Outcomes in Occupational Therapy (& Assistive Technology)

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An overview of the aspects of Outcomes in Occupational Therapy with the latter part of the presentation focusing on the challenges of Assistive Technology and AAC. Please see http://citeulike.org/user/willwade/tag/outcomes for further reading.

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  • http://www.r2d2.uwm.edu/archive/impact2model/impact2model-ld.html\nThis slide diagrams the IMPACT2 Model. The model demonstrates that outcomes of interventions can be described by considering the six stages of 1) Pre-Intervention, 2) Context, 3) Baseline, 4) Intervention Approaches, 5) Outcome Covariates, and lastly 6) OUTCOMES. A left to right bold arrow indicates the direction across the top of the slide. The applications of Universal Design and Health Promotion are delineated in the lower left hand corner of the slide as “Pre-Intervention”, which are two methods to improve functional performance. An arrow connects the pre-intervention approaches to the Context stage consisting of person/task/environment. The Context stage is represented as the person using assistive technology to perform a task within an environment. The Context stage is connected by an arrow to the next stage of Function, which is comprised of performance, quality of life, and participation. The fourth stage, the Intervention Approaches, has six components, which represent six methods available to improve functional performance. These are 1) Reduce the Impairment, 2) Compensate for the Impairment, 3) Use Assistive Technology Devices and Services, 4) Redesign the Activity, 5) Redesign the Environment, and 6) Use Personal Assistance. In these vertically stacked boxes the assistive technology method is highlighted and stands out from the others as an indication of the focus of the ATOMS Project. The next stage is the Outcome Covariates, which identifies potential precursor variables of satisfaction of devices and services, dissatisfaction of device or services, and use and discontinuance of assistive technologies. The final stage, Outcomes, involves measurement of the individual’s function to determine what the outcome of the intervention is. Again, just as the baseline stage did, function consists of performance, quality of life, and participation. Outcome is identified as participation, quality of life, and participation. The model considers cost as well as these six interventions. It is important to understand that the pre-intervention and the person/task/environment context must be considered throughout the process. It is also important to isolate an intervention from other concurrent interventions to understand the outcome of that particular intervention. Dollar signs are located next to the Pre-Intervention stage, the Baseline measurement of function, the Intervention Approaches, and the Outcomes measurement of function to show where cost needs to be considered.\n
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  • Outcomes in Occupational Therapy (& Assistive Technology)

    1. 1. OUTCOMES Outcome measures - what, why, how A brief overview by Will Wade(with particular thanks to Gary Derwent)
    2. 2. • 1. Introduction - What are you measuring? • Paediatric tools • How outcomes fit with • Places to find more assessment • 3. Grouping data for service • Standardised tests - why evaluation • Standardised tests - type. Validity, • Criterion versus Norm Reliability & Responsiveness referenced • Assessing an assessment • Goal setting• 2.Some measures to be aware of • 4. Improving and developing • Models • 5. AT & AAC specifically • MOHO & COPM Specific • 6, Appendix assessments
    3. 3. LETS BE CLEAR There are no clear answers! Thereis no one checkbox fits all solution! (sorry!)
    4. 4. PART 1. WHAT ARE YOU MEASURING?
