Application of the Occupational Therapy Practice Framework to Physical Dysfunction

1. Who is the client? This requires consideration of not only the individual but the significant others in the client’s life. In some settings the client may be identified as a group and not as an individual. For example, a 28-year-old woman, Nora, who sustained a traumatic brain injury resulting in memory deficits and slight difficulties with coordination, is a wife and a mother to two young children. During the evaluation process, Sheena considers not only Nora’s occupational needs but also the needs of her family and her roles as a family member.

2. Why is the client seeking service? This relates to the occupational needs identified by the individual and significant others. The needs of not only Nora but those of her husband and children should be included in answering this question.

3. What occupations and activities are successful or are problematic for the client? This would also include understanding which occupations are successfully completed by the client. Nora may have the physical ability to drive and yet has severe memory problems and difficulties remembering the route to drive her children to school and various activities.

4. How do contexts and environments influence engagement in occupations and desired outcomes? Some contexts may be supportive, whereas others present challenges or prohibit occupational performance. Nora’s parents expect her to be the primary caregiver for her children and when her husband attempts to support Nora, her parents interfere.

5. What is the client’s occupational history? This includes the level of engagement in various occupations and activities along with the value attributed to those occupations by the client. Although prior to her traumatic brain injury Nora was responsible for the majority of the housecleaning tasks, Nora did not highly value these duties. She was also responsible for meal preparation and reports that she enjoys cooking. She places a much higher value on being able to drive her children to school and various after-school activities.

6. What are the client’s priorities and targeted outcomes? These may be identified as occupational performance, role competence, adaptation to the circumstance, health and wellness, prevention, or quality-of-life issues. For Nora, the need to safely drive and resume responsibility for fostering community participation for her children was a primary outcome. This reflects her interest in occupational performance. She was not interested in having her parents or her husband assume these roles.

1. What additional data are needed to understand the client’s occupational needs including contextual supports and challenges?

2. What is the best (most efficient and accurate) way to collect these data?

3. How will this information support the intervention plan?

4. How will this information influence potential outcomes?

1. Prevention of disability. This approach is focused on developing the performance skills and patterns that support continued occupational performance and provides intervention that anticipates potential hazards or challenges to occupational performance. Contextual issues are also addressed using this approach and environmental barriers would be similarly considered. An example of services representing a preventative approach would be instructing a client who has compromised standing balance in fall prevention techniques and asking the family to remove loose throw rugs from the home to avoid falls.²⁴ Clark et al.²¹ demonstrated the beneficial effects of preventative occupational therapy services in the investigation of well, elderly adults. Adults who received preventative occupational therapy displayed far fewer health and functional problems when compared to adults who did not receive these services.

2. Health promotion. A disabling condition is not assumed, but instead occupational therapy services are provided to enhance and enrich occupational pursuits. This approach may be used to help clients who are transitioning in roles or used to foster occupational performance across contexts. An example would be using narratives to promote a healthy transition from the role of a worker to retirement.⁴² As workers described what they anticipated in retirement, they linked “past, present, and future” (p. 49). This process of anticipating changes and making choices was considered to be an important factor in “understanding how people adapt to life changes” (p. 49).

3. Establish or restore a skill or ability. This strategy is aimed at improving a client’s skills or abilities, thus allowing greater participation in occupations. Evidence of the effectiveness of occupational therapy services provides this form of intervention as demonstrated by several investigators. Walker et al.⁸⁰ investigated the effectiveness of occupational therapy services in restoring activities of daily living (ADL) and instrumental activities of daily living (IADL) skills in clients who had sustained a cerebrovascular accident (CVA) but had not received inpatient rehabilitation services. They used a randomized controlled trial and demonstrated that clients receiving occupational therapy services had significantly better ADL and IADL performance when compared to clients who had not received these services. Rogers et al.⁶⁹ also demonstrated that performance of ADLs can be significantly improved when provided with systematic training.

4. Adapt or compensate. This approach is focused on modifying the environment, the activity demands, or the client’s performance patterns to support health and participation in occupations. Instruction and use of energy conservation techniques for clients who have dyspnea (shortness of breath or difficulty breathing) as a result of chronic obstructive pulmonary disease is an example of this approach.⁵⁵ The use of electronic aids to daily living (EADL) is another example of how the activity can be modified to promote participation.²⁹ When clients who had acquired brain damage were provided with training in the use of EADL, they reported a sense of mastery. Even if a client’s previous abilities cannot be restored, employing this adaptive or compensatory approach can promote participation in occupations.

