Model of Human Occupation

Transcription

1 Model of Human Occupation Archived List Serv Discussion MOHOST and the bigger picture (trust reporting requirements etc) April 4, 2011 Dear all I have recently been (?playfully) challenged to justify our use of MOHOST in mental health services by our associate director. He posed the possibility that staff were spending time completing standardised assessments to justify their own professional needs. Thus reducing time that could be spent working with the client or completing the outcomes / data requirements that the Trust is compelled to deliver on. I wish to take up this gauntlet and reply with a well informed justification, alongside our first audit of this data. I would appreciate any of your thoughts and facts. In particular those of you who are aware of the wider reporting requirements for AMH services in the UK, may be able to highlight where our data supports (rather than detracts) from the Trusts. Thanks in anticipation and for the many inspiring conversations that List-serve provides, best wishes toni Hi Toni, I've recently introduced greater use of MOHOST within the Psychiatric Inpatient Unit that I work for in Melbourne and have been receiving positive reports from other disciplines as well as some OT's that are not familiar with it. Some of the feedback has been as follows:

2 - The structure allows a greater breakdown of an individuals occupational competency allowing for more depth of understanding from other disciplines - The report layout makes the understanding and communicating of recommendations much clearer to other disciplines (and the client) - For some OT's this helps to articulate the assessment content by having a prearranged template and encourages the consistent use of terminology - The form enables assessments to transition into the community more easily by using the previously completed MOHOST as a benchmark/outcome measure for evaluation - There's research behind the assessment to demonstrate evidence-based practice/best practice which can only be a good thing - By following the MOHOST structure it is easier to provide a timescale for completion rather than relying on an unstructured observational assessment that could be quite vague with no definitive end point and become slightly anecdotal in terms of recommendations - Using a form such as MOHOST would make reporting outcomes and data to management much easier as the assessment would provide a tangible outcome that can be measured over time. These are just thoughts off the top of my head so I hope they help! Paul Dear Toni, with the currently proposed changes in the way that the NHS is due to be funded (although put on hold as of yesterday!!!) there is going to be an ever increasing need for services to demonstrate and evidence outcomes for their practice. If you cannot prove to the Commissioning Consortia that the input that you as a service provide benefit the service user in the areas that the Commissioning body value you (and the Trust) will lose funding to outside providers. This is going to become even more important as we move towards Payment by Results and Cluster/Pathway based commissioning.

3 Further to this, MOHOST (and the other MOHO assessments) has a well developed body of evidence and is based on a valid, clear and coherent model which bridges the gap between Occupational Theory and Occupational Therapy practice. MOHOST's structured approach provides a framework for rapid and effective initial assessments allowing for ease of effective treatment planning and the OT being sure that they are intervening in the right areas. The risk of not following a structured and standardised initial assessment procedure is that important factors may be accidentally omitted and/or not considered that then may threaten the effectiveness of the treatment plan and actually result in more time, money and resource being wasted in the long term resulting in a negative impact for both the Service User and the Trust itself. I hope this helps, Rob Robert White Deputy Head/Clinical Lead OT - Community Rehabilitation, Recovery & Independent Living Service The MOHOST is an internationally recognised and standardised assessment, making it easier to compare interventions with other organisations nationwide and worldwide. It probably has more research behind it than the data requests from the government. So if the findings are similar, this could support the wider reporting requirements. I m not entirely sure what those measures are, so I m hoping someone else does! Helen Dear Toni: There is a very important aspect to consider as an argument besides all good comments written already. It is the fact that the evaluation process with MOHO represents the first step of intervention. When we apply MOHO assessments we are already doing intervention because we share with clients and plann together, because you use daily situations and occupations to observe at the same time you are implementing OT programs, and because a well applied standarized assessment (which is valid and reliable) will serve to treatment teams as a whole, giving clear information on results for planning

