Occupational
Therapy
Update
A Model for Community Practice Linda
T.
Learnard,
Elizabeth
O.T.R./L.
Devereaux,
A.C.S.W./L.,
O.T.R./L.
Current health care trends have necessitated changes in the design and provision of mental health services. As Dickie and Robertson (1) havestated, “Responsibility for mental illness has shifted from a formal social structure (the state hospital) to reliance on unspecified individual community resources. To help mdividuals with mental illness meet their goals for integration and stabilization in the community, a rehabilitative process that focuses on functional outcomes is required. When clients f.il to achieve goals, too often either the client receives the blame and is labeled a treatment fiuilure or the system is said to lack the necessary fiscal or environmental resources. But more often it is the flilure or absence of a good functional assessment, comprehensive planning, and rehabilitative interventions. Successful community intervention for people with mental illness requires an individualized plan that has multiple facets and multiple levels. Hospitals and other inpatient “
Ms. Learnard is in private practice. Address correspondence to her at R.R. 1, Box 4075, Lincolnville, Maine 04849. Ms. Deveneaux is associate professor in the department of psychiatry at Marshall University School of Medicine in Huntington, West VirginiL This column is part of H&CP’s Interdisciplinary Update series; editor for occupational therapy is Kathleen Kannenberg, M.A., O.T.R.
Hospital
and
Community
Psychiatry
treatment settings have been the traditional sites for occupational therapy. But the practice of occupational therapy, along with that of other mental health professions, is in transition from hospitals and clinics to community settings. This column presents a model of how a community-based occupational therapy practice can effectively support the community integration of people with severe mental illness. It describes an independent practice ofoccupational therapy serving rural areas ofthe state ofMaine. Clients are referred to the therapist from a variety of state agencies, community programs, and independent institutions. They have a primary diagnosis of severe mental illness, often with dual diagnoses. The referring agencies contract with the occupational therapist to help them creatively rethink and assess their interventions with severely disabled clients. These clients have long been considered treatment failures because of their inability to function in normal daily routines or social interactions in vocational or community settings. They have typically consumed large amounts of fiscal and institutional resources. The services provided through this model are generally not financed by direct health care dollars but by funding from agencies such as vocational rehabilitation departments and adult protective services. The conceptual model This model of practice is based on an individualized client plan composed of three levels of intervention: planning, environmental structure, and skill building. The levels of intervention are not provided in isolation or
September
1992
Vol.
43
No.
9
sequentially but must occur as part of the individualized plan. The timing, level, pace, and sequence of the interventions are directed by the client’s needs and wishes. To provide these levels of rehabilitative intervention, the occupational therapist must have a thorough understanding of community systems, the client’s environmental requirements, and functional assessment. The client’s need for these interventions and the occupational therapist’s expertise in providing them form a natural marriage for community practice. Planning. Intervention at the planning level requires a clear understanding of the client’s goals and of the resources that are available for achieving them. Intervention at this level gives clients the opportunity to express long-term goals, hopes, and dreams and to define them in terms of performance outcomes-holding a job, being able to take care of personal needs, having a safe and secure place to live, and maintaining relationships. Family members and caregivers often identify crisis intervention services and respite care as desired outcomes. Work at this level requires the occupational therapy professional to convey respect, encouragement, and a sense of individual dignity to the client while helping the client frame his or her vision of the future. At the same time, the professional must link the client with resources and supports for accomplishing the goals. Practitioners must be aware of a variety of strategies and resources and select the approaches best suited to the client’s world view. Because no single approach will work for all clients, an informed eclecticism that addresses the resources and needs of the client and the system is essential. An example of an occupational therapy intervention at the planning level is work with a seriously ill woman who was under state guardianship in a long-term-care institution. The client’s major goal, to return to a job similar to one held years before-sorting and hanging items in a clothing store-had been considered unrealistic because she was housed on a locked unit to con-
869
trol her constant screaming. However, the resources of the state guardian, the Maine Department of Mental Health, the institution, a Goodwill agency, the Bureau of Vocational Rehabilitation, and a local grocery store were coordinated to design an individualized plan to help the client achieve her goal. The client’s screaming, a response to her disorganized and chaotic setting, was eliminated by providing her with a structured, organized setting that was more compatible with her need for decreased sensory stimuli. She is currently working four hours aday at alocal thrift shop while awaiting a community placement. She shops at a localgrocery store with the money she earns, which is the positive reinforcement she desired. Thus the approach selected for this client combined recognition of her goals with psychosocial and cognitive rehabilitation and an environmental assessment of a variety of community resources. Environmental structure. In the three-level model, the environmental structure provides the support that &cilitates learning and enables the client to achieve the highest level of function in the desired activity. The environmental structure encompasses not only the physical setting, such as the residential situation or work place and its many components, but also the individual’s cognitive, sensorimotor, and psychosocial environment; adaptations must be made in both kinds of structures to help support successful outcomes. The client may need environmental supports such as one-step directions, visual or physical cues, or slower pacing of cues to process the information he or she needs to perform the desired activity effectively. The client’s values, familiar roles, and past successes and failures indicate where the environmental intervention should begin. An example of this level of intervention is the development of a group home for clients under state guardianship. The state’s adult protective services contracted with the occupational therapist to move six patients from a long-term institutional setting into the community.