5. Maintain current functional abilities. This approach recognizes that many clients are faced with degenerative disorders, and occupational therapy services should actively address the need to maintain occupational engagement.^19,31 Intervention may focus on the activity demands, performance patterns, or context for occupational performance. As an example, an individual in the early stage of Parkinson’s disease is still able to complete many self-care activities but should develop the habits that will maintain these skills as motor function continues to deteriorate. Maintenance also includes clients who have a chronic, nonprogressive disorder; in this situation there is a need for maintaining physical conditioning to meet activity and environmental demands.

1. The client and clinician identify the occupation or activity to be performed.

2. The specific features of the environment that are required for occupational/activity performance are identified. This includes contextual and environmental factors in addition to the necessary equipment to engage in the occupation/activity.

3. The OT and client identify potential safety risks or challenges to engagement in the occupation/activity that are located in the environment or with the objects required.

4. The OT and client develop a solution for these risks or challenges.

1. Nora and the OT identified the occupation of driving her children to after-school music lessons as the focus for intervention.

2. The car has an automatic transmission. The route typically used to drive her children from school to the lessons includes a busy street with four lanes, but no highway driving is required. She does need to make one left-hand turn on this street, but there is a left turn light. The travel time typically takes 10 minutes.

3. Nora reports that traveling on the one busy street can be a challenge because many drivers exceed the speed limit on this road and drive erratically. This is the quickest route to the music lessons and because she is very familiar with the route, it provides less challenge to her memory. Nora’s husband also reports that this road often has construction, presenting an additional challenge.

4. Instead of changing the route, Nora develops a solution whereby she allocates an additional 5 minutes to transport her children to lessons, allowing her to feel less pressure when drivers are exceeding the speed limit. Strategies to address the erratic drivers encountered on this road included frequent checks of her side mirrors and moving to the left lane two intersections before the left-hand turn light. An alternate route is also mapped out for Nora to use when road construction presents a challenge.

• Define and explain relationships between concepts or ideas related to the phenomenon of interest (for example, occupational performance and occupation).

• Explain how these relationships can predict behavior or events.

• Suggest ways that the phenomenon can be changed or controlled.”

Model of Human Occupation: In the model of human occupation (MOHO),⁴⁴ the engagement in occupation is understood as the product of three interrelated subsystems that cannot be reduced to a linear process. These three subsystems are linked to produce occupational performance. The volitional subsystem refers to the client’s values, interests, and personal causation. A client may clearly identify values and interests to a clinician but then express a sense of incompetence to engage in a desired occupation. Volition is the client’s thoughts and feelings, including occupational choices. The habituation subsystem refers to the habits and roles that are often critical to a sense of self. Colloquial phrases such as “I don’t feel like myself” expressed by a client often speak of a distortion of habit or role experienced in life. A client, faced with a disabling condition, often experiences a severe disruption in roles and habits. The sense of self can deteriorate when roles such as driving to work, driving to go shopping, or driving friends to enjoy a picnic are eliminated because of a disabling condition. The performance capacity subsystem reflects the client’s lived experience of the body. This is not the strength or range of motion available but refers to the client’s previous experience, changes, and expectations of performance capacity. Again, using the a colloquial phrase “once you’ve ridden a bicycle, you never forget” captures a portion of this concept and requires the therapist to consider the client’s experience of successes or failures in using the body to engage in occupations.

Ecology of Human Performance: Ecology of human performance (EHP)²⁷ was not designed to be used exclusively within the profession of occupational therapy but was intended to serve as a mechanism for understanding human performance across professions. An important concept expressed in the EHP is the interaction of the person, the task (activity demands), and the context. Occupational performance is intertwined with, and the product of, the interaction of these three variables. EHP is a client-centered model in which each person is viewed as unique and complex and includes past experiences, skills, needs, and attributes. The task is understood as the objective and observable behaviors to accomplish a goal. The context includes the person’s age, life cycle, and health status from a perspective of the cultural and societal meanings of each. Context also addresses the physical, social, and cultural factors that influence performance. EHP recognizes that these three factors influence each other and that the person and task are inextricably linked with the context. Performance is the product of the person engaged in a task within a context. A significant contribution of this model is the equal importance placed on each variable in producing occupational performance. Instead of focusing only on improving skills in the person, intervention using this model can assume several forms. Five intervention strategies are described, and a close similarity to the OTPF-2 can be seen. The five strategies include the following:²⁸

Person-Environment-Occupation Model: The person-environment-occupation model (PEO)^48,49 shares characteristics with EHP where occupational performance is seen at the intersection of the person, environment, and occupation. It is a client-centered approach, but equal emphasis is placed on the environment and the occupation when designing intervention. PEO defines the person as a dynamic and changing being with skills and abilities to meet roles over the course of time. The environment includes the physical, social, cultural, and institutional factors that influence occupational performance. Occupations include self-care and productive and leisure pursuits. PEO further differentiates the progression from an activity, a small portion of a task, a task that is a clear step toward an occupation, and the occupation itself, which often evolves over time. An example would be the activity of safely handling a knife. This is a small portion of the task of making a peanut butter and jelly sandwich, and the task of making a sandwich is seen as a part of the occupation of meal preparation. Occupational performance is the result of the person, environment, and occupation interacting in a dynamic manner.

