At first glance this list is a no brainer, but I challenge you to review how you are actually demonstrating your proficiency in these skills so that you are giving your clients the best therapy available.
#1. Perfect the OT Interview
I would reach to say this is the most important part of the OT process. The client/caregiver interview initiates your therapeutic rapport, sets the stage for the tenure of your treatment, and gives the client the opportunity to tell their story--for many an invaluable opportunity of which they have never been given.
Put yourself in your patient’s shoes. Have you ever been to see a healthcare provider who barely let go of the handle of the door during their visit with you? You walked out of the office and felt like you had basically wasted your time. You were given answers, sure, but you felt the practitioner had answers formed in their mind before they even talked to you to hear your questions.
Now imagine you have experienced some traumatic event as many of our OT clients have. You have been bounced from healthcare practitioner to healthcare practitioner with no real explanation of why or what to expect next. The answers you are given don’t add up, and you have come to believe no real hope exists to rehabilitate your symptoms.
And then you meet the occupational therapist. When he enters the evaluation room, he sits down. He explains why he is there and how he may be able to help you. He asks to hear your story. He listens. To the whole thing. He asks for details. He probes to know your hopes, your desires, your goals. He wants to know what you want to look differently in 3-6 months time. He then spells out a plan to help you to where you want to go.
Every time you perform an OT interview, you have the opportunity to change the direction of your client’s healthcare path.
I am not claiming that this will be every clients’ story. In fact, I would reckon to say that most of your clients will not have this story. Instead, they will arrive at your clinic after working with a caring and competent healthcare team.
Even still, a kind, compassionate, patient, and educational client interview may change the trajectory of their healing process.
Have a plan to gather the important information. You may find it helpful to create and use an interview template with questions outlined so that as the interview progresses, you can stay on track and gather the pertinent information.
A rough example of a written template may look like this:
1. Explanation of occupational therapy. This is where you do the talking. Provide a short introduction of yourself, your job, and the purpose of your visit.
What is occupational therapy? Why does the client need occupational therapy? What types of occupations are you assessing (ADL for skilled nursing and acute care; play and social participation in outpatient pediatrics; work and leisure in outpatient adults)?
2. “What brought you to therapy today?” (Or, What brought you to the hospital?)
3. “What concerns do you have?” “How long have you or your child been experiencing these symptoms?”
4. “How do these concerns affect your daily life?”
5. Tell me about home.
6. Ask about relevant home environment
who does the client live with
is assistance needed at home
home set-up--falls risks--adaptive equipment
Does the child have particular behavioral changes at home vs in the community?
One of my favorite questions: “Walk me through a typical day for you. You wake up in the morning, what happens next?”
7. Gather information about current level of function
IADL--work, volunteer, school participation
8. “What are you hoping to get out of therapy?” “What do you want to look differently for you at the end of our time together?”
#2. Write measurable and appropriate goals
Yall. Measurable and appropriate. Not the froo-froo nonsense goals we have come to believe trick the insurance companies into believing we are making progress when we’re not. I know you have seen what I’m talking about. You may have written a nonsense goal. I know I have written many of them. I felt that they were beautiful goals until I went to write the progress notes and realized I had no way to measure if we had actually made progress or not.
The good news is, if you completed a really good client interview, goal writing should be a breeze. You will simply take the information from the last bullet of the above template, “What are you hoping to get out of therapy?” “What do you want to look differently for you at the end of our time together?”
If you are in a skilled nursing facility and the patient responds, “I just want to go home,” discuss with her the specific needs to reach that goal. Maybe she needs to dress herself, be able to put together a small meal, and step into the shower over a 4 inch threshold when there is no room for a tub bench. Those three needs become your goals.
Note the patient-stated goals and then you determine why the deficit is in place.
Why couldn’t Sally step into her shower? She doesn’t have the hip flexor strength needed to clear the 4 inch threshold. She is unable to maintain balance with unilateral stance--a key factor of the shower transfer.
Why couldn’t Sally dress herself independently? She had significant oxygen desaturation during the dressing task leading to fatigue and loss of concentration. She is unable to maintain a sitting position without unilateral upper extremity support. She is unable to maintain a standing position for longer than 15 seconds and requires bilateral upper extremity support.
Sally’s occupational therapy goals might look like this:
Sally will complete upper body dressing increasing to modified independent by 6 weeks.
Sally will demonstrate improved independence in UBD and grooming tasks to no more than minimal assistance due to improved sitting balance as measured by Kansas University sitting balance scale 4/5 by 2 weeks.
Sally will complete lower body dressing increasing to modified independent, utilizing adaptive equipment as needed by 6 weeks.
