuation cac> again, but unfortunately we need to be able to document cac> improvements relatively quickly for insurance to foot the bill. If improvement in arm function yields improvement in occupation, then you should be able to document occupational gains. cac> This sytem of billing does not match up with the natural cac> progression of improvement in a patient's arm after a stroke.The cac> road to recovery for a stroke patient's flaccid arm is a long and cac> painful one, in which sometimes the road does not lead to a cac> positive outcome. How can we justify seeing them for an entire cac> year, and then finally one day we state that the patient is not cac> appropriate for OT any longer. And this is why we need to focus on occupation. If occupation is the goal then it is 100% clear when the goal has been achieved. Of course, occupational goals are often not achieved but then it's an issue of lack of progress. cac> There needs to be incremental steps along the way to occupation cac> showing that the patient is making progress towards that goals that cac> we predicted would eventually be achievable. Yes, ALL therapy improvement is incremental. A PT doing range of motion on rotator cuff repairs yields incrmental changes over time. An OT doing occupational therapy also yield incremental chnages over time. cac> And let me tell you, when that area of occupatiion is finally cac> achieved after such time and effort from the therapist and patient, cac> there is not greater feeling in OT. I wish we could see them for an cac> entire year, following one occuaptionally based goal and not having cac> to worry about the measurements of tone, strength, ROM, cac> coordination, but with the system that we bill under now, we have cac> to follow the rules. Medicare doesn't care about measurments of tone, strength, ROM, etc. They care about patient's being able to take care of themsleves in a safe and effective manner. cac> Your examples of training in sit to stands, balance retraining, cac> functional transfers are on the mark of occupation. However these cac> areas of impairment are often easier to demonstrate improvements in cac> occupation simply showing the assist level of improvement (patient cac> inproved from a total assist to a supervision when toileting). These cac> areas of occupation are more certainly easier to treat in the timeframe cac> we are given to show progress. You are 100% wrong in your assertion. I've done it both ways and I can assure you that treating occupation is infinently more difficult than treating a body part. cac> The area of impairment involving the cac> flaccid UE is much more complex and difficult to show immediate cac> progress. It is impossible to write goals that focus on occupation cac> because it would be impossilbe to show incremental progress on the cac> actual occupation when the patient wants to incorporate he flaccid arm cac> into occuaption again. No occupational goals = no occupational therapy. If the patient's focus is no improving arm function then I say send them to PT. OT's don't focus treatment on spine, knees, pelvis, ankles, etc. so what is the philopsophical basis for treating an UE? There isn't any. cac> If the patient is a total assistance with reaching for a glass of cac> water using the hemi arm, it would be impossible to demonstrate in cac> a months time that the patient is at a maximal assistance, cac> moderate, or minimal assistance for the task while using the hemi cac> arm. The assist levels do not quantify the small incremental cac> improvement. If small incremental changes do not yield changes in occupation, they who cares. What possible difference does it make if a patient regains 30 degress elbow flexion if he stil requires assistance with dressing, wiping his butt, getting on/off toilet, in/out of chairs, driving, etc. cac> I can certainly document that the patient is using their arm more cac> duing occupation through the use of activity journals, or cac> subjective surveys that the patient fills out based on their cac> perceptions, but it is near impossible to visually recognize that a cac> patient improved from a total assistance to a maximal assist with cac> the reaching task, because of the limitations of the assist level cac> scales. Again, a reaching task is not occupation. It's exactly that, a task! cac> It is much more quantifiable to use standardized scales cac> that focus on body impairments like the dynamomenter, goniometer, cac> Motor Assessement scales, Wolf Activity Scales, Modified Ashworth cac> Scale, and the like to show these small incremental scales of cac> progress required for changes in the patient's occupational goals. cac> Chris Nahrwold MS, OTR. cac> -----Original Message----- cac> From: Ron Carson <rdcar...@otnow.com> cac> To: cmnahrw...