Biomechanical: The understanding of kinematics and kinesiology serves as the foundation for the biomechanical FOR.⁷⁵ The clinician views the limitations in occupational performance from a biomechanical perspective, analyzing the movement required to engage in the occupation. Based on principles of physics, the force, leverage, and torque required to perform a task or activity are assessed. These also serve as the basis for intervention. A client may be unable to open a jar of peanut butter or jelly because of limitations in grip strength or the available range of motion required of the hands to hold the jar. A biomechanical approach would focus intervention on addressing these basic client factors to improve occupational performance. Although intervention may take the form of exercises, splinting, or other orthopedic approaches, the outcome must reflect engagement in occupation.⁴¹

Rehabilitation: The rehabilitation FOR focuses on the client’s ability to return to the fullest physical, mental, social, vocational, and economic functioning as is possible. The emphasis is placed on the client’s abilities and using the current abilities coupled with technology or equipment to accomplish occupational performance. Compensatory intervention strategies are often employed, and examples include teaching one-handed dressing techniques to an individual who, following a CVA, no longer has functional use of one hand. The focus of intervention is often engagement in occupation through alternative means. (For additional examples of intervention strategies supported by the rehabilitation FOR, see Chapters 10, 11, and 17.) Returning to the same example of making a peanut butter and jelly sandwich, instead of having the client work on strengthening the hands to finally open the jar, the clinician would suggest using a device to stabilize the jar and use a gripper to help accomplish the task with current abilities. Regardless of the technology or equipment available, the clinician must always link the intervention to the client’s occupational performance.

Sensorimotor: Several FORs are included in this grouping, such as proprioceptive neuromuscular facilitation (PNF) and neurodevelopmental treatment (NDT) (see Chapter 31 for additional information). These approaches share a common foundation of viewing a client who has sustained a central nervous system insult to the upper motor neurons as having poorly regulated control of the lower motor neurons. To recapture the control of the lower motor neurons, various techniques are employed to promote reorganization of the sensory and motor cortices of the brain. The specific techniques vary but the basic premise is that when the client receives systematic sensory information, his or her brain will reorganize and the return of motor function will be obtained.

1. Does the theory, model of practice, or frame of reference help with understanding and interpreting the evaluation data while considering the client’s expressed needs?

2. Does the theory, model of practice, or frame of reference provide a good fit for the type of intervention that will meet the client’s needs?

3. What evidence is available that the theory, model of practice, or frame of reference can efficiently produce the results requested by the client?

1. Administering selected screening instruments or assessments such as range of motion (ROM) tests, interviews and questionnaires, ADL evaluations, and other assessments that follow a defined protocol.⁷

2. Collaborating with the OT and client to develop portions of the intervention plan (e.g., planning for dressing training and planning for kitchen safety training).⁷

3. Implementing interventions supervised by the OT in the areas of ADL, work, leisure, and play. With appropriate training and supervision, the OTA can implement interventions related to other areas of occupational performance.⁷ As determined by the OT, an OTA can also implement interventions where competence has been demonstrated. An example would be intervention related to the client factors of strength or range of motion.

4. As assigned by the OT, assisting with the transition to the next service setting by, for example, making arrangements with or educating family members or contacting community providers to address the client needs.

5. Contributing to documentation, record keeping, resource management, quality assurance, selection and procurement of supplies and equipment, and other aspects of service management.

6. Under the supervision of the OT, educating the client, family, or community about OT services.

Acute Care Inpatient Setting: Clients in an acute care inpatient setting typically have a new medical condition, such as a heart attack, burn, cerebrovascular accident (CVA), or a traumatic brain injury (TBI), that led to hospitalization or an exacerbation of a chronic condition, for example multiple sclerosis. An acute decline in a chronically progressive condition abruptly confronts the client with a long-term prognosis of increasing disability. The client may require life support because of the severity of the condition. Terminally ill clients who have managed in their own home with support from a hospice program may require acute hospitalization for pain management, placement, or imminent death; in such cases, a client’s hospice goals should be clearly stated and respected by the hospital staff. (For additional information on hospice care, see the section on skilled nursing facilities later in this chapter.)