Sally will thread B LE through LB clothing articles increasing to modified independence while maintaining O2 saturation >95% by 2 weeks.
Sally will have improved standing tolerance to at least 2 minutes by 2 weeks.
Sally will pull pants over hips in standing increasing to no more than minimal assistance due to improved standing balance as measured by Kansas University Standing Balance Scale 4/5 by 4 weeks.
Sally will step over a 4 inch threshold into her shower with no more than stand by assistance by 6 weeks.
Sally will have improved strength of gross motor hip flexor group to 3+/5 by 2 weeks to improve independence in stepping into a shower.
Sally will demonstrate bilateral single leg stance for 5 seconds with no more than unilateral support and without loss of balance by 4 weeks to improve independence in stepping into and out of a shower.
In the outpatient pediatric setting, your client’s mother expresses she wants to be able to go grocery shopping weekly with her child in tow. Right now, that has become a long chore she avoids because her child has a meltdown every time they pull into the parking lot. She additionally has concerns over his negative behaviors (crying, hitting, pulling his hair) during bath time. Those two needs become your goals.
Note the caregiver-stated goals and then you determine why the deficit is in place.
Why does Tatum have a meltdown when pulling into the grocery store parking lot? Tatum tends to a sitting task for only 5 minutes. He is easily overwhelmed by loud noises and bright lights. You find during your assessment process that Tatum does an excellent job of following instructions and finishing “jobs” you give him.
Why does Tatum demonstrate self harming behaviors during bathtime? During your (excellent) caregiver interview, you find that bathtime is typically rushed before bed. Tatum has not had the opportunity to explore and play in the water and seems to have some sensory processing difference, particularly with touch and changing temperatures.
Tatum’s occupational therapy goals may look like this:
Tatum will participate in a 30 minute grocery shopping trip with no meltdown behaviors by 6 months.
Tatum’s mother will list 5 options for “jobs” Tatum can complete while grocery shopping (ie checking items off the list; gathering the canned goods) by 1 month to decrease instances of meltdown behaviors while grocery shopping.
Tatum will demonstrate no meltdown behaviors while riding in the car to the grocery story or parking in the grocery store parking lot by 1 month.
Tatum will participate in bath time on three occasions weekly with no self harming behaviors by 6 months.
Tatum will participate in water play with hands/arms only with no self-harming behaviors by 1 month.
Tatum will demonstrate independence in doffing upper and lower body clothing including shoes and socks by 2 months.
Tatum will choose from a two-option choice within a reasonable amount of time (7 seconds) on 10/10 trials in a therapy session to improve decision making to improve behavioral response to self-care and IADL tasks by 2 months.
#3. Plan your interventions
Good intervention planning can only come after completing a thorough patient/caregiver interview and writing relevant goals.
Just as we have all likely written a nonsense goal, I am willing to guess you have done some sub-par intervention planning. I have, for sure.
I’m talking about the intervention planning where you quickly glance at your day’s caseload and brainstorm of 2-3 ‘interventions’ that kind of relate to their goals. OR maybe your “intervention planning” is done as you walk from the documenting office to a patient’s room. OR maybe your “planning” is done as your pediatric client participates in a “preparatory activity” of swinging.
We need to do better. Our clients need better. Our interventions should be well-intended, purposeful, and client specific.
If Sally’s goal is to have improved sitting balance for UE dressing, your intervention should not be to have her sit in a wheelchair to play a card game. Instead, she should be working to sit on an unsupported surface and completing a self care task or a therapeutic activity which facilitates core muscle engagement.
If Tatum’s goal is to have improved behaviors while grocery shopping and during bath time, but has no deficits in vestibular processing, he should not be placed on a swing every OT session.
How do we do better?
Schedule time for intervention planning.
Consider: at the start of every week (Monday morning); at the start of each workday; or before you go home for the day.
Create specific interventions for each goal to actually improve your clients’ performance in the occupational deficit.
This should include upgrading, upgrading, upgrading the task until the goal is met
This may include environmental adaptation
Allow your interventions plan to be flexible
We work with people. Our clients may have really good days and not-so-good days. They may have achy joints with bad weather. They may have not slept well the night before. This is real life, and is an excellent opportunity to have a true understanding of the deficits and where progress has been made.
We can make progress on bad days too.
Sometimes we have to go back to the basics to succeed. Therapists in all settings have room to do better, and that's a good thing, if you ask me. Occupational therapists thrive on progress. For our clients and for ourselves.
You're doing well, my fellow OT. Keep helping your clients live today. Live better tomorrow. And inspire others to do
Your (fellow) OT,