John S. Luna, OTR, OTD
Assistant Professor, University of Texas Rio Grande Valley, 1201 W. University (SWOT 1.306) Edinburg TX, 78539, United States.
Corresponding Author Details: John S. Luna, OTD, OTR., CRC, Assistant Professor, University of Texas Rio Grande Valley, 1201 W. University (SWOT 1.306) Edinburg TX, 78539, United States. E-mail: John.Luna@utrgv.edu
Received date: 23th June, 2021
Accepted date: 17th August, 2021
Published date: 19th August, 2021
Citation: Luna, J.S., (2021). Integrating Occupation-Based/Focused Assessments During the Evaluation Process. Opportunity to Revisit the Topic in a Post COVID-19 Practice Setting. J Rehab Pract Res, 2(2):125.
Copyright: ©2021, This is an open-access article distributed under the terms of the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Occupational therapists treat clients across the lifespan, and every successful intervention begins with a successful evaluation. Incorporating a variety of norm-referenced standardized assessments into the assessment process has become increasingly important to justify services to third party payors identification of goals, and intervention strategies. However, occupational therapists tend to select assessments that are focused and measuring performance skills and client factors versus occupations and performance of occupations. The purpose of this article is to examine the topic of occupation based and occupation focused assessments. While using occupation-based/ occupation-focused assessments is not a new topic, the COVID-19 pandemic has changed how many Americans perform their daily occupations. These changes may be an opportunity for practitioners to consider integrations of standardized Occupation based and occupation focused assessments in daily practice.
Throughout the history of the occupational therapy profession, occupation has been instrumental as both an outcome and an intervention. During the evaluation process, best practice, as outlined by AOTA [1], involves occupational therapists assessing occupational performance and identifying potential underlying factors impacting the client's ability to engage in their desired daily activities. However, occupational therapists have historically assumed a strong correlation between the improvements in client factors with an improvement in occupational performance, which is not always the case [2]. This assumed correlation might contribute to an evaluation process that emphasizes the evaluation of performance skills over occupation. Hocking's [2] article provides a historical perspective on the evaluation habits of occupational therapists, and this is not a new topic. However, why does this remain a topic at all?
What are Occupation-based/focused assessments?
Fisher [3] differentiated the terms occupation-based (occupation as the foundation )/ occupation-focused (occupation as the immediate focus). When applied to the assessment process, these terms can guide occupational therapists in the evaluation process to gather a more comprehensive view of the client. Occupation-focused assessments can help therapists identify client priorities, and occupation-based assessments can be instrumental in ascertaining specifics on client's performance of their daily occupations. Simply put, these assessments can examine what clients do and how they do it. While these concepts may seem part of everyday practice for occupational therapists, do occupational therapists use standarized assessments that are occupation-focused and based?
Therapists in the United Stated infrequently use occupation-based or focused assessments. Numerous studies identify the current practice methodologies of pediatric occupational therapists during the evaluation process in the United States. Therapists (54% of respondents) indicate the routine use of standardized assessments monthly [4]. Kramer, Bower, O'Brien, Kielhofner, and Maziero-Barbosa [5] concluded that therapists select evaluations that focus on body structure/function rather than occupation and utilize these standardized evaluations as a means to meet external factor such as reimbursement requirements. Additionally, upon analyzing the list of assessments used most frequently by respondents in Piernik-Yoder and Beck's [4] study, many evaluations reported as frequently used by respondents focused on evaluating client factors or performance skills. Finally, Bagatell, Hartmann, and Meriano's [6] mixed methods study analyzed the responses of 370 occupational therapists from the Northeast region of the United States to identify assessment methods currently utilized for pediatric clients. Again, therapists tend to use assessments focused on evaluating client factors or performance skills [6].
An argument could certainly be made that some of the assessments identified by respondents in the studies mentioned above could be considered occupation-based. For example, in Piernik-Yoder and Beck's [4] study, Folio and Fewell's (2000) Peabody Developmental Motor Scales 2nd Edition (PDMS-2) was the assessment most frequently used by respondents. When practitioners use the PDMS-2, therapists administer standardized activities for clients to perform, potentially allowing practitioners to analyze the performed activities to determine the underlying impairment. However, the PDMS -2 measures developmental motor skills (Folio and Fewell, 2000), not the performance of client occupations. So, what are the barriers to using assessments intended to measure aspects of occupational performance?
Understanding the practitioners' perception of the evaluation process is critical to implementing an evidence-based approach focused on integrating occupation-based/focused evaluations for clients. Kramer et al.'s [5] study identified the influence of professional context on the evaluation process. Primary influences affecting the assessment process identified within this study included reimbursement and regulations. Additional influences included current practice within the practitioner's immediate environment and factors such as cost and time restrictions associated with the feasibility of using the assessment [5]. These findings are similar to those reported by Bagatell et al.'s [6], which identified time and the cost of assessment tools as constraints to the evaluation process. Estes and Pierce's [7] concluded that occupation-based practice is challenging to use because it takes more time, requires support from the clinical culture, and practitioners may experience difficulty mentally shifting to an occupation-centered approach and the creativity required on the part of the practitioner to engage in occupation-centered practice. In combination with Kramer et al. [5] and Bagatell et al.'s [6] study, these findings depict the influences of reimbursement, regulations, time, and clinical culture on occupation-based practice and the utilization of occupation-based/focused evaluations. Identifying barriers and supporting factors to the evaluation process is imperative to both selecting occupation-based and focused assessments that possess characteristics to effectively contribute to neutralizing challenges as perceived by therapists to utilizing occupation-based/focused evaluation. Additionally, generating awareness of the obstacle's practitioners encounter in selecting occupation-based and focused assessments may help practitioners identify trends in the assessment process that may not align with best practice. Are there opportunities for practitioners to start new habits and integrate occupation-based and focused assessments as part of the evaluation process?