Each had a history of severe mental illness with more than 20 years’ institutionalization and numerous unsuccessful attempts at community placement. The occupational therapist administered comprehensive functional assessments to identify each client’s skills and deficits within the context of individual goals, and the results were used to design the residential program. The major conceptual difference between this group home and others was that it did not force clients to fit into an existing program structure. The group home was designed to incorporate picture cues, double stairway railings for those who were gravitationally insecure, and rocking chairs and hammocks that provided calming sensory stimuli. Clients helped select colors for the rooms and for linens and other furnishings. A consistent daily schedule with set times and activities was developed. Household tasks and social activities were geared to match clients’ attention spans and performance levels. The move to the group home was a carefully planned transitional process. Before the move, the staff from the group home visited the institution and interacted with the clients to help develop familiarity and trust. After the move, the institutional staff came to the group home and worked with each person, tapering off their intervention as the home’s staff assumed the role ofprimary caregivers. All six clients have remained in the group home for eight months; previously their longest community stay was two weeks. Clients’ overall performance levels have also improved. The program has reduced the cost of care for each client by more than $100 a day compared with institutional care. Skill building. Intervention on this level focuses on the day-to-day functional skills of clients. A comprehensive review of the client’s abilities and deficits in desired activities of self-care, work, or leisure is critical. Difficulties in performance can arise from cognitive, physical, perceptual, psychological, social, or developmental dysfunction. The underlying skill deficits often exacerbate psycho-
social disabilities and contribute to experiences of failure. At the skill-building level, the occupational therapy practitioner may provide direct or indirect services to help the client develop skills or use compensatory strategies or both. These strategies might include a change in the environment or the alteration of normal task procedures so the client can accomplish the task successfully. Instructions given by job coaches or employers can be clarified. The practitioner helps the client learn to ask for guidance in whatever form is most helpful, whether it is verbal directions or visual demonstration. Clients’ work tasks can be reorganized to use their strengths rather than adapted to accommodate their weaknesses. The approach used with a vocational rehabilitation client in a janitorial job illustrates intervention at this level. The client had difficulty concentrating and paying attention to detail on certain tasks. The functional assessment showed that he had gravitational insecurity and unstable balance on uneven surfaces, which meant that he did a poor job cleaning stairs. His work assignment was changed to tasks on flat surfaces. It was also determined that proprioceptive cues such as the use of heavier tools were more meaningful to him and held his attention longer than did using alight broom for sweeping. Thus the job coach and the vocational counselor could adapt work tasks to the client’s needs more quickly than if they relied on a time-consuming trial-and-error approach.