4 and evaluation of outcomes, therefore saving time for all professionals in the process of coordination and meetings, and incresing their knowledge about the person. MOHOST forms also facilitates team work on data colletion, and meets with characteristics explained above. I am sorry for my english Much love Carmen Gloria de las Heras, MS, OTR Chile Dear Helen and Leckie What an interesting challenge! One could argue that time spent during assessment (and writing up assessment) would be better spent in direct service time with the client. However, my argument would be: if you don t have a well articulated and evidence based understanding of the client, their needs, their desires, and what may need to change to enable them to achieve goals, then intervention will not be directed and focused, and will be time wasted. That is, intervention activities delivered by a therapist that are not systematically thought out and aligned with client needs and goals, will not help the client achieve or make advancements towards their goal. It s a sort of cost- benefit analysis. Yes the therapist may spend more time away from the client in the beginning, with the outcome that the better articulated understanding of the client will lead to more effective and efficient intervention approaches. The MOHOST can help because it is theory based and systematic, helping therapists identify client needs and strengths holistically, and aligned with an evidence based theory that can help therapists select effective and efficient intervention techniques. This is a very important question, and speaks to the importance of good assessment (and our need as OTs to be able to explain why good assessment is just as important as good 1:1 intervention time with clients!!) Best to you in responding to this (hopefully playful!) challenge Leckie! Best- Jessica Hi Toni,

5 I was looking forward to seeing the replies to your and it's brilliant to see such an international response - I'll content myself by sending you the shortest of replies along with all my good wishes. If an assessment is completed solely for the benefit of the profession then it's a wasted opportunity, but if it aids the therapeutic process then the fact that it may also provide evidence of a profession's effectiveness is a bonus.... I've just received ethical approval for a little research study comparing OT services where OTs work as OTs and OT services where OTs have difficulties maintaining their occupational focus. The trust's research committee were also happy for me to go ahead but their one question was, 'how will this benefit the trust?' and I had to explain that we were interested in providing quality services that were able to demonstrate greater productivity. I guess we'll always need to explain our actions to some people! Sue Parkinson Toni, I hope to add to what others have said already. Like other MOHO assessments, the MOHOST is client-centered. It allows the therapist to achieve a unique empathic understanding of the client through an intimate "seeing" and "knowing" of the client according to the dimensions that are central to his or her occupational participation and engagement (i.e., the dimensions of MOHO). In addition to assisting the therapist with treatment planning and therapeutic reasoning, there is no reason why the MOHOST cannot be used as an intervention tool in itself. Results can be shared with clients periodically with each new follow-up administration, and clients can track their own progression through therapy. Thus, they can empower themselves by learning how to see themselves within an empathic light and from an occupational perspective - leading to greater insight, self-understanding, and ultimate behavioral change. Thanks for initiating this interesting discussion. - Renee Taylor

6 April 6, 2011 Dear all, I think that the original poster might be finding themselves having to justify what they do against current policy drivers in mental health such as being service-user led, adopting a recovery approach and empowering self-determined care planning. I happen to think that OT is ideally placed to deliver that agenda - whether MOHOST is the ideal tool to support that process would seem to me to be the question that has to be answered. The answers so far have not done so as far as I can see but rather are justifications against criteria current policy is perhaps not so interested in! Best wishes Rayya April 6, 2011 Hi Toni and all, I couldn t add much to the excellent and informed responses that have been posted, especially in relation to the really useful précis of what MOHOST offers us, but I do feel your question may also raise political issues that I seem to spend most of my time thinking about in various guises as a leader. I wonder if your associate director also playfully challenges medics, psychologists and nurses about their use of discipline specific assessment tools? I believe that your challenge may mirror the challenge we face as a profession, certainly when times are as economically tight, as anxiety provoking and as politically charged as they are right now here in the UK. I sense that the issue you are obviously actively addressing (and credit to you for doing so!) is far from uncommon. I would advocate that we need to be clear in our thinking; that we need to back up what we do with evidence, that we need to be assertive, that we need to challenge and that we need to take initiative. Moreover, we (and every other discipline) need to be able to justify sustained investment in our services. The work that has been done around mental health OT and payment by results for example is really helpful and very much part of healthcare culture in the UK. You are being proactive, you are beginning with the end in mind, you are thinking winwin and you are collaborating with others. These are some of Stephen Covey s 7 habits of highly effective people!

