Model of Human Occupation

Transcription

1 Model of Human Occupation Archived List Serv Discussion MOHOST Date: November 13, 2007 Hello, Are you able to send me details of the MOHOST and how to use it in assessment please? I work with Older people in Intermediate care so assess people in their own homes. Thankyou. Janet Ferry Date: November 15, 2007 Hi Janet, I was just wondering if you've looked at the information about the MOHOST on the MOHO website? - It gives a much more complete introduction than I can accomplish in an , but I thought that I'd try to anticipate some of your questions anyway! The MOHOST is a therapist-rated assessment that was built on the premise that occupational therapists get to know their clients over a period of time and become sufficiently confident to summarise the person's attributes and how they typically respond in their given environments. There are times when it may take successive visits to build up this picture, which will be based on talking with the client, observing them in everyday situations, talking to relatives, other team members, reading notes and perhaps completing other assessments. In these circumstances the therapist may use the single observation MOHOST to help build their knowledge of the person. However, I have a colleague who works in community mental health with older adults and she reports that she is generally able to complete the first MOHOST after an indepth initial contact. She will have talked to colleagues and read notes before the visit and spends time getting to know the client in their own home, often observing them completing everyday tasks and having the opportunity to talk to carers during that first visit. The MOHOST manual includes some of the recommended questions from the OCAIRS to help therapists get to know their clients and I find these questions to be invaluable. Therapists may decide to complete the OCAIRS if the client is fully able to engage in an interview-based assessment, or may continue to use the MOHOST - perhaps because of it's greater emphasis on communication and interaction skills, process skills and motor skills. (12 out of the 24 items assessed on the MOHOST relate to performance skills whereas the OCAIRS is more devoted to volition and habituation, with only one item out of 12 rating performance skills).

2 Hope this helps Sue Parkinson Date: November 15, 2007 I'll add to what Sue has noted. In our hospital setting the MOHOST is used across a number of services. Therapist in inpatient acute care and outpatient work rehabilitation have been able to incorporate the MOHOST into their regular documentation process. They gather much of the needed information as part of the usual observations and interactions necessary to do a basic physical assessment plus some additional very brief and basic interviewing with the client. There are some excellent examples of using the MOHOST in different contexts and also how to document data from the MOHOST in the new 4th edition of A model of Human Occupation (available through F.A. Davis--you can find it on their website or through a link on the MOHO website) Gary Kielhofner Date: November 15, 2007 Hi there, I am an occupational therapist from Singapore. I read with interest on this topic of incorporating data from the MOHOST into the regular documentation process. I am working in a community setting and am overseeing about 400 clients in various settings from geriatrics to mental health. I am looking into using the MOHOST to profile my clients such that I can split them up into suitable activity groups. The problem that I have faced with is that there lacks an analysis tool for me to analyse the results gathered from MOHOST. I would like to appeal for anyone who has any ideas on how to go about solving this problem. Being not very technically inclined, it would be quite a difficult feat for me to write a database or something for this purpose. Does anyone have a simple solution? Ruijie Date: November 20, 2007 Hello, 400 clients - that's a huge caseload! It would be hard for anyone to analyse the results. I wonder if the emoho system would help? - (Details on MOHO website) However this would depend on whether Malay(?) or English is used in your health system.

3 In my organisation, although the MOHOST is used fairly extensively, if clients can manage to self-assess then OTs often use the results of the OSA to help bring people with like needs together. The OSA items cannot only be divided according to MOHO concepts (skills, habituation and volition) but can also be analysed in terms of 1) basic tasks of living, 2) managing life & relationships and 3) satisfaction, enjoyment and actualisation. Good luck. Sue Parkinson Date: November 20, 2007 Hi Ruijie, I developed a simple spreadsheet for organising the data from the MOHOST where the assessment had been used in an individual case. I adapted this to provide a before and after analysis too, so the results could be compared before and after treatment. However, I think you are looking for something that looks at a large sample of data. A spreadsheet might be suitable but, as you say, a database might be better. Does your organisation have an IT department that can help? Ed Gillam Date: November 20, 2007 First of all, thanks Gillam and Sue for your valued responses. Yes indeed I am looking at something like a database sort of tool. I did explore the emoho but the cost is an issue and the primary tool that I am using is the MOHOST so it would be a little hard to justify the cost for the emoho to my organisation. Furthermore, the emoho does not have any sort of analysis capability. The key thing that I need is to group the clients into meaningful groups. This grouping is essential because the range of activities that are prescribed for each group would depend on this grouping. I have considered several methods of grouping like assigning numerical values to the FAIR system and totalling up their scores to group them but such a method would give me clients who have very varied needs. So I am still racking my brains for fresh ideas. As for contacting of the IT department that Gillam suggested, well, I currently work in the community in Singapore and resources are quite scarce so there's not really an IT department that I can approach. As to the OSA that Sue suggested, it's definitely an idea that I would try for some of my clients. However, a majority of them are illiterate or non-communicative so the OSA's use would be limited.