870
September
Hospital
1992
VoL
43
No.9
Case example A recent case referral to the occupational therapist highlights the three levels of rehabilitative interventions. The state guardian of a 35-year-old man who lived in a boarding home requested intervention to help keep the client out of continual crisis. The client had diagnoses of mental illness, closed head injury, and learning disabilities; he also had a lengthy criminal record and was on parole. The current crisis involved weekly arrests for shoplifting. Interventions by formal systems such as criminal justice and mental health had been unsuccessful and were considered in-
and
Community
Psychiatry
appropriate because of the client’s severe functional decompensation while in these systems. Intervention began at the skillbuilding level with a functional assessment aimed at clearly identifying the client’s strengths and limitations. The client performed best in prevocational testing, where he expressed his desire to go to work in the community rather than staying all day in the boarding home with nothing to do. The assessment showed that he responded to clear limit setting, visual cues, and positive reinforcement of successes and that his attention and memory could be improved by continuous cues. He could actively engage in talking about new behaviors and desired activities rather than focusing on old performance patterns. Intervention at the environmental level was aimed at facilitating new patterns of behavior in the desired activities. The occupational therapist developed a daily schedule for the client, including breakfast, grooming, and yard work at the boarding home. The schedule was posted so that the client could check off completed activities, and the boarding home operator agreed to provide cues to help him begin and end tasks. The guardian purchased an electronic game to help the client build his concentration. The client visited a variety ofwork sites, which provided visual cues for work options. A multidisciplinary team was created from key players involved in the client’s case, including the parole officer, the state guardian, the boarding home operator, and the representative of a Goodwill agency. The team met to review the assessment and discuss desired outcomes and supports. The guardian agreed to fund some community activities and transportation. The probation officer provided the name of another parolee performing community service who would act as a buddy and would provide continuous cueing to help the client interact appropriately in the community-that is, would review a list of appropriate social behaviors with the client at the beginning of each community interaction. A community-based exercise program and
a volunteer job at a soup kitchen were arranged. As outlined in the individualized plan, a follow-up meeting was held at three months. All team members, and especially the client, were pleased with his ability to demonstrate appropriate public behavior and avoid any criminal activity. The vocational rehabilitation agency is now willing to place the client in a sheltered workshop program.
Hospital
September
and Community
Psychiatry
the specific needs of each client. Each profession brings a unique perspective to an intervention plan. Occupational therapy’s holistic approach to service provision, its longstanding emphasis on rehabilitation outcomes, the variety of activities it can offer, and its ability to assess clients’ function in an environmental context and adapt physical and social environments all provide a strong base for community practice. As noted elsewhere, occupational therapists practicing in community settings can form collaborative relationships with consumers and with other professionals to tailor interventions to consumers’ needs in a way that preserves their dignity and enhances their quality of life (2).
Conclusions The individualized plan developed for each client must change, grow, and adapt in response to the client’s fluctuating needs. Interventions must focus on desired functional outcomes rather than on diagnosis and symptoms. Intervening on the planning, environmental, and skillbuilding levels is a dynamic and creative process. There is no cookbook. The broader the provider’s perspectives are, the better able the health care team is to work collaboratively in developing the resources and flexible approaches necessary to meet
NORTH
References 1.
DickieVA,
Robertson SC: Perspectives on functioning. Hospital and Community Psychiatry 42:575-576, 1991 Devereaux EB: Community-based practice. American Journal of Occupational Therapy 45:944-946, 1991
human
2.
DAKOTA
State.
Hospi Nodh Dokoio Depoilment
o Humon
S.res
SUPERINTENDENT STATE HOSPITAL TheNorthDakotaStateHospital, catedinruralsouthcentraiNoflh Dakota, seeks a board certified psychiatrist to serve as CEO of a 398-bed, JCAHO-accredited, TItle XIX certffied inpatient psychiatric and addiction hospital. As Superintendentyou will have complete responslbllityfordirecting all treatment and care program activities including all administrative and support functions for the facility. Auademic appointment with the University of North Dakota School of Med,cine is possible. Interested candates must have received an MD degree. and achieved a resency in psychiatry, all at approved locations, while having a minimum of two years of experience in the management of a comprehensive mental health care facility. The successful candate wouki also be board certifled in psychiatry or accompllehboardcertfficationwfthinthreeyearsfollowing thedateof appointment. The candate would be qualified to obtain a license to practe rneddne and/or surgery in North Dakota. Salary commensurate with qualifications excellent fringe benefit package. We offeradvantagesof urban lifenestled in aruralsettingwhich includessomeof North Dakota’s most outstanding recreational opportunities. Interested applicants should send curriculum vitae in confidence (to be received prior to the close of business September 18, 1992) to: Lyle A. Grove, Personnel DiectDr, North Dakota State Hospital, North Dakota Department of Human Services, Post Office Box 476, Jamestown, North Dakota 58402-0476. For more information, call collect (701) 253-3015. E/O/E/M/F/H
1992
VoL
43
No.9
871
Therapy
Update
A Model for Community Practice Linda
T.