    5. 5. ARE YOU WANTING TO?• Analyseperformance of an individual? (e.g. Given one or more interventions)• Analyse the performance of your team/service? (e.g. How effective is the handwriting service?)• Be careful with terms: Outcomes, Assessment, Audit
    6. 6. SOME TERMS• Assessment is the broad holistic analysis looking at a range of types of data Evaluation prompts a need for greater specificity and so narrows the judgement. Outcome measurement becomes the need for standardized measure• Outcomes. The visible result. a measurable end result or consequence of a specified action or essential step “outcomes should relate closely to the clients social, psychological, emotional & cultural needs in relation to occupational performance” (COT, 2003a 25) “The desired outcome could be improved occupational performance, function or successful adaption” (Henderson 1991, 13)
    7. 7. The relationship between assessment, evaluation and outcome measurement (p13 Fawcett) Evaluation to make a judgement about amount or value Outcome measurement should be at the heart of the assessment process The Overal assessment process, encompassing all data ollection methods Assessment has numerous purposes: Descriptive - describing current status Discriminative - useful as screening tools. Used when no criterion exists. (Parent reported DCDQ has strong relationships to therapy carried out MABC & AMPS (Green 2005)) Predictive - predicting a future outcome. E.g. Kitchen Ax to see if someone safe to be discharged Evaluative - detect change in function over time. E.g TOMs
    8. 8. ASSESSMENT DATA COLLECTION• Chia (1996) demonstrated that Paed OTs used a variety of methods to collect data:• Interviewing (n 49) 98%• Standardized (n 40) 80%• Structured Obs (n 36) 72%• Non-standardised (n 35) 70%• Unstructured obs (n 29) 58%
    9. 9. OUTCOMES & EBP - THE WHY• “Now critical appraisal, reflective practice, systematic audit, peer review, best value review, service evaluation, clinical governance and a host of other methodologies are accepted parts of the professionals landscape. The need to deliver evidence-based practice is well understood and all professionals have to play their part in the total quality management of service delivery” (COT, Richards, 2002, p. xvii)
    10. 10. WHAT ARE YOU COLLECTING THE DATA FOR• Effectiveness: Whether treatments do more good than harm in those whom they are offered under the usual conditions of care, which may differ from those in the experimental situation. The measure of ability of a programme , project or task to produce a desired result that can be measured.• Efficiency : Measure of production or productivity relative to input resources. Operating a programme or project economically. Relates to resources expended or saved - not effectiveness• Efficacy: Assessing whether a treatment actually works for those who receive it under ideal conditions. The degree to which a therapeutic outcome is achieved in a patient population under rigorously controlled and monitored circumstances such as RCTs (Maniadakis & Gray 2004 p27)
    11. 11. A REMINDER: STANDARDISED V’S NOT• Standardisation: made standard or uniform; to be used without variation; suggests an invariable way in which a test is to be used as well as denoting the extent to which the results of the test may be considered to be both valid and reliable (Hopkins & Smith 1993b, 914) (AOTA)• If you use non-standardised or adapted tests its not a crime but do be aware of the limitations.
    12. 12. SOME BENEFITS OF STANDARDISED TESTS• Health care policy level - EBP • Larger research - clinic based demands accountability and quality. research & multicentre trials would Funding for services is coming be easier as you could combine increasingly linked to effectiveness small samples & efficacy. • Therapist level - improve• Perception of you as professionals communication (Lewis & Bottomley improves - and your own 1994) confidence! • Client level - receives an improved• Research theory/Practice gap service in which assessment and outcome data are based on reliable valid & sensitive measures
    13. 13. REFERENCED TESTS• Criterion referenced tests examine performance against pre- defined criteria and produces raw scores that have direct meaning. Not compared to ability of others. E.g. AMPS. A standard being “making a jam sandwich”• Norms referenced tests involve data from a norming study. Raw scores need to be referenced against the norms to mean something.
    14. 14. VALIDITY• How well does the test do what it says it does?• Face validity. What it seems to measure - to a the test-taker, tester,• Content validity. Does what it says judged on appropriateness of its content - should have all variables associated with the thing being measured.• Criterion validity. Effectiveness of a test to measure the performance - measuring somebodys performance with a independent criterion. Concurrent validity compares it with variables in other tests and Predictive validity is the accuracy that a test predicts some future event (e.g. Mortality).• Construct validity. The ability to perform as hypothesised in some facet. e.g. Those discharged to an independent living situation should score higher on a self-care ax than those discharged to a long-term care living situation. Discriminative validity - does it measure between groups or groups and Factorial validity relates to factor analysis.
    15. 15. RELIABILITY• In retesting of an individual are variations in results due to the intervention - thing being measured - or some other facet? If therapist b carries out the test the results should be v. similar.• Look for the reliability coefficient or correlation coefficient. The relationship between two sets of data being compared. 0 (no correlation) - 1 (perfect). (i.e. Closer to 1 is good)• Level of significance. How much chance influences results. The lower the level of significance reported the greater the confidence (i.e. Closer to 0 is good)• Standard error & confidence interval. How certain are we that the stats are correct and the test is accurate? Confidence level usually 95% - and states that “You can be 95% confident the true score lies within the interval range of scores” On a standard bell curve 95% of scores lie within 1.96 s.d of the mean. Rasch analysis can be used.• Correlations from 0 to +/- .5 are low. +/-.5 to .70 are moderate. +/-.70 to 0.80 are high..