7 I think the discussion you are having with your associate director mirrors the kinds of courageous conversations (or?playful challenges) that we need to have at all levels of our profession and I congratulate you on doing this! The very best of luck Toni, Best wishes all, Mark Spybey. April 6, 2011 Hi all Yes I totally agree with Jessica's extremely well articulated response below. Others have also expressed a host of positive reasons for the time investment in using the MOHOST. A slightly more negative/confrontational counter argument to the views expressed by Toni's manager is that presumably no one ever questions time spent by our medical colleagues carrying out mental state, or a host of physical examinations, in order to come up with a diagnosis...or time spent by psychologists conducting psychometric testing? But to end on a postive note I just wanted to highlight the benefit to service users themselves. The concept of volition helps us understand what motivates and drives people, which means that it is very compatible with the recovery approach and provides a firm foundation for collaborative working. When service users are shown the summary of assessments they often report feeling listened to and understood: It captures a lot about me and it feels therapeutic to read (Service user) That s me down to a tee.can I keep it? (Service user) And as has already been expressed, since the MOHO assessments allow occupational therapists to identify why service users are having difficulty doing the things they need or want to be able to do, this understanding can be used to provide the most effective intervention package. Finally, when the assessment tools are used in a pre-post way they can provide service users with tangible evidence of change, which can affirm their recovery. David

8 April 7, 2011 Dear Rayya, dear all, I agree with you Rayya. My response referred only to the value of assessment. The actual choice of assessment depends on a number of finely balanced factors, with the needs of the service user at the centre. Other factors include: the need for assessments to reflect our scope of practice, (mostly, this means being occupation-focused for OTs but clearly we are sometimes responsible for generic assessment too); to fit with time demands and the resources available (to have clinical utility); to support decision-making and enhance communication - (having a theoretical base helps to do this because it enables the practitioner to be able to explain the priniciples and pupose of the assessment); and in some instances to add standardisation to the assessment process (to be evidence-based with proven relaibility and validity) although informal assessment will always be important too. It is only because MOHO offers a choice of assessments that it is able to meet all of the above criteria, but this should not rule out the use of other assessments according to the circumstances. With regards to how MOHO theory can help to explain our scope of practice, I've been meaning for some time to send the attached leaflet to the MOHO listserv. It's based on the OT leaflet by Manchester Community OTs that is available on the MOHO website and was created by Derbyshire OTs with Gary's encouragement, (6 pages 20.5cm square using corporate colours). With all good wishes, Sue Parkinson April 8, 2011 Hello Sue, really interested in the issues both you and Toni raise and can strongly identify with both issues in my practice. Very relevant. I am particularly interested in the challenges occupational therapists face in maintaining occupational focus, as I work in primary care mental health, where this as obvious implications for therapists and where psychological therapies are promoted and hold high evidence bases. Catriona Dillingham

9 April 8, 2011 Hi Catriona, There are so many pressing issues at the moment, aren't there! This week I decided to write to all the Members of Parliament in Derbyshire asking them to consider mentioning occupational therapy as well as talking therapies, and including a copy of the leaflet that I shared in my last . So long as we all work together and do what we can, I have every confidence that the value of occupational therapy will be recognised, especially if we work with service users to get their voices heard as Rayya suggested. :-) Sue Parkinson April 10, 2011 Dear MOHO Sun, Renée: I sent this message below but I think I sent it only to Sue. Please, post it for everybody!! Well, if you accept it! Thank you very much carmen gloria Dear Sue and everybody: All you are describing is part of our role of occupatinal therapists. We have been very active to change Mental Health Authorities reasoning about priorities based on mental health CONSUMERS AND THEIR FAMILIES NEEDS through different means. The best results on changing minds on deciding the needs of mental health consumers have been: Consumers with OTs demonstrating changes in their occupational lives through conferences, individual needs advocacy in treatment teams from their part and occupational reports, and teaching MOHO through practice and formal education. Showing authorities the effect that occupational participation and development of all factors involved has on health and therefore in health economics (well written reports on group responses to moho interventions, evidence based practice)

