Thinking Bigger!

I love the great work that Occupational Therapy can do for humankind and the world. We have an important perspective on Health Care and we can do so much more to advance the goals of OT.

Recently, I published a book, it is a parable about acceptance and resignation. It is about finding joy in the face of obstacles. I believe it has a message for everyone. It is on $0.99 promo on Amazon currently (it's at http://www.amazon.com/recognition-of-a-prisoner-ebook/dp/B00ANFD1TE/ref=sr_1_1?ie=UTF8&qid=1360215629&sr=8-1&keywords=recognition+of+a+prisoner).

This was a little of me thinking bigger but really not what I mean. Occupational Therapy and Functional Therapy are such powerful ideas. It's time for me to do more with them.

If you would like to be a part of it contact me at EdKaine@FunctionalTherapist.org and lets see how far we can go.

Yours,
Ed

Top 5 Differences between Acute Care and Outpatient OT

Top 5 Differences between Acute Care and Outpatient OT

 

Currently I am making a transition to Outpatient. I have done a little outpatient OT in the past and 17 years of Inpatient and Acute Care from Pedi to Geriatrics, Neuro to Burns.... Outpatient is a different animal.

 

The main differences are:

1. Scheduling
2. Billing and Coding
3. Documentation
4. Patient Type (Acuity and Diagnosis))
5. Outcomes Measurement

Scheduling

In Acute Care there are so many factors that can influence your time. Patients are ill, they leave the floor for testing. In our case we made an extensive list of patients that the therapists would see. If the patient was unavailable you may check back, otherwise you proceed.

 

In Outpatient there is a much more regimented pattern. Blocks of time are in 1/2 hour for treatments and 1 hour for evaluations. It is possible to get the patient from the waiting room, see the patient and write the note in a 1/2 hour but just barely. If there are any delays to the schedule it is very difficult.

 

There would surely be ways to make the process for both more efficient.

 

Billing and Coding

In Acute Care we are paid by DRGs or Diagnostic Related Groups. Essentially, if some one has a pneumonia with no modifiers you get one rate. There is a tremendous benefit to this if your facility recognizes the benefits of rehab for decreasing Length of Stay - LOS. The more Rehab, the shorter LOS, the more money for the facility. However; many places did not figure this out and Acute Cares may be somewhat understaffed as a result.

 

In Outpatient we are tied to the myriad Insurance Company Demands. The history of Outpatient includes a little bit of fraud, so... everyone suffers and a lengthy process to justify treatment ensues. Now, there were a few bad apples but everyone is required to dedicate a lot of time to making sure the payers believe rather than treating the patients. Necessary evil? Or unfortunate consequence of a few bad apples. Anyway, we document ICD9 codes, E-Codes and Now G-Codes, just to make sure it's okay.

 

Authorization in Outpatient is an unfortunate waiting period after the evaluation while the Insurance Company decides if you merit treatment. Usually you do, but certain insurances take more than a week to tell you. Unfortunately, that week can be the most painful of weeks.

 

In our facility Acute billing is electronic for the therapists but only because I wrote the database that did it. In Outpatient it's on paper and gets added by administrative support people.

 

Documentation

In Acute Care many facilities have gone to Computer Based systems, we have. We write an Eval with separated data in a database. This generates as report that can be pasted into Cerner. Later this year we will be going to Epic which may have a lot of clicks and limited reproducibility but we shall see.

 

In Outpatient there are significant concerns due to the billing and coding process and the need to have Doctors specifically sign the plan of care. Also, an authorization must be sent with the Doctors reviewed POC to the insurance company to seek the Authorization I mentioned above. 

 

Patient Type (Acuity and Diagnosis)

In Acute Care therapists see the sickest of the sick. Patients who need to stay in hospital need to have a lot of care given to them. Also, the culture of hospitals often leads to patients spending much too much time in bed. Bed rest is terrible for most conditions (maybe preterm labor can justify it and the others are for very short periods of time, like just after a procedure).

 

In outpatient, the great majority are ambulatory. They have a few focused injuries and if the Doctor ordered care for any particular one we can work on it. The body and function is divided and specialists are called for a careful review of the body part the Doctor referred for. I have an inclination to want to review and treat the whole person. In this case sometimes I can't.

 

This doesn't make much sense sometimes as we are trying to get people better and more functioning. I think this is the challenge to expand the care of patients to their ultimate needs rather than what they remembered to ask for in the Doctor's office. Also, with the minimal recognition of OTs roles many Shoulder and Elbow patients are referred to PT and not OT. If we're going to go by that unfortunate divide the body system we should at least adhere to it.