@aol.com <OTlist@OTnow.com> cac> Sent: Sat, 21 Feb 2009 5:19 am cac> Subject: Re: [OTlist] Occupation as THE goal: Does it matter cac> Chris, after thinking about your question, I conclude that the best I cac> can offer is a hypothetical situation. So, here goes.... cac> Take my patient today. A CVA patient. He has a flaccid UE with no cac> functional use. He requires assist for sit/stand and ambulates with a cac> quad cane with supervision. cac> IF the goal is improving the occupation of self-care to the cac> supervision/setup level, treatment might look like this: cac> Therapeutic activity to include: sit/stand and transfer cac> training. Balance training without UE support. Hemi dressing cac> techniques training cac> IF the goal is improving UE ROM to increase ability to perform self-care cac> with supervision/setup, the treatment might look like this: cac> Therapeutic exercise to the affected UE. Self-care training in cac> hemi-dressing. cac> ================================================================= cac> For the record, the patient verbalized mixed goals. Of course he said he cac> wants to get his arm working but he also wants to reduce the strain on cac> his wife by increasing his ability to sit/stand without assistance from cac> her. cac> Look forward to feedback and comments from you and EVERYONE else! In my cac> opinion, the issues and topics being discussed are too important to not cac> be involved! <smile> cac> Ron cac> ----- Original Message ----- cac> From: cmnahrw...@aol.com <cmnahrw...@aol.com> cac> Sent: Monday, February 16, 2009 cac> To: OTlist@OTnow.com <OTlist@OTnow.com> cac> Subj: [OTlist] Occupation as THE goal: Does it matter cac>> Ron, cac>> Great outline.? Can you next explain how the treatment will differ? cac>> Chris cac>> -----Original Message----- cac>> From: Ron Carson <rdcar...@otnow.com> cac>> To: OTlist@OTnow.com cac>> Sent: Mon, 16 Feb 2009 7:52 am cac>> Subject: [OTlist] Occupation as THE goal: Does it matter cac>> Hello All: cac>> What follows are thoughts and opinion about using occupation as cac> *THE* cac>> goal for OT treatment. cac>> Here's is the premise for my arguments: cac>> (1) When occupation is *THE* goal, outcome statements may be cac> written in cac>> concise occupation-based outcomes. For example: cac>> Patient will safely and independently ambulate to/from cac> toilet cac>> with RW and perform all hygiene without assistive cac> equipment. cac>> Patient will transfer from w/c to bed using slide cac> board cac>> transfers cac>> Patient will dress self using adaptive equipment as cac> necessary cac>> (2) Conversely, when occupation is not *THE* goal, outcomes cac> may be cac>> written so that occupation is a desired outcome but is cac> based on cac>> improving underlying impairment(s). For example: cac>> Patient will increase UE elbow ROM to 115 degree active cac> flexion cac>> to all for donning/doffing of shirt cac>> Patient will increase standing endurance/balance to cac> allow them cac>> to safely and independently carry out toileting hygiene. cac>> cac> -------------------------------------------------------------------- cac>> Some argue there is little difference in the above approaches. cac> However, cac>> I believe these approaches frame patient problems very cac> differently. This cac>> is important because how we frame a problem drives our treatment. cac>> The first example clearly identifies that occupation is the goal. cac> There cac>> is no expressed concern for underlying factors impairing cac> occupation. cac>> However, and this if often overlooked, it is IMPLIED that all cac> factors cac>> impairing the goal will be treated within the therapist's cac> abilities. cac>> This is true because occupation includes the following factors: cac>> Physical, emotional, mental environmental, behavioral, cac> social cac>> Thus, as OT's and within our scope of practice, cac> occupation-based cac>> outcomes address all factors impairing the desire occupations. cac>> While the second example does include occupation as an cac> outcome, only cac>> factors addressed in the goals are included for treatment. This cac> severely cac>> limits treatment and cac>> in my opinion indicates that remediation of cac>> underlying impairments is the real goal. The implication is cac> that if cac>> underlying impairments are remediated, occupation will improve. cac> However, cac>> is inconsistent with OT theory because occupation is ALWAYS cac> more than cac>> physical. In my opinion, the second example is much more cac> like a PT cac>> rather than an OT goal! cac>> In closing, writing occupation-based goals is important for us cac> and for cac>> the patient. These goals allow us to focus on occupation's many cac> elements cac>> and complexity to best enable our patients. cac>> Thanks, cac>> Ron cac>> -- cac>> Ron Carson MHS, OT cac>> www.OTnow.com cac>> -- cac>> Options? cac>> www.otnow.com/mailman/options/otlist_otnow.com cac>> Archive? cac>> www.mail-archive.com/otlist@otnow.com cac>> -- cac>> Options? cac>> www.otnow.com/mailman/options/otlist_otnow.com cac>> Archive? cac>> www.mail-archive.com/otlist@otnow.com cac> -- cac> Options? cac> www.otnow.com/mailman/options/otlist_otnow.com cac> Archive? cac> www.mail-archive.com/otlist@otnow.com cac> -- cac> Options? cac> www.otnow.com/mailman/options/otlist_otnow.com cac> Archive? cac> www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