Acute hospitalization, especially when unplanned, results in a sudden change in the client’s environmental supports and context(s). Previous social roles may be abandoned when the person becomes hospitalized. External stressors such as financial issues or disruption of career and educational pursuits must be considered when providing services in an acute care setting. An individual who felt in control of his or her life becomes controlled by the circumstances requiring the hospitalization. Nora had a sudden change in her ability to control her environment and exercise her role as a wife and mother. When she sustained her TBI, she was admitted through the emergency room, hospitalized in an ICU to stabilize her condition, and had both a nasogastric (NG) tube and a catheter inserted. On the second day in the ICU, the occupational therapist evaluated Nora’s ability to manage oral secretions and swallow her own saliva. She would continue to receive the majority of her nutrition through the NG tube but was cleared to begin to eat thick liquids such as nectar. When her vital signs stabilized on day 3, she was transferred to an acute rehabilitation setting for continued therapy services.

Three general roles have been identified for the occupational therapist working in the acute care setting: education, initiation of the rehabilitation process, and consultation.¹⁴ Education may address safety precautions and activity analysis. Rehabilitation services may be initiated for clients who will be transferred to a rehabilitation facility. Consultation is focused on the discharge environment and client needs after leaving the acute care hospital. An experienced occupational therapist, equipped with knowledge of available resources in the hospital and community, can offer a better coordinated and efficient intervention plan to promote client progress and anticipate outcomes. For example, a therapist who determines that a client living alone at discharge would be unable to prepare meals should contact the social worker who would help arrange for the delivery of meals to the home. Another example is a therapist who evaluates a client scheduled for imminent discharge and finds that the client is impulsive, lacks insight into the consequences of his or her actions, and is confused when performing self-care tasks. In this instance, the therapist expresses these concerns to the discharge coordinator or the physician. The social worker might be consulted about family support available, or discharge may be delayed to determine if appropriate environmental supports are available for the client.

Acute hospitalizations are frequently stressful and frustrating for clients. Away from home while ill, subjected to multiple tests and examinations with sleep interrupted, clients are in a socially compromised environment. They may experience sleep deprivation and overstimulation because of the frequency of procedures or interventions. Some clients, after 2 or 3 days in the ICU, may display marked difficulties with orientation, appearing confused, agitated, and disorganized.⁶¹ This has been referred to as ICU psychosis, and clients may experience hallucinations in addition to anxiety and confusion. The client’s history should be reviewed to determine if previous episodes of disorientation and confusion were present or if they are produced by the disorienting effects of being hospitalized in an ICU. Concerns as to whether they might be able to return home after the hospitalization, who will help with care, or who is helping care for dependent loved ones may add to clients’ feelings of stress.

The acute hospitalization has many physical environmental factors that present a challenge to clients. Often clients have several monitors in place or tubes inserted such as oxygen saturation monitors, cardiac monitors, arterial lines, and catheters that may compromise engagement in occupations.⁴⁰ The arrangement of the hospital rooms and extra equipment can further impact the client’s occupational performance. The absence of carpeting and the presence of a slippery floor surface may prove challenging for clients during a transfer and when walking. The incidence of falls in the geriatric population is higher in acute hospitals than in either the community or skilled nursing facilities.²⁰

Providing OT intervention services in an acute care setting may be challenging for therapists, because it is often necessary to perform assessments in client rooms rather than in more natural environments designed for ADLs. Performance of various activities may be influenced by catheters, feeding tubes, or monitors. Likewise, client performance in some self-care activities may be artificially enhanced by a lack of the extraneous stimuli found in the home and by the physical attributes of hospital equipment. For example, a client whose home includes three very active cats, several throw rugs on a slippery floor, a very soft bed several feet from the bathroom, and a tiny bathroom faces far more challenges to get up in the middle of the night to use the toilet when compared to the same activity performed in the hospital. The hospital has no throw rugs or active cats as obstacles and often the bathroom is adapted to support safety and performance in toileting. To partially replicate the home environment during the intervention session, the therapist might position the client’s bed flat, eliminate the bed rails, and lower the bed to better simulate the client’s home. Most hospitals would not allow further challenges such as bringing a cat into the room or scattering throw rugs on the floor as an obstacle for the client. Using clinical experience and judgment, along with information provided by the client regarding the home environment, the therapist must be able to anticipate the client’s performance at home. However, referral to a home health therapist is also advisable to assess occupational performance and accessibility in the client’s home.

The acute care hospital also presents the occupational therapist with unique economic, social, and physical challenges. Medical intervention is directed toward promoting medical stability and providing for safe, expedient discharge. It is not unusual for the individual in acute care to receive OT services for the first time on the day of discharge. During this single visit, the therapist must communicate the role of OT, establish an occupational profile, and assist the client in identifying problems and assets in the discharge environment. The client and the family frequently look to the therapist to identify what the client will need at home. The therapist, in collaboration with the client and family, must develop intervention priorities by identifying issues and concerns after discharge from the acute care setting. The intervention plan may include purchase of durable medical equipment and referral for further intervention to inpatient rehabilitation, a skilled nursing facility, an outpatient clinic, or home health therapy providers. By contacting other members of the healthcare team and communicating concerns, the therapist can facilitate implementation of the recommendations.