Learnard,
Elizabeth
O.T.R./L.
Devereaux,
A.C.S.W./L.,
O.T.R./L.
Current health care trends have necessitated changes in the design and provision of mental health services. As Dickie and Robertson (1) havestated, “Responsibility for mental illness has shifted from a formal social structure (the state hospital) to reliance on unspecified individual community resources. To help mdividuals with mental illness meet their goals for integration and stabilization in the community, a rehabilitative process that focuses on functional outcomes is required. When clients f.il to achieve goals, too often either the client receives the blame and is labeled a treatment fiuilure or the system is said to lack the necessary fiscal or environmental resources. But more often it is the flilure or absence of a good functional assessment, comprehensive planning, and rehabilitative interventions. Successful community intervention for people with mental illness requires an individualized plan that has multiple facets and multiple levels. Hospitals and other inpatient “
Ms. Learnard is in private practice. Address correspondence to her at R.R. 1, Box 4075, Lincolnville, Maine 04849. Ms. Deveneaux is associate professor in the department of psychiatry at Marshall University School of Medicine in Huntington, West VirginiL This column is part of H&CP’s Interdisciplinary Update series; editor for occupational therapy is Kathleen Kannenberg, M.A., O.T.R.
Hospital
and
Community
Psychiatry
treatment settings have been the traditional sites for occupational therapy. But the practice of occupational therapy, along with that of other mental health professions, is in transition from hospitals and clinics to community settings. This column presents a model of how a community-based occupational therapy practice can effectively support the community integration of people with severe mental illness. It describes an independent practice ofoccupational therapy serving rural areas ofthe state ofMaine. Clients are referred to the therapist from a variety of state agencies, community programs, and independent institutions. They have a primary diagnosis of severe mental illness, often with dual diagnoses. The referring agencies contract with the occupational therapist to help them creatively rethink and assess their interventions with severely disabled clients. These clients have long been considered treatment failures because of their inability to function in normal daily routines or social interactions in vocational or community settings. They have typically consumed large amounts of fiscal and institutional resources. The services provided through this model are generally not financed by direct health care dollars but by funding from agencies such as vocational rehabilitation departments and adult protective services. The conceptual model This model of practice is based on an individualized client plan composed of three levels of intervention: planning, environmental structure, and skill building. The levels of intervention are not provided in isolation or
September
1992
Vol.
43
No.
9
sequentially but must occur as part of the individualized plan. The timing, level, pace, and sequence of the interventions are directed by the client’s needs and wishes. To provide these levels of rehabilitative intervention, the occupational therapist must have a thorough understanding of community systems, the client’s environmental requirements, and functional assessment. The client’s need for these interventions and the occupational therapist’s expertise in providing them form a natural marriage for community practice. Planning. Intervention at the planning level requires a clear understanding of the client’s goals and of the resources that are available for achieving them. Intervention at this level gives clients the opportunity to express long-term goals, hopes, and dreams and to define them in terms of performance outcomes-holding a job, being able to take care of personal needs, having a safe and secure place to live, and maintaining relationships. Family members and caregivers often identify crisis intervention services and respite care as desired outcomes. Work at this level requires the occupational therapy professional to convey respect, encouragement, and a sense of individual dignity to the client while helping the client frame his or her vision of the future. At the same time, the professional must link the client with resources and supports for accomplishing the goals. Practitioners must be aware of a variety of strategies and resources and select the approaches best suited to the client’s world view. Because no single approach will work for all clients, an informed eclecticism that addresses the resources and needs of the client and the system is essential. An example of an occupational therapy intervention at the planning level is work with a seriously ill woman who was under state guardianship in a long-term-care institution. The client’s major goal, to return to a job similar to one held years before-sorting and hanging items in a clothing store-had been considered unrealistic because she was housed on a locked unit to con-
869
trol her constant screaming. However, the resources of the state guardian, the Maine Department of Mental Health, the institution, a Goodwill agency, the Bureau of Vocational Rehabilitation, and a local grocery store were coordinated to design an individualized plan to help the client achieve her goal. The client’s screaming, a response to her disorganized and chaotic setting, was eliminated by providing her with a structured, organized setting that was more compatible with her need for decreased sensory stimuli. She is currently working four hours aday at alocal thrift shop while awaiting a community placement. She shops at a localgrocery store with the money she earns, which is the positive reinforcement she desired. Thus the approach selected for this client combined recognition of her goals with psychosocial and cognitive rehabilitation and an environmental assessment of a variety of community resources. Environmental structure. In the three-level model, the environmental structure provides the support that &cilitates learning and enables the client to achieve the highest level of function in the desired activity. The environmental structure encompasses not only the physical setting, such as the residential situation or work place and its many components, but also the individual’s cognitive, sensorimotor, and psychosocial environment; adaptations must be made in both kinds of structures to help support successful outcomes. The client may need environmental supports such as one-step directions, visual or physical cues, or slower pacing of cues to process the information he or she needs to perform the desired activity effectively. The client’s values, familiar roles, and past successes and failures indicate where the environmental intervention should begin. An example of this level of intervention is the development of a group home for clients under state guardianship. The state’s adult protective services contracted with the occupational therapist to move six patients from a long-term institutional setting into the community.