    16. 16. TYPES OF RELIABILITY• Test-retest. Correlation of scores by the same person between two points• Inter-reliability. Scores between different therapists• Intra-reliability. Scores between the same therapist over time.• Rater-severity. How lenient or stringent a therapist is on judging performance• Parallel form reliability / Alternate form. Correlation of scores between two points but different test. Used when learning effect may cause issues• Internal consistency. Degree to which items measure the same construct. Helpful to have related observations.• (Responsiveness. The efficiency with which a test detects clinical change. A likelihood ratio 0-1)(NB: not reliability)
    17. 17. ASSESSING A TEST• Clinical utility. The overall usefulness of an ax in a clinical situation. Reasonable cost, time, energy & effort, portability, acceptability• Remember why you are carrying it out. Individual development or service development? If it is for the latter make sure it does get used or your team won’t bother with it!• Lookat & Use the worksheets in Fawcett 2007. Will help you understand a test’s clinical utility, validity and reliability for your population
    18. 18. Name of test:Full reference:Is there a test manual? YES NO YES NODoes the test manual describe the test development process? developed? YES NO the client group for whom the test has beenDoes the test manual describe the purpose of the test and YES NO studiesundertaken establishreliability and validity? toDoes the test manual provide details ofpsychometric of the test package? YES NODoes the test manual describe the materials needed for test administration or are these included as part be used for testing? YES NODocs the test manual describe thc environment that should YES NO instnlctions required to administer the test? ls there a protocol for test administration that provides all the Is there guidance on how to score each test item? YES N0 Is therea scoringform for recordingscores? YES NO Is there guidance forinterpretingscores? YES NO Ifit is a norm-referencedtest, is the normative sample well described? YES NO NOT APPLICABLE of scores obtained by the nonnative group? YES NO Are there norm-tables lrom which you can compare a client’s score with the distribution/» nf/1_ ciii lfzf Outcome Mea.rure/ne/ztfbr04-cupalio/za/ l1empi.v1.s°and I T Theory,Skills and Application by Alison Laver Fawcett © 2007
    19. 19. PART 2. SOME MEASURES TO BE AWARE OF
    20. 20. MODELS• MOHO, CMOP• ICIDH (Intl classification of Impairments, Disabilities and Handicaps), ICF, NCMRR (National Centre for Medical Rehabilitation Research)•A model can help conceptualise your thinking and categorise your terminology. Helps to articulate your reasoning to others. Within an MDT can be useful to define your thinking and see where overlapping areas are/missing areas of data collection.
    21. 21. MOHO • SCOPE - Short child Occ profile. Overview of participation. Based on MOHOST. Simple and Occ focused. • COSA - Self-assessment tool.• OTPAL - OT Psychosocial Assessment of learning. 6-12 yrs. Observational and descriptive ax tool. • PVQ - Observational Volition, habituation and enviro fit within classroom. Volition: sim to PVQ items and assessment tool examining a Habituation sim to SCOPE items child’s motivation.• School Setting Interview - assist intervention planning. Focused on the student role.
    22. 22. COPM• Measures changes in client’s perceptions of their performance & their level of satisfaction with their performance of self-care, work and leisure tasks.• Originaltest-retest reliability was done in 27 older adults with a range of impairments (stroke, parkinsons, nof). Reliability was low. Another study looked at COPD and was high. Another reliability study looked at stroke. Time though was over 7 days. ? Reliable? In general yes - but do think about the client group and be aware of what hasn’t been proven with statistics.
    23. 23. PATIENT RECORDED OUTCOME MEASURES• “Patients experience of treatment and care is a major indicator of quality and there has been a • Population-specific – eg. Child Health and Illness huge expansion in the development and application Profile-Child Edition/CHIP-CE of questionnaires, interview schedules and rating scales that measure states of health and illness from • Dimension-specific - eg: Beck Depression Inventory the patient’s perspective. Patient-reported outcome • Generic - eg: SF-36 measures (PROMs) provide a means of gaining an insight into the way patients perceive their health • Individualised - eg: Patient Generated Index and the impact that treatments or adjustments to lifestyle have on their quality of life” • Summary items - eg: UK General Household Survey questions bout long-standing illness• Many OT based measures are already PROMs - e.g. CMOP, SCOPE • Utility measures - eg: EuroQol, EQ-5D• Disease-specific - eg: Asthma Quality of Life http://phi.uhce.ox.ac.uk/home.php Questionnaire
    24. 24. MORE SPECIFIC TOOLS • Paediatrictherapy attracts assessment tools! • Occupational Therapy Assessment Tools: An Annotated Index 3rd Edition • Pediatric Occupational Therapy Handbook: A Guide to Diagnoses and Evidence-Based Interventions.