 

Outcome Measurement

In Acute Care this is currently pretty limited. The DRG system has devoted resources towards monitoring Length of Stay or LOS. The focus is on getting people out, back home and not returning within 30 days for any reason. The measurement around these values is somewhat patchy but can be done with effort.

 

In Outpatient there has been a lot more effort on developing and using outcome measures. Currently, I am writing a tool to help administer, score and report on the DASH - the Disability of the Arm, Shoulder, Hand Scale. This scale nicely gives a score out of 100. It looks like a disability score but not officially. It has a lot of great ideas for helping guide the functional components of treatment.

 

I think the outcomes measures would be a big help.

 

Summary

Overall there are many key differences between acute care and outpatient OT. There are several others and I'd love to hear your ideas and experiences about them in the comments below. 



The CRAFT Model - Dynamic Variations of a Holistic Model - Part 5

Restoring Balance To The Platform

In the preceding scenarios we reviewed the sources of imbalance, now we will discuss a central principle of Functional Therapy, supporting function.

Let's revisit the model as it is unbalanced by a deficit in abilities. No matter the ability pillar we can upset the balance of functions. Most often healthcare professionals work to restore the physical body, in fact, most of medicine is working towards addressing physical complaints, symptoms and problems. The deficits from mental, social and motivational impairments can lead to similar imbalances.

Let's return to the person with the deficit of the motivational pillar. This might have been caused by a depression or perhaps the depression is caused by the imbalance of functions; by not performing a balance of functions you can lose your motivation. Consider the lack of balanced function as a risk for other deficits.

The CRAFT Model is a snapshot of the status of an individual; consider personal history an elucidation of which caused which, in other words we get to find out if it was 'the chicken or the egg'. I wish to popularize the idea that an imbalance in functions could lead to other deficits any of the other areas. 

In order to most effectively help a person we work to restore balance to function. In this case we depict an external support, possibly a social support, to help restore balance to the platform of functions. 

"The worst place to decide whether to get up and get dressed is in bed." - Unknown  

By supporting a person doing functional things we allow them to use their mental, social, physical and motivational abilities in  functional way. In short, "the more you do, the more you can do." They also engage with their physical environment, social supports, temporal situation and consider their cultural background more deeply. The Functional Therapist and Functional Therapy Associate works to assess the limitations and then seeks to expediently restore balance. The ability to call on the whole model and more gives Functional Therapy its strength.

OTs and Functional Therapists might occasionally find themselves off the course of purely a functional or occupational approach to care; the CRAFT model seeks to help get us back to the value of doing functional things in therapy. We must consider the paths of remediation and compensation as ways to restore function along with external support and means to seek balance in function as a reasonable jump off point for a return to living.

Thank you for reading.

Yours,


Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC

P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line. 

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 4

Contextual Barriers to Function

Today we'll explore the imbalances in the model as imposed by contextual barriers. Let's review the CRAFT Model as we consider the Context Level.

The CRAFT Model is built on the Context of the individual. One premise advanced by the World Health Organization in 1980 is that environmental, or as we call them contextual, barriers can limit life roles and hold a person back from reaching their full potential. In the CRAFT Model we represent this as unbalancing the person. Let's look at the external barrier as a depiction of contextually imposed imbalance...

With or without any disability or volitional causes, external barriers can impose functional imbalances; let's consider some particular external barriers.

Cultural Barriers

The culture of a people can be hard to define but fresh eyes can often distinguish differences. For instance, in New England some basic premises are that most work days are 8 hours, that men and women work in certain careers that are somewhat gender typed, that racial prejudice is discouraged and that education is valued. In some European cultures a siesta, or afternoon period when work closes for a nap is customary, in other places it is very discouraged for women to work outside the home or even to be educated, and other stark differences in equality between different groups. Imagine the effect of a culture which prevents a little girl from learning to read, or who's family must give a dowry to have their young daughter married. These are just more dramatic examples of how the culture of a place, an institution or even a family may affect an imbalance in the roles you take on.

Temporal or Situational Barriers

The temporal (time based) or situational context is often interpreted through cultural eyes. What happens in the different times of day, times of year, times of life? What happens in a situation where people or events are involved? In the middle of the night, after 'bankers hours', in the winter, or when we're at retirement age in America. In terms of situational barriers, times of war or famine spring to mind as particular situational and temporal barriers to full human potential.

Social Barriers
When there may be many positive people and supports in a person's life imagine the debilitating impact if a harmful person as a parent, or caregiver. A person in a position of trust may betray it; a misleading statement or a lie may lead to disaster. In a group people may make unwise choices, a gang may influence a person to harm others or break the law. In light of these, more and less dramatic mistakes can be made.