On March 13, 2020, the White House declared COVID -19 a national emergency [8]. This marked a significant shift in their roles, routines, and habits that support occupational performance for many individuals. The daily routines and context for people across the world changed. Marshal, Bird, and Burrows [9] report that more than one-third of individuals in the United States exchanged their morning commute to the office for a walk from the bedroom to the kitchen table and worked from home during the pandemic. For school-aged children and youth, their daily routine and contexts changed as well. In the early parts of 2021, 48 % of students (8th graders) reported learning from home full-time [10]. Adapting to these contextual changes created perceived challenges to many individual's perceived role competencies. For example, many parents were challenged balancing their roles and responsibilities of employment with their children's learning needs [11]. While what we did remained relatively unchanged, how we did it changed for many individuals during the COVID-19 pandemic. Can the same be generalized for clients seeking rehabilitative services such as occupational therapy services during and after the COVID-19 pandemic?
Occupational therapy is an occupation-centered profession using occupation-based and occupation-focused evaluations and interventions to achieve our objectives within the paradigm of occupational therapy. Based on these distinguishing characteristics, any assessment that focused on occupation as an outcome is more occupation-focused. In contrast, evaluation based on the observation of performed occupations is occupation-based. In this proxy and self-report, occupation-focused evaluations present themselves as a time-efficient way to assess critical areas of occupations, values, and beliefs to develop the occupational profile successfully.
The recent changes in the healthcare landscape offer practitioners opportunities to revisit the question. Why not integrate occupation-based/focused assessments into my daily practice? Occupation-focused and occupation-based assessments may offer practitioners (and interdisciplinary teams with OTs) a systematic way of assessing what clients do and how they do it. Occupation-focused/occupation-based assessments are inexpensive and time-efficient. For example, the Child Occupational Self-Assessment (COSA) /Occupational Self-Assessment (OSA) is an occupation-focused evaluation that explores the client's perception of their performance and value of their daily occupations [12]. The COSA /OSA can also be used as an outcome measure to determine intervention effectiveness in achieving client-centered occupation-focused/based outcomes [13]. The cost for the COSA/OSA is approximately $40.00 [14]. Because the COSA /OSA is a self-assessment, the questionnaire can be given to the client before the evaluation. This may provide the practitioner with the needed information to either focus on in an extended semi-structured interview or develop intervention strategies and outcome areas directly from the COSA/OSA in a time and cost-efficient manner. Similarly, the Canadian Occupational Performance Measure [15] is available electronically through a web-based application to mitigate the time factor in performing an occupation-based interview [15] while keeping costs comparable to the COSA/OSA.
However, the COSA/OSA, COPM, or other occupation-focused evaluations, are probably not the first thing that comes to most practitioners' minds when deciding on assessment tools. Practitioners need to take the time to expand or refresh their repertoire of assessment tools to include occupation-focused/based evaluations. This is more challenging for some populations than it may seem. Brown and Bourke-Taylor [16] reviewed thirty-five studies published in The American Journal of Occupational Therapy [17] between 2009 and 2013, focusing on children and youth instrument development. Findings from this study indicate that the evaluations reviewed in the selected literature focused primarily on evaluating body structure/ function. The authors' conclusions from this study indicate the need for future research to focus on developing client-centered, self or proxy report measures and occupation-based/focused evaluations [16]. With the limited development of occupation-based/focused evaluations, it becomes essential to provide occupational therapists educational opportunities to integrate occupation-based assessments.
Utilizing occupation-based/focused evaluations facilitates the development of occupation-centered intervention [3], contributing to both practice scholarship [17] and meeting AOTA's Vision 2025. However, studies have demonstrated that occupational therapists do not select evaluations that focus on occupation [4-6,18]. Breaking this trend does not mean the abandonment of assessment tools focused on evaluating performance skills, contexts, or client factors; it means supplementing the evaluation process with occupation-based/ focused assessments to benefit the client. Kielhofner [19] warned practitioners about evaluation that focus merely on the client's condition and note to clients that these evaluations, "…may unwittingly rob individuals of both the voice and their power to determine the direction of their own lives" (p249). However, evaluations devoid of an occupational focus or basis not only can rob the client of their voice but can rob the profession of occupational therapy of its identity. The topic of occupation-based or focused assessments is not a new discussion to the profession. However, this discussion may hold a greater significance level in a post-COVID-19 practice setting as we take a closer look at what occupation our clients do and how they perform these occupations. Society has changed; using occupation-based/ focused assessments to examine occupations systematically can help practitioners and interdisciplinary teams gain a holistic perspective to inform the intervention process for the clients we serve and society as a whole.
The author declares no competing interests.
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