Inpatient Rehabilitation Setting: Clients may be admitted to an inpatient rehabilitation unit when they are able to tolerate several (usually 3) hours of therapy per day and are deemed capable of benefiting from rehabilitation. Rehabilitation settings may be classified as acute or subacute (discussed later). Clients are generally medically stable in this setting and require less acute medical care when compared to services provided in an acute care hospital. Pain, which may be present and affecting client performance, should be addressed in this setting. Performance in ADLs will reflect the client’s adaptation to pain, and the energy expended to perform self-care tasks should be considered (see Chapter 28 for a further discussion of pain).

During Nora’s acute rehabilitation hospitalization she received occupational therapy services twice a day along with daily services from a speech and language pathologist and a physical therapist. These services were coordinated to support client outcomes. As is common during acute rehabilitation hospitalization, Nora was expected to dress in her typical street clothing and eat meals at a table in a dining area. This environmental feature of the acute rehabilitation setting provides a social element that is not present in the acute care hospital.

Acute Rehabilitation: When clients are medically stable and able to tolerate 3 hours of combined therapy services for 5 to 6 days a week, they may be transferred to an acute inpatient rehabilitation setting. Clients may still require some level of acute medical care in this setting. The length of stay (LOS) in acute rehabilitation settings generally ranges from 2 to 3 weeks, but it varies according to the client’s needs. The usual discharge plan from acute rehabilitation is to a lesser level of care (e.g., residential care or the client’s home with assistance such as a home health aide or personal care attendant).

The process of adjusting to disability has begun by the time the client enters acute rehabilitation. As the client begins to participate in areas of occupation, deficits and strengths become more defined. An improvement in the client’s function from the onset of the disabling condition may have occurred. Within a rehabilitation center, many clients form new social relationships with individuals who have similar disabilities. The advantages of these relationships are emotional support and encouragement from the progress of others. In rehabilitation, interventions are focused on resuming those roles and occupations deemed important to the client’s life. For example, an adolescent will reestablish social roles with peers; a parent will resume childcare responsibilities.

Although bedrooms in acute inpatient rehabilitation settings are similar to those found in acute care hospitals, clients are often encouraged to personalize their room by having family and friends bring in pictures, comforters, and other items from home. In this setting, clients are expected to wear street clothes rather than pajamas. The clothing that clients most often select is easy-to-don leisure wear. The OT practitioner must consider the range of clothing the client will be expected to wear to resume his or her occupational roles upon discharge and include training with appropriate clothes such as neckties, button-front shirts, and pantyhose if necessary.

Simulated living environments, family rooms, kitchens, bathrooms, and laundry facilities can be found at most rehabilitation centers. These environments may be inaccurate replicas of the client’s home. For example, laundry machines may be side-by-side and top-loading versions rather than coin-operated and front-loading machines. Kitchens may be wheelchair accessible in the facility but inaccessible in the home. Clutter, noise, and types of appliances encountered in the rehabilitation setting often vary from the client’s natural environment.

Access to the community is not generally evaluated during the acute rehabilitation hospitalization. Some urban facilities are able to integrate community training more smoothly because stores, restaurants, and theaters are located near the hospital. Although the community surrounding the hospital may differ from the client’s neighborhood, this offers an opportunity to experience a more natural environment.

The culture of rehabilitation facilities is focused on client performance and goal attainment. The client’s own culture may be compromised in the process of rehabilitation unless the team is sensitive to and incorporates client’s perspective into the intervention plan.¹⁷ For example, some cultures view hospital settings as a place for respite and passive client involvement. Engaging clients in ADLs can be in direct conflict with client and family expectations. When cultural perspectives clash, unrealistic goals may result. As is the case in any setting, meeting the established outcomes is dependent on clear communication and the identification of goals that are relevant and meaningful to the client.⁷¹

Upon completion of the acute inpatient rehabilitation program, some clients return home and receive home health services. Unfortunately, not all clients eligible to receive home health services are referred for these services.⁵⁸ The occupational therapist should actively participate in discharge planning for clients to ensure they receive the necessary services when discharged from the acute rehabilitation setting. Clients are also referred to a subacute rehabilitation setting upon discharge from the acute rehabilitation hospitalization for continued services. There are several similarities between the acute and subacute rehabilitation settings. The primary differences found in subacute settings are discussed in the following section.

