Person-Centered Evaluation and Assessment Administration

Choosing and Administering Assessments

• Occupational therapists choose assessment tools to gather data, selecting tools designed to elicit the data they lack.
• If a tool requires training, the practitioner should complete it as directed by the assessment developer before using the tool.

Establishing Competency

• Practitioners should read the manual and observe a competent practitioner administer the tool.
• Novice evaluators should practice administrations and scorings, followed by observation from a competent occupational therapist.
• Observation helps determine competency and allows for feedback.
• Establishing competency in a tool is an ethical responsibility.
• Incompetent administration can lead to faulty recommendations and poor intervention planning.

Ethical Components of Assessment Delivery

• Consent: Obtain consent, adhering to the principle of autonomy in the AOTA Code of Ethics (AOTA, 2015).
  • Inform the person of the assessment's purpose, procedures, and how the information will be used, using understandable language.
  • Respect the right to decline the assessment.
  • If the client cannot understand, provide information to the responsible party (e.g., spouse, partner, family member with power of attorney).

Preparing for Assessment Administration

• Set up the testing environment and gather necessary materials.
• Follow procedures outlined in the manual for standardized assessments, including verbal/behavioral cues or scripts.
• Being prepared facilitates smooth data gathering and reduces errors.
• Anticipate factors that could impact administration (e.g., medication effects) and adjust the schedule if needed.
• Be prepared to manage and adapt to unexpected occurrences by providing choices, switching tools, or making data gathering more informal.

Table 4-2. Properties of Reliability to Consider When Choosing an Assessment:

• Intended Use of Tool: Intake measure
  • Property of Reliability: Internal consistency
  • Rationale for Use: Shows that the items are measuring a single construct consistently.
• Intended Use of Tool: Outcome measure
  • Property of Reliability: Rater reliability (inter and intra)
  • Rationale for Use: Can be confident the information you are getting at intake is reliable regardless of who completes assessment.
• Intended Use of Tool: Diagnostic tool
  • Property of Reliability: Test-retest reliability
  • Rationale for Use: Measurement does not change when a change is not expected.
• Use by multiple therapists
  • Property of Reliability: Interrater reliability
  • Rationale for Use: Can be confident the information you are getting at intake is reliable regardless of who completes assessment.
• Property of Reliability: Standard error of measurement
  • Rationale for Use: Can identify how much error is likely present in this observed score.
• Property of Reliability: Minimal clinically important difference (MCID)
  • Rationale for Use: Can identify if a change is clinically important.
• Property of Reliability: Internal consistency
  • Rationale for Use: Shows that the items are measuring a single construct consistently.
• Property of Reliability: Sensitivity/Specificity
  • Rationale for Use: Demonstrates the tool's ability to diagnose a condition.
• Property of Reliability: Interrater reliability
  • Rationale for Use: Useful when it is important or essential that two or more therapists assign similar ratings to performance.

Therapeutic Reasoning Throughout the Evaluation Process

Table 4-4

• Component: Screen data
  • Purpose: Establish if the person can participate in the evaluation process and benefit from occupational therapy.
  • Guiding Questions for Therapeutic Reasoning: Does the referral list specific concerns? Have there been recent changes in occupational performance, living situation, or health status? Does this person need occupational therapy services?
• Component: Consider key outcomes
  • Purpose: Establish indicators that reflect therapy-influenced positive change.
  • Guiding Questions for Therapeutic Reasoning: What are the target areas of intervention for this person? What data do I need to provide evidence of program effectiveness? What outcome areas are present for a majority of our clients that we want to measure?
• Component: Choose assessment(s)
  • Purpose: Intentionally choose assessments based on the person, setting, and circumstances of therapy.
  • Guiding Questions for Therapeutic Reasoning: What data from the screening helps define my approach to the person? Given the person and the context, which valid and reliable assessments could elicit the occupational performance data I need the most? Do these tools take into account the client's culture or cultural identities? Is this tool practical for use in my current practice setting? Am I qualified to administer the assessment?
• Component: Administer assessment(s)
  • Purpose: Effectively and efficiently collect valid and reliable data.
  • Guiding Questions for Therapeutic Reasoning: Have I obtained consent from the person or his or her proxy? Are there precautions to consider? Is the testing environment set up to support success of the person and reduce error?
• Component: Generate an occupational profile
  • Purpose: Establish a synopsis of the person's occupational history and patterns of performance.
  • Guiding Questions for Therapeutic Reasoning: Who is this person and what has been his or her pattern of occupational performance through time? Are there other relevant sources of data (e.g., caregivers, spouse or partner, other professionals/staff) that I need to consider? What are key occupations of priority for this client?
• Component: Analyze occupational performance
  • Purpose: Determine a person's capacities.
  • Guiding Questions for Therapeutic Reasoning: What key areas of occupational performance do I most need to know about in order to understand my client? What performance abilities may interfere the most with this person's most valued occupations?
• Component: Synthesize data and set goals
  • Purpose: Use data from assessments, in collaboration with the person, to make informed decisions about therapy.
  • Guiding Questions for Therapeutic Reasoning: Have I adequately identified the person's strengths, areas of need, and priorities for intervention? What practice model is guiding my therapeutic reasoning around intervention planning? What, if any, referrals to other professionals should be considered?
• Component: Reevaluate
  • Purpose: Reevaluate or reassess the client after a certain period of time to monitor the progress or increase understanding of the client.
  • Guiding Questions for Therapeutic Reasoning: Have more recent observations led me to believe a deeper understanding of a particular construct is needed? Are there components of the occupational profile that require expansion? Are there areas of occupational performance that need further in-depth analysis to determine the root cause?
• Component: Measure outcomes
  • Purpose: Compare findings of tools across time with support adjustments in individual plans of care as well as programmatic changes.
  • Guiding Questions for Therapeutic Reasoning: Do the tools used have established reliability and validity for the populations we see most often at my setting? How do we build outcome measures into our processes to ensure reliable data gathering?