10 Working with families on their empowerment to advocate for their rights (MOHO education and outcomes with their family members) Initiatives with consumers on educating communities through formal and informal events of education (Kronemberg et all, 2011) Developing formal views of Services goals and results as Sue has shared, in more simple samples according to our economic possibilities Working very hard with teams, and therefore using a common view to persuade mental health administration MOHO has been an excelent tool for educating and showing evidence based practice. The one issue I want to reafirm is that consistency and persistence are key on achieving our practice functions as part of any helath system. Let s use all wonderfull resources MOHO has available today! I belong to generations who had to develop assessments and interventions based on MOHO for all population in order to advocate for our practice. Despite differences on administration views between our countries, I find challenges for us requiring the same skills. Any more specific contents, just let me know! Big hug and a lot of conviction and courage... Carmen Gloria de las Heras, MS, OTR Chile April 11, 2011 Dear all Thankyou for such animated and stimulating responses. I will be drawing on these to highlight both the clinical benefits (to service users and in supporting the MDT s approach) and the economic benefits (in terms of efficiency and in meeting the policy drivers) of OTs continuing to use MOHOST. Carmen, in particular I wonder if you have any further detail / examples of the reports you have used to articulate the benefits in health economics ( point 2 in your list) that you would be willing to share? Many thanks again Best wishes to all toni

11 April 12, 2011 Dear all A lot of the discussion around the use of MOHO seems to focus on Mental Health services. My understanding is that it can be applied to various settings and I work in an acute and rehab. stroke service. Increasingly, we need to illustrate the benefit of our service to patients and also to managers. Does anyone have experience of using MOHO in this setting and what assessments specifically do you use? Would anyone be happy to share their experience in this area? All comments and views gratefully received. Jo Richardson Occupational Therapist Dorset County Hospital Dorchester April 18, 2011 Dear Jo, I am a stroke specialist OT providing a service to a community rehab hospital and a community rehab service. The services I work in are generic but I only see stroke patients and my two colleagues see the general medical and progressive neurological patients. We also use MOHO and have found it invaluable; both for us in clarifying our role and also for promoting what it is exactly that we do to our Colleagues. We complete our initial assessments generally as we always have but use the OCAIRS questions to help guide us when appropriate which is most times. I am AMPs trained and I try to complete an AMPs for every one but I probably manage about 70%. This is no extra work to normal as you would be completing a functional assessment anyway and now I ve got into the swing of it, it s becoming habit. And the software writes the report for you! We complete neurological screens as normal and as Bel does, we collect all our findings into the MOHOST. I have been finding that people on the ward and newly discharged are better with the MOHOST and for people who have been home longer, the OCAIRS works better. I have become reliant on the MOHOST to identify the often complex psychosocial and communication issues that can arise with stroke. On a busy stroke ward you can get so tied up with cognitive and motor issues that you can easily miss how a person is reacting to their stroke and coping with the often huge and sudden losses. Gathering a person s previous routine and observing how they initiate their routine on the ward or at home can

12 often highlight very important and fundamental issues. And properly assessing a person s personal causation when their insight may be affected or they are still in denial as to the effects of their stroke can sometimes help the person themselves by highlighting it as an issue. I find the MOHOST invaluable to untangle the sometimes very complex issues that can arise for people who have had a stroke. Like Bel, we have a prompt card that we keep in our pockets to try to ensure that our documentation of daily treatment echo our assessments and our therapy support staff use the single assessment. We have provided training on the motor and process terms and will look at Volition and habituation this year. I have also been doing some training to the nurses and health care assistants on the ward on the OT role using MOHO and it has created a really fantastic structure to highlight the breadth of our role and the importance of considering environment, routine and motivation in rehab. We have also altered our home visit and transfer reports to reflect our MOHO assessments. I would echo Bel s comments that the fourth edition of the MOHO book is essential reading. Also, it has taken us a very long time to introduce this and make it habit as our management support has been variable (about 3 years). I do not think that it takes any more time to do than non MOHO based OT intervention and I find that we can be more eloquent about the issues people are facing and where we need to target our intervention; we find that we may spend slightly longer at the assessment stage but that it pays dividends later on. Finding out what is truly important to a person and reflecting their normal routine is very motivating and no matter how unrealistic that goal is we find that working towards it can often mean they get further than they would possibly have done to one we would consider important. We would not consider ever going back to life without MOHO! We wish you luck on your journey and if we can help, please let us know. Regards, Maisie April 19, 2011 What a powerful MOHO based practice Maisie describes! Very impressive. I wish we had more of that in the U.S. Are there any U.S. therapists that can describe their use of MOHO with a similar population of rehab inpatients, outpatients or home health patients so we have a point of comparison? Gail Fisher, UIC