Subacute Rehabilitation: Subacute rehabilitation facilities are found in skilled nursing facilities and other facilities that do not provide acute medical care. The equipment available to the occupational therapist for intervention and evaluation in the subacute setting may be comparable to that found in the acute rehabilitation facility. The focus of intervention continues to address restoring functional abilities, but with the slower rate of change the occupational therapist must also consider the need to adapt or modify the environment to promote occupational performance. Lengths of stay in the subacute setting vary, and stays may last from a week to several months. This setting is also known as a short-term skilled nursing facility admission. Clients are usually discharged to a lesser level of care when they leave a subacute rehabilitation setting.

The pace of intervention services varies, and engaging in 3 hours of therapy per day is not mandatory. Client endurance will influence the frequency and duration of therapies. A client may continue to make steady gains but at a slower pace than was seen during the acute inpatient rehabilitation stay.

Because many subacute rehabilitation programs are located in skilled nursing facilities, the client may have roommates who are convalescing rather than actively participating in rehabilitation services. This presents as an additional variable to be considered in the intervention plan because the social context does not always support participation in the rehabilitation services provided at the setting. Staff may be more oriented to the skilled nursing care services and not allocate similar efforts toward the rehabilitation goals of independence.

Skilled Nursing Facilities: A skilled nursing facility (SNF) is an institution that meets Medicare or Medicaid criteria for skilled nursing care, including rehabilitation services. Although subacute and short-term rehabilitation programs may be housed in SNFs, occupational therapy services are also provided to individuals who are not in a subacute rehabilitation program. They are known as long-term skilled programs. Many residents (the preferred consumer label for persons who live in long-term care settings) will remain in SNFs for the remainder of their lives; others will be discharged home.¹³ Goals should be directed toward independence and meaningful occupational pursuits and may include fostering engagement in occupations through environmental modifications and adaptations. An example would be reading materials and playing cards with enlarged print to foster leisure pursuits for clients with macular degeneration. Hospice services may be included in this setting if appropriate.⁷⁸ Hospice care requires the physician to document that the client “probably has 6 months or fewer to live” (p. 8).⁷⁸ The services provided do not focus on rehabilitation but instead address palliative care and environmental modifications. Occupational therapy services for hospice clients should address access to the environment and participation in occupation through support and modifications. For example, occupational therapy services could address participation in leisure pursuits as a hospice client creates a memory book for significant others.

The physical and social environment in skilled nursing facilities may impede the natural performance of ADLs. Clients often receive additional assistance with self-care tasks to expedite task completion, but this assistance is not focused on fostering engagement in occupational performance.⁷⁰ An investigation within SNFs demonstrated that even clients who were severely cognitively impaired benefited from intervention that was focused on fostering client participation in ADLs. Not only did clients increase participation in self-care tasks but there was also a reduction in disruptive behavior.

Extreme variations in disability status are present in SNFs. Observing residents who are severely and permanently disabled may lead newly disabled individuals to form negative expectations of their own prognosis and performance. Younger adults placed in SNFs (where most residents are older adults) may feel isolated and abandoned, which can adversely affect performance. Friends are less likely to visit in this environment. Family and friends may expect less of the individual than they would in other settings. Maintaining connections with friends from the community may require the client to actively pursue these relations. A therapist who facilitates identification of realistic and meaningful expectations and goals with the resident can promote a more positive outlook and outcome. A strong family commitment can support outside relationships by providing transportation to various community gatherings.

Home- and Community-Based Settings: An alternative to an acute inpatient rehabilitation program for clients with traumatic injuries such as head or spinal cord injuries is a home- and community-based therapy program. This type of program provides intensive rehabilitation in the client’s own home and community. The client receives comprehensive rehabilitation services and acquires functional skills in daily activities in the normal environments of home, school, work site, and community. This enhances the likelihood of a successful and functional outcome.

For example, Nora may benefit more from working on tasks in her home and community than in a clinic or acute rehabilitation setting. The client is performing in her natural physical, social, and cultural environment. Scheduling is within control of the client, and intervention sessions vary in length and frequency depending on the goals. An all-morning session to work with the client as she moves through her daily routine (e.g., bathing and dressing her child, going grocery shopping, and performing various household chores) would be possible.

When practice is necessary for goal attainment, a rehabilitation technician or therapy aide may be charged with carrying out specific and limited programs established by the therapist. The technician who spends many hours with the client can provide insight when the program is not succeeding because it interferes with the natural context of the client’s lifestyle. Adjusting intervention strategies to adapt to these lifestyle differences will ensure better clinical outcomes.