Physical Barriers
When a person with a mild limitation in mobility confronts a major physical barrier it can prevent them from participating in activity. Something we now take for granted, like ramps into buildings and at curb sides, can allow a person to enter their workplace, and a lack of them can prevent someone from working, or shopping, or getting into a movie. Our culture has often worked to limit physical barriers, and OTs have often been the catalysts to find other barriers. Not all cultures have such strong advocates or such resourses that they can provide these adaptations. Consider the availability of prosthetics, wheelchairs, reading glasses and other devices to overcome physical ability barriers in the developing world. Consider the availability of clean drinking water, food and shelter as aspects of physical context and we can see part of how this area can expand.

The areas of the 4 contexts overlap in areas and are interpreted through the experience of the person in their context. In this article we only touched the surface of how we might interpret barriers in context; it is for the eyes of the OTs and Functional Therapists along with engineers, architects, governments, businesses, and individuals to find and continue to work for the betterment of personhood through removal or compensation for external barriers.

In light of all the potential limitations that may be caused by external environmental or contextual barriers we may also find where external supports help a person regain balance. That will be the focus of our next discussion as we elaborate on dynamic variations of the CRAFT Model.

Thanks for reading,

Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC




P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line.










 

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 3

The latest posts have depicted imbalances at the Functional level and the Ability pillar level. In this we will identify the change we have made at the Context level; you'll notice that, with a nod to Gary Kielhofner and the Model of Human Occupation, we have added the Temporal Context to the context level.

Each of the contexts influence the effectiveness of the Abilities and the choice and balance of Functions. In previous posts we have reviewed the Physical, Cutural and Social aspects of context; why does the temporal context merit inclusion at the context level? We'll see it plays a particularly important role in our lives.   

Temporal relates to factors of time. On the most rudimentary level that could include the time of day, or time of year, but let's also consider factors like time of life. For instance, we are currently preparing for the start of a new school year. That has aspects of it being August, but also of the time of our lives; it is much different for my children who will be going to school than for me who will be getting them ready in the morning and helping to get them there 'on time'. Also, it will be different at 7am than it will be at 3pm; temporal factors have influence on all other areas.

Time influences us greatly and we initially left it as part of the Abilities as in the time of a person's life (and it certainly remains there) and as a modifier for social and cultural contexts. Now though, considering that we have included it here I hope you can see how well it fits.

If you would like to learn more about the Model of Human Occupation for a thorough look at the multifactorial influences in a persons life I reccommend this link: http://books.google.com/books?id=WOYkTQNvNUgC&pg=PA5&lpg=PA5&dq=temporal+moho+model+of+human+occupation&source=bl&ots=ZL9YhsqRGG&sig=y10u4LhupUoOU1z0c8xu5WNFHTI&hl=en&ei=3ExvTL7DNYK88ga98ZHwCw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCIQ6AEwAg#v=onepage&q=temporal%20moho%20model%20of%20human%20occupation&f=false. This is Google Book's full version of the text Model of Human Occupation: Theory and Application By Gary Kielhofner. This important text is a core part of an OTs training, and I am proud to reference it here. 

When we graduated from University with our degrees in Occupational Therapy we marvelled at our new eyes for seeing the world. We were given a gift in being able to pull together the many ways that people function and we had tools to help them. It is the gift of seeing a person wholistically and in relation to the many other persons and factors around them. In some ways we are almost constantly surprised at the amazing feats we can acheive and at the relative of simplicity of its 'common sense'. OTs and Registered Functional Therapists and Associates have a very refined and deeply trained 'common sense'; and I want us to share it with the world.

Thank you for reading.

Yours,

Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC

P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line.  

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 2

Balance and the Ability Pillars of the CRAFT Model


People need to participate in life roles; enabling people to do things that are meaningful to them is a central goal of Functional Therapy. In our last segment we delved deeper into the 'things we do' as functions in our lives. We looked at what might happen when the categories of function are out of balance with the depiction of the adage 'All work and no play makes Jack a dull boy!' Now we will look more at the pillars of ability and problems that may arise from impairments and disabilities.

The ability pillars support the balanced platform of the 'things we do' or functions, these are sometimes called occupations by OTs. The balance of this platform depends on the integrity of the 4 pillars; a significant impairment in any of the Physical, Mental, Social or Motivational pillars can prevent a person from performing functions and participating in life roles. Lets consider the model as we depict a failing pillar.

In this simplified case, only one pillar has been affected; this may be how an imbalance starts. Over a period of time, if the imbalance should persist, it is probable that other pillars may falter. It is important that a Functional Therapist work to restore the balance of personhood in order to start the process of recovery.