    25. 25. PART 3. SERVICE EVALUATION
    26. 26. GROUPING YOUR DATA: HOW DO YOU COLLECT YOUR DATA CURRENTLY?• Can you summarise goals and outcomes of these goals easily?• Are you trying to evaluate a specific part of the process - for example a group or specific intervention? Is there a measure you are using already that you can summarise? Is it safe to?!• Ifyou the answer is no - then your challenge is to find ways to do this!
    27. 27. TOMS & AUSTOMS Therapistidentity/code : Patient/client Identity: IAMES BOND 007 (Name or Code Number)EmployingAuthority: ANYWHERE PCTLocality: PT outpatientjclientclinicProfession: Speech and Language Therapy, hysiotherapy, ccupational Therapy,Rehabilitation Nursing, Hearing Therapists Patient/client/Client DetailsAge at EntgDate ofBirth : 1959 Carer: SPOUSE (person rated) dd mm yyyyAetiology(Lode l : M 25 AetiologyCode2: R 62.0 • Therapy Outcome Measure’s. Enderby, John & Petheram 2006.Impairment Code 1 : M 62.9 TOM Rating Sheet : Musculo-skeletalImpairment Code 2 : R 52 TOM Rating Sheet : Core Scale used to rate PainRatings Uses ICF/ICD-10 codes. Code* Impairment Activity Social Well-being Date Rated Codel Code Participation Patient/ client Carer • ’ 04 Quantitative. Shows data at °“’ Admission Intermediate (numerous) and Final (discharge). A=Admissionto therapy,First rating:I = Intermediate ratings(when placed at thefirstentry it denotes previous interventions fromtherapy);F = Final rating.Number ofContacts: 21 Totaltime : 12 hrs 30 mins Discharge Code: • Easy and quick. Adapted scales Use R0 if analysing rating but case is not discharged broad ranging. ? Limiting perhapsComments:Please send this formto your keyworker for checking and dataentry.
    28. 28. GOAL SETTING Goal-setting is the identification of, and agreement on, a behavioural target which the patient, therapist or team will work towards over a specified period of time. (Royal College of Physicians, 2008)• Holliday et al (2005) found that 30% of 202 respondents in a survey of goal setting methods used goals as an outcome measure. Wilson (2003) ‘one of the main outcome measures in our program is the percentage of goals achieved’.• In one way or another we all set goals, aims and objectives• Be consistent and careful with your language across the team - make sure you are all on the same page!• Make sure SMART goals are being followed• Make sure they are about the client• “Standardise” your goal setting across the team. Be aware of the dangers - particularly when using tools to generalise. E.g. Making them very attainable
    29. 29. (MY!) GOAL SETTING LINGO• Goal: Theoverall, usually one, goal that the client wants to achieve. Usually long-term. Could be that your service is only playing what may seem a very minor part of this process• Aims.(Short-term goals or specific objectives). The individual, often medium-term aims needed to reach the bigger goal. Aims - need to be SMART. State the activity the person will perform, under specified conditions and to a particular degree of success. A progressive series contribute to the goal.• Objectives - the actual on the ground activities that need to be met to meet each of these aims. Can be overlapping.
