OTA 209 - Continuity of Care (1)

Intervention Review

Monitoring of the client’s progress, needs, circumstances, and condition.

Intervention Review - Methods

• observation

• formal re-evaluation

Intervention Review - Observation

• Is the activity too easily accomplished?

• Are there signs of the client avoiding the activity?

• Does the client demonstrate frustration, anger?

• OTA reports observations to the OT for collaboration on modifying the treatment plan.

Intervention Review - Formal Re-evaluation

• Assessments used in initial evaluation are re-administered.

  • Completed by the OT or OTA with service competency

Modifying the Tx Plan - Changes may be due to:

• Interventions

• Medications

• Spontaneous remission of symptoms

Modifying the Tx Plan - Decision may be to:

• Continue per plan

• Modify the plan

• Discharge the client

• make a referral

Modifying the Tx Plan - Roles

• OTA notices and reports changes

• OTA  and OT collaborate on modifications to plan

Transition Services

services that prepare a client for a change

Transition Services - Reasons for Transition

• Client’s changing functional levels

• Developmental stage (e.g., aging issues)

• Need for programming change

• Environmental changes (e.g., living situation)

Transition Services - Role of OTA in planning for transition

• observes & reports changes

• collaborates in planning

• implements transition activities

• promotes continuity of care

• advocates and educates

Continuity of Care

Care across transitions that seamlessly addresses a client’s needs

Continuity of Care - Purpose

• Minimizes chances of regression

• Ethical care

Continuity of Care - Process

Consent from client to share information

Case Management

The CCMC (2013) has defined case management as the process of managing client wellness and autonomy through advocacy, communication, education, and identification and facilitation of services

Case Management - Purpose

Ensures the client receives the services they need

Case Management - Process

Understand the client holistically

Case Management - Who is in charge?

client

Case Management - What is the impact of care funding source (Medicare, private insurance, other)

impacts the types, frequency, duration and continuity of OT services

Case Management - What are the roles of the OT Practitioner?

• advocacy

• communication

• collaboration

• education

• service coordination

• client-centered

• quality + ethical care

Discontinuation of Services

Termination of OT services

Discontinuation of Services - Reasons

• Goals have been met

• Client wishes to terminate services

• Client has achieved maximum benefit

Discontinuation of Services - The Discharge Plan

• Summary of client’s progress

  • Goals

  • Changes

• Recommendations

  • Follow-up services

  • Equipment

• Environmental Support

  • Training of caregivers

• Roles

  • OTA provides input

  • OT prepares and implements summary

Quality Management

• A systematic assessment of the outcomes of a program

• Outcomes are the changes brought about by occupational therapy programming

Quality Management - Purpose

Assess, identify, and resolve issues that impact the client care process.

Quality Management - Roles

• OTA is in best position to observe and identify items that require attention

• OT is responsible for the overall process

QA Assessment Areas

• major assessment areas in mental health

  • progress toward goals

    • review observable behaviors and their measurements. were they achieved?

  • client satisfaction with programming

    • exit interviews

  • behavior rating (accomplishment of desired occupational behaviors)

    • rating scales (COTE, COPM)