Intermediate Care Facilities (Residential Care): Generally, residential facilities more closely resemble home situations; persons may reside there on a permanent or transitional basis, depending on prognosis.⁶⁴ Similarities in the age of residents, their disability status, and even diagnoses are commonly present. Although clients do not require ongoing intensive medical care, the facilities are staffed with care providers 24 hours a day because of the clients’ need for safety and supervision. OT services may not be available on a daily basis, and rehabilitation technicians may implement the unskilled portions of the intervention plans addressing ADLs, select IADLs, and leisure. Often clients require ongoing assistance for portions of these tasks, and personal care attendants or technicians complete portions of the activity or task. The therapist can identify key performance issues in this context. Difficulties with evening self-care, follow-through with safety guidelines, problem solving, schedules, and client performance are reviewed and discussed with the OT. Modifications in the intervention plan can be more easily tailored to promote independence under such close supervision.

Assisted Living Units or Residence: An assisted living unit (ALU) provides health services in a cooperative living setting. A client may live in an apartment or cottage where one or more meals are provided on a daily basis, medication management is provided as needed, and 24-hour support is available. These settings usually have age restrictions and residents must be over the age of 55 years old, or if a couple, one person must be over the age of 55. The client generally does not plan or anticipate a move to another type of setting and is often expected to own or rent the living space in the ALU. Because there is an age restriction for most ALUs, the social and environmental support is present to preserve living in one’s own space. For example, apartments or cottages may be equipped with safety railings in the bathroom and walk-in closets for ease of accessibility.

In this setting, occupational therapy services are provided to foster and enhance the habits and routines necessary to remain housed in this environment, which often includes personal care skills such as dressing, grooming, hygiene, and simple home care tasks. Some household tasks may be partially assumed by the services provided in the assisted living setting. For example, an ALU may provide a service of laundering towels and bed linen, but the individual is responsible for the care of his or her own clothing items. Some ALU settings provide all meals, whereas other settings provide only one meal and the individual will need simple meal preparation skills to live in that setting. It is important for the OT to determine what services are available at the ALU prior to designing an intervention plan with the client. An important occupational pursuit for those in this setting would be leisure activities. Environmental supports such as magnifiers for reading, enlarged print playing cards, and a universal remote to access the television may provide opportunities for leisure activities in this setting.

Home Health: Home healthcare provides services within the client’s home and affords the most natural context for intervention. The desired outcome for services provided within the home could include supported completion of ADLs or IADLs such as bathing, dressing, and meal preparation. The client, returning home from the hospital, begins to resume life roles at home. The focus of occupational therapy intervention would be to support participation in those roles.⁷⁷

A visiting therapist is a guest in the client’s home and is subject to certain social rules associated with guests. For example, the family may practice the custom of removing street shoes within the home and the therapist should respect and comply with this practice. The client and family establish daily schedules for meals, waking, and sleeping. Appointments should support the family’s routines and not interfere with daily schedules. For example, if the client is accustomed to eating a larger meal during the middle of the day and a very small evening meal, an intervention to address meal preparation skills should be scheduled to support this routine.

Self-care, homemaking, and cooking tasks evaluated in the context of the home clearly identify the challenges that the client meets daily. The familiar clothing, furniture, appliances, and utensils used in everyday life are present and promote orientation and task performance. However, moving of furniture to make things more accessible and safe for the client or modifying equipment to be used within the home may challenge orientation skills and increase confusion. Caring for and feeding pets, answering the door safely, and determining a grocery list for the week are potential issues to be addressed within the home setting. Self-care tasks such as bathing can be addressed within the natural environment and when appropriate modifications to the home are made, the client’s dependence on others may decrease.³⁰

Social and family support, or lack thereof, is readily evident to the home health therapist. Individuals who appeared alone and unsupported while hospitalized may have a network of friends and family members who lend support at home. Conversely, other individuals who had frequent visitors in the hospital may be abandoned when the realities of disability reach the home setting.

The client who receives home health services typically requires assistance for some aspects of his or her ADLs. Nearly 20% of all family caregivers are employed full-time outside the home.¹¹ These caregivers are available for only part of the client’s day and will be concerned primarily with the safety of the client during their absence.

Stress is common among caregivers. Respite care, which temporarily places the client under the care and supervision of an alternative caregiver for a few hours and up to several days, can provide necessary relief for a caregiver.¹¹ Caring for a person with a disability in one’s home is not an easy task. Box 3-2 identifies practical concerns surrounding the presence of a client in the home. By providing individualized occupational therapy recommendations for home modifications, caregiver approaches, and community-based resources for clients who had Alzheimer’s disease, caregivers reported a decrease in a sense of burden and improved quality of life.²⁵

When viewing the client’s home environment, the therapist can make recommendations for environmental adaptations, see them implemented, and modify those changes as needed to best meet the client’s needs.³⁹ Physical changes to the home, including moving furniture, dishes, or bathing supplies, should not be undertaken without the permission of the client and are best considered through a team approach to support the collaboration between professionals and client.⁶⁵ If the client is in the home of a family member or friend, the permission of the homeowner must also be sought.