    30. 30. Prioritised Problem List: VM Skills leading to difficulty with classroom activities, Poor motor control, Unable to form letters Goal: The overarching end For James to be NB: Indepdence should result. Its your job to help independent within encapsulate a lot. That means make this realistic and class without the to do something effectively, achievable through aim assistance of efficiently and in a timely setting. "The direction of an learning support staff manner. action or actions" For James to be able to For James to recognise and For James to correctly formAims: The steps to reach have developed letters to enable manipulate the goal. "The desired a functional maximum shapes outcome or specific handwriting/ occupational involving result" Client-centred drawing pencil performance oblique lines – essential for grip. within class optimal (written work). productivity.What are the objectives - 1. Using a pencil and 1. To have tried one 1. To correctly form 11the methods on reaching paper, reproduce two- demonstrated strategy of lower case letters of the those aims? "Definable lined shapes at 90˚ by the pencil grip with two weeks alphabet with verbal prompts actions undertaken to end of one week, e.g. of intervention. by the end of the fourth weekachieve a specific result" 2. To accurately 2. To demonstrate one of intervention (c, d, g, o, a, q, reproduce shapes strategy by the fourth week j, u, e, l, m) involving simple oblique of intervention with 2. To correctly form a lines with straws after 4 prompting. different 12 lower case letters weeks with support, e.g. 3. To demonstrate one of the alphabet with verbal 3. To reproduce three strategy of pencil grip by prompts by the end of the out of four of the following the end of eight weeks with seventh week of intervention designs with no support no prompting. (s, x, z, f, p, r, m, n, h, i). after eight weeks. 3. To correctly form 23 out of 26 lower case letters of the alphabet with no verbal prompts by the end of eight
    31. 31. UNIVERSAL SERVICES• Goalsoften get messy in universal services. What the child wants may be very far from what you can achieve in your service but do consider how you can impact into their overall goal - even if it does seem so far away.• Make sure they are easy to communicate with a wider group - plain english. Use standardised measures to back up reasoning.• Commissioning is moving towards integrated care pathways - not away. A need to prove the efficacy of your work within it.
    32. 32. TOOLS TO COLLATE GOALS• EKOS - East Kent Outcome System/Sheets (Johnson 1997)• GAS - Goal Attainment Scaling (Ottenbacher & Cusick 1990)• Westcotes Individualised Outcome measure (Eames et al 1991)
    33. 33. Assessment Client needs group: Aetiology & communication disorder EKOS Health benefit Expected outcome State aim(s) and • East Kent Outcome Sheets/SystemInformation for objective(s) of Managers/ intervention within Commisoners agreed timescale • Common across many SLT services Record baseline measurements • “Liked by commissioners”. Simple, Treatment Plan meaningful easy data collection Delivery style No./frequency of contacts method. Interventions/Small-step programme • “a good outcome is one where the OUTCOME Have objectives been met? aims of therapy have been Fully Mostly achieved” Partially Not
    34. 34. EKOS• Limitationsif not all aspects filled in. Buckles, L 2003 found that following areas were missing from notes (n=159) timescale of intervention (18.4%), type of intervention (21%), outcome (5.3%), reasons for outcome (38.5%), and Health Benefit (38.9%).• No method of recording client involvement in plans e.g. A signature to agree, area for client & carer satisfaction.. But you can modify it.
    35. 35. GASWith GAS you effectively set 5 goals (“states”) for each goal -defining what will be called “best outcome and worst outcome”+2 Best expected outcome, Much better than expected+1 More than expected outcome, Somewhat better than expected0 Expected outcome-1 Less than expected outcome, Somewhat worse than expected-2 Worst expected outcome, Much worse than expected
    36. 36. GAS - EXAMPLE+2 Transfer to toilet with raised toilet seat independently on home visit.+1 Transfer to toilet with raised toilet seat twice daily independently.0 Transfer to toilet commode with raised toilet seat supervised twice daily.-1 Transfer to toilet commode with raised toilet seat with prompts (50% of time).-2 Transfer to toilet commode with assistance x 1.
    37. 37. GAS - WEIGHTING• Each goal is weighted for two factors… • Importance (weighted by client / patient) • Difficulty (weighted by clinical team)• Weightings are 0-3 • 0 = not at all important / difficult • 3 = very important / difficult• Giving 0 for either weighting effectively rules that goal out of the overall calculation• If weighting are not required, all weightings are set to 1
    38. 38. GAS - SCORING x = raw scoreThe ‘raw score’ of each goal is combined with its weightings. w = weight (usually importance x difficulty)The group of raw scores and weightings are converted .7 and .3 signify the expectedinto a standard normal score correlation of the goal scaleswith a mean of 50 and SD of 10 (Known as T-Score)
    39. 39. GAS - ISSUES• Time consuming - effectively 5 goals• Maths and stats controversial• Writing an effective goal difficult (Problem for all goal-setting, but magnified for GAS with 5 statements per goal)• Many different procedures used• Different factors altered in each statement• Where to place baseline ?• Short or long term goals ? Derwent G, 2010, Communication Matters Symposium
    40. 40. TACO (ET AL) GOALS Defines structured approach to writing a goal. Not necessarily for GAS • 1. Defining the goal • 2. Weighting the goal • 3. Scaling the goal • 4. Evaluating the goal • 5. ScoringBovend’Eerdt, T., Botell, R. & Wade, D. (2009). Writing SMARTrehabilitation goals and achieving goal attainment scaling: apractical guide. Clinical Rehabilitation. 23. 352-361.