Each had a history of severe mental illness with more than 20 years’ institutionalization and numerous unsuccessful attempts at community placement. The occupational therapist administered comprehensive functional assessments to identify each client’s skills and deficits within the context of individual goals, and the results were used to design the residential program. The major conceptual difference between this group home and others was that it did not force clients to fit into an existing program structure. The group home was designed to incorporate picture cues, double stairway railings for those who were gravitationally insecure, and rocking chairs and hammocks that provided calming sensory stimuli. Clients helped select colors for the rooms and for linens and other furnishings. A consistent daily schedule with set times and activities was developed. Household tasks and social activities were geared to match clients’ attention spans and performance levels. The move to the group home was a carefully planned transitional process. Before the move, the staff from the group home visited the institution and interacted with the clients to help develop familiarity and trust. After the move, the institutional staff came to the group home and worked with each person, tapering off their intervention as the home’s staff assumed the role ofprimary caregivers. All six clients have remained in the group home for eight months; previously their longest community stay was two weeks. Clients’ overall performance levels have also improved. The program has reduced the cost of care for each client by more than $100 a day compared with institutional care. Skill building. Intervention on this level focuses on the day-to-day functional skills of clients. A comprehensive review of the client’s abilities and deficits in desired activities of self-care, work, or leisure is critical. Difficulties in performance can arise from cognitive, physical, perceptual, psychological, social, or developmental dysfunction. The underlying skill deficits often exacerbate psycho-
social disabilities and contribute to experiences of failure. At the skill-building level, the occupational therapy practitioner may provide direct or indirect services to help the client develop skills or use compensatory strategies or both. These strategies might include a change in the environment or the alteration of normal task procedures so the client can accomplish the task successfully. Instructions given by job coaches or employers can be clarified. The practitioner helps the client learn to ask for guidance in whatever form is most helpful, whether it is verbal directions or visual demonstration. Clients’ work tasks can be reorganized to use their strengths rather than adapted to accommodate their weaknesses. The approach used with a vocational rehabilitation client in a janitorial job illustrates intervention at this level. The client had difficulty concentrating and paying attention to detail on certain tasks. The functional assessment showed that he had gravitational insecurity and unstable balance on uneven surfaces, which meant that he did a poor job cleaning stairs. His work assignment was changed to tasks on flat surfaces. It was also determined that proprioceptive cues such as the use of heavier tools were more meaningful to him and held his attention longer than did using alight broom for sweeping. Thus the job coach and the vocational counselor could adapt work tasks to the client’s needs more quickly than if they relied on a time-consuming trial-and-error approach.