4 I welcome any more suggestions as to how I can derive meaningful groupings from the MOHOST results. Thanks in advance for any input! Have a nice day everyone! Ruijie Date: November 21, 2007 Hi Ruijie Where I work we have done something similar to what I think you are aking for help with. Admittedly it is with a considerably smaller client load than yourself, so you have my admiration and respect for that! We have used the results of MOHOST's to split our patients up in to suitable activity groups, and in fact I wrote to the listserv about this very thing, some time earlier in the year. Basically we used the rating system on the MOHOST (i.e. the F, A, I, R), and for each of the six components of the assessment (motivation, pattern etc) we took the patients lowest score, and took this as an indicator of where the areas of greatest need were. Even if a patient had scored an F for something, but the rest were I's for example, we went with the lowest score. In order to have this information available pictorially, we have laminated 6 A3 size posters, one for each section of the MOHOST, and then split each poster in to 4, so that each box is an F, A, I or R. We the noted the lowest score for each patient for each item, by writing their initials in the appropriate box. So for example, we may then have 6 patients who have low scores in process skills, and they may all have needs in terms of problem solving skills. We then looked at what intervention would be suitable for addressing that need. On our unit, we use a lot of kitchen based sessions, subject to risk obviously, and have groups where the emphasis is on problem solving, or relationships, etc. But this is just an example. The programme we run is all very practical activity based, and all based on grading activities according to the needs of the groups, as we have divided them according to their MOHOST scores. Our patients are all very much on board with what we are doing, and understand what needs the groups they are in, are addressing. This is great in terms of getting them involved in their treatment and motivated. I hope this gives you some help with your questions.

5 Best wishes Katherine Buttimer Date: November 21, 2007 Hi, I am Carmen G.de las Heras from Chile, and I have long experience working with this population and using MOHO. I would like to help you as I am used to work with few resources and high demands of services. I will give you some ideas according to the information I have from you: Thinking of your reality I would suggest as a first step to get to know the occupational needs of the group, observing, interviewing in groups of people, trying to get an idea of their volition and occupational skills and types of occupational settings where they will be living and participating, so you can orient yourself of how to set up your occupational opportunities and groups. Then I would suggest you could have two types of Initial assessments tools so you could choose. One of them could be MOHOST which gives an overall information of different aspects of occupational participation and allows you to use mixture of ways to obtain it. It helps to summarize information especially when you have little time to cover all needs. Having the observational assessments of MOHO always with you, will help you to clarify crucial aspects of volition and skills with this population. Working with people who need long term interventions in the community, I have used the OPHI-II as most important initial assessment tool, but in your case may be it would be impossible to apply due to the amount of people and little time. How many OTs work with you? Are you the only one? Are other disciplines available? Other resourse staff?. What are the expectations of OT intervention according with what you evaluate as "real" according to resources, culture? Which would be your priorities according to what you see on population and resources?. I ask you these questions, because it depends on this information the type of assessment process you could implement to guide your interventions, and the way you could organize your programs to be effective and efficient for both, evaluation and intervention processes. I would be happy to know more about it, so I can help in a better way... warm regards Carmen-Gloria de las Heras Date: November 22, 2007 Thanks Carmen for your detailed reply. Truly it is a huge challenge for me given that I am quite a new therapist and am the only OT in the setting that I work in which makes replies from this community the more valuable to me. I agree very much that I need to understand the occupational needs of my group which is