Strategies to Increase Clarity of Individual's Occupational Picture

Triangulating Data

• Gather multiple perspectives by combining data from medical charts, client evaluations, and information from family members or other members of the medical team.
• This gives greater insight into the person's occupational picture and identifies unclear areas.

Performing Validity Checks

• Involves interpretation, reflection, and questioning to ensure observed actions align with their perceptions.

Nonverbal Communication

• Practitioners should be aware of nonverbal signs and signals.
• Extrinsic signs of professionalism include:
  • Maintaining an open and welcoming posture.
  • Eye contact.
  • Active listening.
• Effective use can support communication and enhance the evaluation process.

Scoring and Interpretation

• Competent practitioners practice scoring chosen assessments.
• Practitioners should be vigilant for the possibility of scoring errors such as being too lenient, too severe, or inconsistent.
• Ethical practice requires studying assessment manuals, practice, and ensuring competency in scoring and interpretation.

Generating an Occupational Profile

• The occupational profile presents a picture of the person's unique values, beliefs, roles, habits, and routines.
• It is an essential component of every evaluation (AOTA, 2014).
• Practitioners should gain an understanding of how a person views himself or herself and identifies the person's occupations of importance.
• Practitioners identify intervention priorities and the key desired outcomes of therapy.
• Occupational therapists generate an occupational profile that summarizes a person's occupational history, his or her patterns of daily life, occupational engagement and performance, and the person's personal interests, values, and goals related to engaging life in meaningful ways.
• The occupational profile creates a holistic picture.
• The AOTA created an occupational profile template that includes essential components drawn from the OTPF (AOTA, 2014).
• The template structures the process to ensure the profile a therapist generates elicits the person's report; gathers data about the person's environment; and considers cultural, personal, temporal, and virtual contexts that support or create barriers to occupational engagement and elicit the person's goals (AOTA, 2017).
• The creation of the occupational profile supports client-centered practice and the creation of collaborative goals.

Analyzing Occupational Performance

• Observation of performance is one of the first tools a practitioner can use to generate data.
• Practitioners synthesizing initial cues could reason that cognition, ability to care for self, surroundings and safety may all be areas to target.
• A critical aspect of therapeutic reasoning is decision-making regarding which components of a person's occupational performance are most likely to impact function.

Synthesizing Data and Setting Goals

• Synthesize data to inform the creation of person-centered, occupation-focused goals and intervention plans.
• Synthesis of data is supported when the practitioner considers the person's strengths and areas in which occupational performance is challenged, including the identification of specific skills and factors that impact performance.
• Summarizing the person's performance is enhanced when a therapist uses a theoretical model to support the organization of key pieces of data about the person's occupational profile, current occupational performance, and environmental and social context.
• Goals within occupational therapy should be relevant, valued by the person, and focused on function and improving an individual's occupational performance.
• Goals should be measurable so that progress toward them can be monitored.
• Goal setting is evidence of a complete initial evaluation and should reflect the data that were gathered while generating an occupational profile and analyzing occupational performance.

SMART-goal model

• A framework commonly used by a variety of health-care professionals including occupational therapists to write goals
• S = Specific, M = Measurable, A = Attainable, R = Relevant, and T = Time (Bowman, Mogensen, Mardland, & Lannin, 2015).
• Constructing SMART goals can help practitioners document the intended outcomes of therapy and help engage the person in a goal-setting process that provides a roadmap for collaboration in therapy.

Prioritizing Goals Using Therapeutic Reasoning

Table 4-3

• Goal Component: Urgency
  • Therapeutic Reasoning Questions: Is the problem situation urgent? Does it cause a high level of distress? Does it occur frequently?
• Goal Component: Importance
  • Therapeutic Reasoning Questions: Is this a problem situation the person feels is so important she or he is motivated to act on it?
• Goal Component: Timing
  • Therapeutic Reasoning Questions: Is this a problem situation that can be managed now? Does the person currently have the resources to address this situation now?
• Goal Component: Complexity
  • Therapeutic Reasoning Questions: Is this a complex problem situation with many parts? Can the situation be divided into more manageable parts?
• Goal Component: Success
  • Therapeutic Reasoning Questions: Is there a high probability that addressing this problem situation can lead to success?
• Goal Component: Spread effect
  • Therapeutic Reasoning Questions: Which of the problem situations, if it was managed, could lead to improvements in other parts of the person's life situation?
• Goal Component: Control
  • Therapeutic Reasoning Questions: Is this a problem situation that is under the person's control, that is, she or he can address it? Does action to address this situation require that someone other than the person take action?
• Goal Component: Cost/Benefits
  • Therapeutic Reasoning Questions: Do the benefits of working on this problem outweigh the costs in time, stress, effort, or impact on relationships?

Reevaluation

• Reevaluating is a key part of the evaluation process.
• Evaluation is an ongoing process that occupational therapy practitioners continue each time they engage the person.
• Ongoing synthesis of all available data can help the practitioner consistently build depth into the occupational profile and his or her analysis of a person's performance to build on the foundation established in the initial evaluation.

Measure Outcomes

• Outcome measurement determines whether the intervention is effective or if a new strategy needs to be implemented.
• Reliable outcome measurement justifies the interventions the practitioner provides.
• Practitioners are able to build the body of evidence that supports occupational therapy practice (Unsworth, 2011).
• The use of reliable and valid assessments in the evaluation process supports outcome measurement.
• These practices allow for the measurement of change through time and provide one form of evidence that can support practice.