The motivational pillar contains the abilities that get us up in the morning, in many ways these are central to choosing to do things. In the following depiction, the motivational pillar has collapsed and this has unbalanced the platform of functions. During a depression the motivational pillar can be significantly impaired; in this case the first thing to falter is the self care function. In this unbalanced system the stresses on the rest of the system will cause other areas to falter.

Imagine replacing this broken pillar with any of the other pillars, deficits in physical abilities can have a profound impact on being able to do things, mental deficits can prevent a person from organizing and performing functions, and deficits in social abilities can limit all functions which involve interactions with others. These can be very limiting to the performance of life roles and a balance of functions.

At this level Functional Therapists can focus on remediation or working to restore the ability. While it is possible to perform exercises and tasks to improve physical skills one of the more effective ways of restoring the motivational pillar is to return to functional tasks. The central tenent of Functional Therapy is "The more you do, the more you can do!" By supporting the motivational deficit while supporting and encouraging function we help people return to balance.

In the next section we'll look at the CRAFT model and the context level.


Ed Kaine

President of the League of Functional Therapists
"Functional Therapy... the Next Generation of Occupational Therapy."


P.S. Please submit your comments or contact us at RFT@FunctionalTherapist.org.

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 1

Balance and the CRAFT Model


The CRAFT Model, the Context Related Abilities Functional Therapy Model, is a holistic model for a person living a life. As a concept it is designed to be dynamic and responsive to changes. In this article we will review the model and then focus on our the things we do (functions or occupations) and the concept of striving towards balance.

Lets review the CRAFT Model briefly. The Model is built upon the surface of a globe, this represents the context of the individual. The 3 aspects of context are the Physical Environment, Cultural Background, and Social Supports. If we consider a person in their workplace we encounter the physical layout of the place, this includes obvious things like accessibility with ramps and elevators but also less concrete things like propinquity (the proximity of your colleagues). This ties closely to the social environment and supports of your workplace; who can you rely on, who can you consult and who you can't. This is closely tied to the culture of your institution and to the area of the country in which you live; does work start at 8 am, are there lunch breaks, is overtime expected / appreciated / discouraged, is there a siesta?

Upon this context springs the abilities of the individual; the following are some examples to help you as you consider a person and the various abilities they display. The Physical pillar may be the most obvious, almost all of the effort in medicine goes towards realigning this area. Medications are most often directed at restoring organ function, reducing pain, reducing inflammation, etc.; surgical medicine is primarily focused on physical correction while most exercise and therapy is dedicated to restoring physical strength and structural integrity of a persons physical self. The Mental pillar is also significant as a person's safety and function relates to their attention, judgement, memory, orientation, etc.; more attention has been placed on this as the population ages as conditions like Alzheimer's Syndrome are more prevalent, but brain injury has highlighted coping skills and many challenges even for the very young. The Social pillar governs how a person interacts with others, different from the the social supports, these are the abilities that allow a person to maintain friendships, read others reactions, be empathetic, etc.; autism and schizophrenia have highlighted some of the social interaction disorders but as we know the spectrum from the charismatic to the recluse displays many skill levels. The Motivational pillar embodies those skills that get us up in the morning, ready for the world and its challenges; depression may make its biggest impact on this area, causing a malaise that may prevent a person from using many of the other abilities.

Upon the ability pillars sits the platform of functions or 'things we do', these are sometimes called 'occupations' by OTs. In particular we have three categories: Work, Leisure and Self Care. These are divided by the meaning of the activity; for instance cooking can be for work if you are employed as a chef or are preparing food for your family, or cooking could be self care if you are making a meal for yourself, or it could also be leisure if you are making a recipe from a new cookbook or magazine for a fun change. The meanings of the tasks reflect which category it goes into. Now let's explore an old adage where someone is out of balance.

"All work and no play makes Jack a dull boy."

This is what it might look like on the CRAFT model. What might be the consequences for Jack? Well, we can see that Jack's sleep and hygiene might be suffering, also his creativity may be stunted as he is not opening himself to outside leisure pursuits. He may in fact be a "dull boy." What might happen to his ability pillars, he might most obviously suffer from a lack of exercise and his physical health may falter, there is some evidence that working far too much overtime may lead to other deficits in mental performance, but he may also find himself irritable or lacking motivation. This may then impact his social supports who might be angry about him cancelling the vacation and a wife who is considering divorce.

As you can see, we have a dynamic model that allows us to quickly visualize the state of imbalance that someone is in. Over the next few articles we will explore other imbalances and what we might visualize as ways to help a person back to a purposeful and functional life.


Please leave any questions, ideas, or comments on the model below or email: RFT@FunctionalTherapist.org.

Thanks,



Ed Kaine, OTR, RFT
President of the League of Functional Therapists

"Functional Therapy... the Next Generation of Occupational Therapy."