6 the main drive for me to adopt the MOHOST as a starting point. You mentioned using more than one type of initial assessment tool such you can have a choice. I am curious to know which other tool you chose. I was thinking of like creating a work flow such that if my client scores low for process skills in the MOHOST, it would lead to another assessment, maybe the Allen's Cognitive Level Screen. Your mention of the OPHI-II got me started thinking about using it as a prevocational tool to understand about the client and the support that we need to give him/her during the initial phases of work. Maybe I should describe my work setting in greater detail: 1) My time is split between 2 settings -An all male psychiatric residential facility with a population of approximately 180 people -A mixed-gender geriatric nursing home of approximately 220 people 2) For both settings, I am the lone OT 3) For the psychiatric facility, residents are not allowed out of the facility. Only a select few (<5) go out to work independently and return to the facility after work -Other disciplines include the nursing staff, and what we term as welfare officers who are people who overlooks the running of the facility. -Each of them are tasked to look after about 30 residents and they are also involved in any issues that arises from their charge. -OT is a new concept to them and I am working with them to come up with a better system of assessing the clients and planning programmes for them. -For this group of clients, I think that there is a severe need for any form of occupation be it from ADLs to leisure or vocational pursuit -A great challenge that I face is that this group of clients have a lot of free time that they do not know how to spend. I would in the long run hope to run some form of sheltered employment for this group of clients. -I welcome anyone to provide any suggestions as to what a sustainable long term programme can be. 4) For the geriatric facility, -I work with 2 other physiotherapists and the nursing staff. I have a therapy assistant. -The occupational expectation would be to maintain functions of the clients through programmes such that the client is actively engaged in some form of activity throughout the day. I must once again thank you for this reply as it got me thinking hard. Your mentioned of setting priorities is something I am quite stuck at. It would seem to me that it is not easy to prioritise when anyone of the tasks that needs to be seem so important. Would you mind sharing your thought processes in helping you decide on priorities? Thanks! Ruijie

7 Date: November 24, 2007 Hi again, Thought I'd reply once more, not because I have any more ideas re how to use the MOHOST to group people with like needs together - sorry - but because your has got me thinking about whether the MOHOST could be used for this task at all. The MOHOST helps to identify needs in terms of personal and environmental characteristics but when we group people together we have to take into consideration not just the extent of their volition (as rated on the MOHOST) but exactly what they value as individuals (their interests and their goals). Similarly, one would need to take account of not just whether they were able to manage roles, routines and responsibilites (as rated on the MOHOST) but what their roles, routines and responsibilities are. For me, this is why the OSA works well (and I guess I'd still be tempted to read it out to illiterate cleints in the absence of any better assessment). I think that Katherine's ability to use the MOHOST to group people together (see previous below), works well because her unit is able to provide a varied programme for a smaller number of people, where (if I understand the correctly) there might be a range of groups in the kitchen geared towards different levels - perhaps you could elaborate Katherine? Do you, for instance grade your groups to so that the tasks are geared towards beginners'/intermediate/advanced needs or do your set up groups to target e.g., communication and interaction skills... or is it a mixture of both? In my practice I tended to bring people together with similar interests (when the interest checklist came in very handy) and support people to work on their individual goals within these groups. For instance, in any one group, someone may have communication and interaction goals and another might have volitonal goals etc). The beauty of using everyday occupations is that people can work on their particular goals and build their interest so that they can develop a sustainable routine post-discharge. Courses designed to work on particular skills can be appropriate if individuals are able to pursue their own interests as well to practise the skills learned, but skill-based courses can become academic in the absense of interest-based activity. I hope I've made sense - you've certainly got me thinking. Thanks Sue Date: November 26, 2007 Ruijie I would also recommend exploring the Remotivation Process, for both groups of clients. You can read more about the remotivation process intervention manual at

8 The remotivation process builds off of the Volitional Questionnaire and allows you to determine if clients are in the exploratory, competency, or achievement volitional stage- this then allows you to identify what type of support a client needs to facilitate volitional behavior to engage in occupations. This program was developed with clients with Mental health challenges, but can also be used with older adults. Dr. Raber at Shawnee State University in Ohio did a dissertation exploring the volition of older adults with dementia, and may have some interesting ideas and resources for you. Also, another therapist, Fran Allen in the UK, used the Pediatric Volitional Questionnaire and the Remotivation Process to teach support staff the best way to support clients- something you may find useful with your large caseload. I hope this helps, and best of luck to you Jessica ps- the MOHOST may also point to further need for skill assessment, using the ACIS and the AMPS. Date: November 27, 2007 Ruijie, Thank you for sharing your story and challenges with implementing programming for such a diverse population. I agree with Jessica that the Volitional Questionnaire and Remotivation Process could be very useful in assessing needs for occupational engagement and then developing programs that would meet the needs of your client groups. My research examined how persons with moderate dementia demonstrated volition for everyday occupation, and I used both of these resources as part of my research. I'd be happy to discuss the application of these tools with you further, as there are implications for staff training, which could be of great assistance to you as well. Christine Date: November 24, 2007 Hi everyone, Thanks Katherin for sharing your experience with the use of MOHOST in this manner. I initially thought of assigning numerical values to each of the FAIR and tabulate the scores for each section to see which section has the lowest score before setting it as a priority area of intervention but I realised that a flaw in this method is that a client may for example score all F for everything on communication skills except for relationships.