The client and family are in control of the home environment. Clinicians who fail to ask permission before adapting the environment will rapidly alienate their clients. A throw rug, viewed by the therapist as a tripping hazard, may be a precious memoir from the client’s childhood home. In seeking permission of the client and family and providing options, the therapist opens communication. An adhesive mat placed beneath the throw rug will provide a safer surface on which to walk. Another possible solution is to hang the rug as a wall tapestry, where it will be more visually prominent and less prone to damage.

Healthcare workers in the home occasionally encounter ethical dilemmas, typically involving safety.⁵⁹ The therapist must determine the best method for resolving issues of safety hazards. Fire and health hazards must be discussed and corrected when the safety of the client or adjacent households is in jeopardy. By broaching the subject diplomatically and directly, the therapist can address most hazards and provide acceptable solutions. Inclusion of the client, family, and other team members in the process of problem identification and solution generation is strongly recommended.

When Nora returned home after her acute rehabilitation hospitalization, Sheena arranged for her to receive OT services through a home health agency. Nora, Sheena, and the home health OT identified concerns with meal preparation, laundry, and playing with her children as important occupations to be addressed. Sheena was not able to make a home visit prior to Nora’s discharge from the acute rehabilitation program but was able to coordinate continued services through the home health agency. The home health OT worked with Nora on strategies to improve her safety in meal preparation, helped her to simplify her laundry and cleaning routines, and provided suggestions for leisure activities in which Nora could engage with her children in the home.

Day Treatment: Day treatment programs are becoming more popular as a community-based intervention setting. Programs vary, but the underlying philosophy is to provide an intensive interdisciplinary intervention for clients who do not need to be hospitalized.³⁶ Clients receiving day treatment typically live at home but frequently require support and assistance for ADLs or IADLs. Most programs offer a team approach. Professionals from all disciplines are engaged cooperatively, sharing their expertise to meet the client’s individual goals. Clients may seek services from a day treatment program to further recover functional skills following an acute injury or illness such as a TBI or CVA, or clients with a progressively deteriorating disorder, such as Parkinson’s disease or Alzheimer’s disease, may benefit from a day treatment program to foster continued participation in occupations through environmental modifications and adaptations.

Many day treatment programs are designed without the time constraints seen in many outpatient programs. Lengthy community outings and home and work site intervention sessions may be used as a method of attaining goals. In a day treatment setting, the occupational therapist may have the best opportunity to evaluate and provide intervention for clients in all of their natural environments.

Work Site Therapy Settings: Industrial rehabilitation can be conducted in the context of the employee’s place of work. Work site therapy programs are designed to address an employee’s therapy needs related to work injury. The injured worker receives intervention to foster the occupational performance necessary in the workplace, which may include work hardening, back safety, energy conservation, and work simplification techniques. This approach places the client back into the work role. Prevention of further injury occurs in a more natural context when employees are treated at the work site.

Providing OT services to individuals at their place of work helps them make the transition from the patient role to the role of worker. The therapist providing service at the work site must avoid compromising the worker’s status.³⁸ The employer and peers view the employee as a worker rather than as a client. Maintaining confidentiality can be challenging because the coworkers’ curiosity is often aroused by the unfamiliar face of the therapist in the workplace. The therapist should remember never to answer queries that would compromise client-therapist confidentiality. Unsolicited requests from coworkers for medical advice and work site modifications are best referred to that employee’s doctor or manager.

In the work setting, the therapist interacts not only with the client but also the employer and often the insurance company. By encouraging the injured employee to communicate his or her needs for work modification and how productivity might be maintained, the therapist will pave the way for a successful transition to work. The therapist strives to balance the needs of both the employee and employer while promoting resolution of work-related issues that would interfere with a smooth transition to productive work. Scheduling of therapy visits to the workplace should meet the needs of both the employee and employer. Work site visits should be scheduled in a manner that minimizes interfering with the natural flow of work.

The financial impact of work modifications will concern the employer. Employers do not have unlimited resources for modifying work environments. Only reasonable and necessary work modifications should be considered. Suggestions for work modifications that have an associated cost should be discussed with the employer. The therapist can suggest work modifications but must also consider the impact of these modifications on coworkers using the same equipment. As a general rule, modifications that affect workers other than the employee must be discussed with management before they are presented to the employee as possible options.

In a traditional clinic setting, a secretary who sustained a repetitive motion injury of her wrist may receive various modalities to control her symptoms of pain and edema and may be educated on joint and tendon protection techniques while performing various movements. When the secretary receives occupational therapy services in her work environment, additional benefits often occur. Joint and tendon protection techniques are applied at work while performing day-to-day work tasks. Because the client’s injury occurred at work, it could be exacerbated or prevented at work. See also Chapters 14 and 15 with regard to the role of the occupational therapist in relation to workers and work settings.