870
September
Hospital
1992
VoL
43
No.9
Case example A recent case referral to the occupational therapist highlights the three levels of rehabilitative interventions. The state guardian of a 35-year-old man who lived in a boarding home requested intervention to help keep the client out of continual crisis. The client had diagnoses of mental illness, closed head injury, and learning disabilities; he also had a lengthy criminal record and was on parole. The current crisis involved weekly arrests for shoplifting. Interventions by formal systems such as criminal justice and mental health had been unsuccessful and were considered in-
and
Community
Psychiatry
appropriate because of the client’s severe functional decompensation while in these systems. Intervention began at the skillbuilding level with a functional assessment aimed at clearly identifying the client’s strengths and limitations. The client performed best in prevocational testing, where he expressed his desire to go to work in the community rather than staying all day in the boarding home with nothing to do. The assessment showed that he responded to clear limit setting, visual cues, and positive reinforcement of successes and that his attention and memory could be improved by continuous cues. He could actively engage in talking about new behaviors and desired activities rather than focusing on old performance patterns. Intervention at the environmental level was aimed at facilitating new patterns of behavior in the desired activities. The occupational therapist developed a daily schedule for the client, including breakfast, grooming, and yard work at the boarding home. The schedule was posted so that the client could check off completed activities, and the boarding home operator agreed to provide cues to help him begin and end tasks. The guardian purchased an electronic game to help the client build his concentration. The client visited a variety ofwork sites, which provided visual cues for work options. A multidisciplinary team was created from key players involved in the client’s case, including the parole officer, the state guardian, the boarding home operator, and the representative of a Goodwill agency. The team met to review the assessment and discuss desired outcomes and supports. The guardian agreed to fund some community activities and transportation. The probation officer provided the name of another parolee performing community service who would act as a buddy and would provide continuous cueing to help the client interact appropriately in the community-that is, would review a list of appropriate social behaviors with the client at the beginning of each community interaction. A community-based exercise program and
a volunteer job at a soup kitchen were arranged. As outlined in the individualized plan, a follow-up meeting was held at three months. All team members, and especially the client, were pleased with his ability to demonstrate appropriate public behavior and avoid any criminal activity. The vocational rehabilitation agency is now willing to place the client in a sheltered workshop program.
Hospital
September
and Community
Psychiatry
the specific needs of each client. Each profession brings a unique perspective to an intervention plan. Occupational therapy’s holistic approach to service provision, its longstanding emphasis on rehabilitation outcomes, the variety of activities it can offer, and its ability to assess clients’ function in an environmental context and adapt physical and social environments all provide a strong base for community practice. As noted elsewhere, occupational therapists practicing in community settings can form collaborative relationships with consumers and with other professionals to tailor interventions to consumers’ needs in a way that preserves their dignity and enhances their quality of life (2).
Conclusions The individualized plan developed for each client must change, grow, and adapt in response to the client’s fluctuating needs. Interventions must focus on desired functional outcomes rather than on diagnosis and symptoms. Intervening on the planning, environmental, and skillbuilding levels is a dynamic and creative process. There is no cookbook. The broader the provider’s perspectives are, the better able the health care team is to work collaboratively in developing the resources and flexible approaches necessary to meet
NORTH
References 1.
DickieVA,
Robertson SC: Perspectives on functioning. Hospital and Community Psychiatry 42:575-576, 1991 Devereaux EB: Community-based practice. American Journal of Occupational Therapy 45:944-946, 1991
human
2.
DAKOTA
State.
Hospi Nodh Dokoio Depoilment
o Humon
S.res
SUPERINTENDENT STATE HOSPITAL TheNorthDakotaStateHospital, catedinruralsouthcentraiNoflh Dakota, seeks a board certified psychiatrist to serve as CEO of a 398-bed, JCAHO-accredited, TItle XIX certffied inpatient psychiatric and addiction hospital. As Superintendentyou will have complete responslbllityfordirecting all treatment and care program activities including all administrative and support functions for the facility. Auademic appointment with the University of North Dakota School of Med,cine is possible. Interested candates must have received an MD degree. and achieved a resency in psychiatry, all at approved locations, while having a minimum of two years of experience in the management of a comprehensive mental health care facility. The successful candate wouki also be board certifled in psychiatry or accompllehboardcertfficationwfthinthreeyearsfollowing thedateof appointment. The candate would be qualified to obtain a license to practe rneddne and/or surgery in North Dakota. Salary commensurate with qualifications excellent fringe benefit package. We offeradvantagesof urban lifenestled in aruralsettingwhich includessomeof North Dakota’s most outstanding recreational opportunities. Interested applicants should send curriculum vitae in confidence (to be received prior to the close of business September 18, 1992) to: Lyle A. Grove, Personnel DiectDr, North Dakota State Hospital, North Dakota Department of Human Services, Post Office Box 476, Jamestown, North Dakota 58402-0476. For more information, call collect (701) 253-3015. E/O/E/M/F/H
1992
VoL
43
No.9
871