9 The client would probably have a high score but the very area that he is weak in will be extremely impeding in his daily occupations especially in vocational situations in this case. So for this, I think your idea of using the lowest score for each section makes terrific sense. Regarding the grouping of clients, Sue, you've got me thinking too. I think the grouping would probably consist of people that complement each other. Something like a client with poor communication skills would be placed with one with stronger communication skills etc. Instead of classifying clients with a specific area requiring intervention, perhaps matching clients with varying abilities that complement each other may be a better idea. This would also help in maintaining the group in the long term. I also do agree that we have to take into consideration the unique roles and volition of each client before grouping them. I recently had 2 clients A and B of which A would be what most people would call high functioning whereas B would be termed as moderate in functions. However, B scored much higher than A in the MOHOST because there is an occupation that he greatly values and shows pride. From this scenario, I begin to realise that there was no way in which I could group my clients based on just the scores alone. The descriptive aspect of MOHOST is just as important. And it is vital, in my opinion, to state the role that is being assessed as well as the occupation carried out when the volition is being assessed. One problem that I face is that there are a significant number of clients who have very limited functions (A bit of background information: This setting that I am referring to involves primarily male clients with chronic psychiatric disorders with many of them having an ACLS score of between 3-3.5). This prompted me to revert to my previous idea of grouping clients for the lower functioning ones. Most of these clients are severely impaired in communication and interaction skills and the only way to assess volition is to bring them into the actual activity and observe their performance. After interest exploration I can then refer back to the MOHOST to determine the area that is most restrictive towards occupations. I can forsee that this is the ideal case. The more likely scenario would be that we are unable to determine the interest of much these clients and thereby having to move straight into activities that look into their areas requiring interventions. Thanks for the replies and sharing once again. Ruijie Date: November 27, 2007 Dear Ruijie: I am Carmen Gloria from Chile again. With your resources: 1. What you are saying is that you need a needs assessment. I think MOHOST (to begin with for what you need to do) is very complicated for your situation. OBSERVE VOLITION, if you can do some focus groups taht represent the majority, do them. And

10 like Sue says, group people by their goals and interests, not by their skills, because what real life offers us is to live within people of diverse of talents and skills. In real life we complement each other.. 2. To priorize with whom you can work. Evaluate your time available for direct contact and staff available to be trained and work as "environmental managers", so you can train them in MOHO procedures in a simple way. For making decisions of priorizing people you can work with, don t forget to consider in which conditions you see Performance Capacity in some spaciel groups: You are alone, so you need to do this. For example, in an acute psychiatric unit you cannot work directly on assessing and intervening with people who has psychotic symptomps..they need to be cleared from them, in order for you to do an occupational oriented work. But you can work with staff on facilitating an appropriate environment with the same physical resources you have. You can change the organization of objects (for example chairs) in the space to facilitate and "give different messages" to people). May be, if there is a group of people that you can work with, you can do assessments in groups, and you facilitate sharing stories, aspects of their self assessment etc. You can sfor example work with them within the group, if the system allows you, developing a Community Outreach group before they are discharged.. just some ideas In your work with people you can work longer with, I agree with Sue in that it should be focused on participation in real occupations, facilitating a normalizing environment where people can work togueter ( interacting or not depending on the person) in different meaningful projects of common interests and within that context you facilitate individual goals, individual skills, and all aspects togueter giving different expectations according to each individual s reality (you can read in the third edition of MOHO BOOK some of this in the chapter program development (Reencuentros).. 4. I agree with Jessica Kramer on consulting the Remotivation Process, I have developed it and used it for many years with all population, including people with people who suffre from Alzheimer..and staff and family have been so satisfied having the opportunity to learn it and seeing results with the approach... Also, ACIS and AMPS are good tools once you work with them.. 5. It is so much I would like to share with you...allways remember being realistic with the ways you decide to approach your programs...do not work in areas separetely, like don t "cut" people in the different components of the MODEL. Read well the principles, and work with the whole occupational person and group. Remember that all aspects integrate togueter at all times, (thinking, feeling and doing, environment). Talking groups should be: to support, to learn from, to plann, make decisions about, to reafirm both daily occupational organization & experiences, and supporting the reconstruction of occupational lives. 6. Don t feel guilty for not using all tools. Select the more useful for the group, use other as a guide for thinking, for your therapeutic reasoning, etc...

11 7. Share and work in a team with staff or other significant people...also the ROLE OF people you give services needs to be active, meaning they are part of social groups and as part of social groups they can participate also as leaders, as helping peers, etc, etc..as a team with you..ot work, rehab process, recovery process, change, need all people as much as possible..that s how the OT work gets to be real... Keep in touch... Much love to everyone Carmen Gloria de las Heras