    41. 41. Defining the goal - useful guidance for any goal system• 1. Target activity. Be precise. E.g. Walking indoors (not mobilising), cooking a 3- course meal (not preparing food)• 2. Specify specific support. • 2.1 Support by other people. Hands-on, emotional, cognitive • 2.2 Objects. E.g. Aids -wheelchair, cutlery adaptions, ramps etc • 2.3 Items in the environment e.g. Sign-posting for orientation, using barriers to remind someone not to go somewhere, lists to prompt• 3. Quantify Performance. Performance can be quantified in 3 ways; by the time taken to achieve a set quantity of the activity, by the quantity of a continuous activity performed (e.g. Distance) in a set time and/or by the quantity of a discrete activity occurring in a period of time (e.g. Frequency)• 4. Specify time period to achieve the desired state
    42. 42. COMMISSIONERS• What goal outcome based system do they listen to? It varies.• GoalWriter - goalassist.org.uk hopes to help this by creating a system to interchange these outcomes• Gary Derwent @ RHN
    43. 43. TOOLS TO EVALUATE CLIENTSATISFACTION WITH SERVICES• CSQ - Client Satisfaction Questionnaire (CSQ-8) (Attkisson CC 1987) not necessarily a measure of a clients perceptions of gain from treatment or outcome, but does elicit the clients perspective on the value of services received• Experience of Service Questionnaire (ESQ) (CAMHS)• Feedback forms & Self-made questionnaires. Think who your audience is and what you need to find out. Keep it minimal. Follow-up.
    44. 44. PART 4. IMPROVING AND DEVELOPMENT
    45. 45. 1. Analyse your currentassessment and measurementprocesses t . . 2. C -mpfovemem plan for future modernisation ___ have everrebre7. Evaluate whether the change `has led to the desired and whether there 3_ rderrrrrvareas your HVB een alll assessment and measurementunforeseen undesirable practice that could benefit fromconsequences ofthe change improvement•] clear goals for improvement 4. Set . and think how you could measure 5_|mp|emer-rr whether this improvement Changes has been achieved 5. identify changes required to achieve the desired improvement Figure ll.l Process forimprovingyour assessment and measurement process.
    46. 46. PART 5. AAC/AT SPECIFICALLY
    47. 47. ASSISTIVE TECHNOLOGY• "Assistive technology is any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities” (Public Law (PL). 100­407. The technical assistance to the States Act in the US.)• AT is wide-ranging. Low-tech e.g. Pen, paper, chart, pencil grip, Medium-tech: simple mechanical operations, High-technology: electronic components/controlled by a computer.• What is your view of AT? How does this differ with the outcome measure authors?• Cook & Hussey define 4 areas: (a) augmentative and alternative communication; (b) technology that enables mobility; (c) technology that aids manipulation and control of the environment; and (d) sensory aids.
    48. 48. A QUICK NOTE ON CONCEPTUAL MODELS IN AT• All the others: ICF, MOHO, CMOP etc.. ICF in particular.• Human Activity Assistive Technology(HAAT) model . The HAAT is adapted from the Human Performance Model and is described by Lenker and Paquet as "thoroughly considering person and environment factors, emphasizing the influence of environment and culture on task performance."• The Matching Person Technology (MPT) model
    49. 49. MPT Primary ComponentsLanguage Representation Methods Vocabulary Methods of Utterance Generation Single Meaning Pictures Core SNUG (spontaneous novel utterance Alphabet-Based Methods Extended generation) Semantic Compaction Pre-stored sentences Sec0ndary Components User Interface Control Interface – Outputs Selection Methods Symbols Direct Selection Speech Navigation Keyboard, head pointing, eye gaze Display Automaticity Scanning Electronic/Infrared/Radio Frequency Human Factors Switches Data logging Physiological (EMG, BCI, etc.) Morse Code Tertiary ComponentsPeripheral and Integrated Features Training and Support Telerehabilitation Hill & Scherer, 2008; Hill, 2009 in press
    50. 50. IMPACT2 MODEL
    51. 51. ASSESSING OUTCOME & EFFICACY• Assessing outcome = to demonstrate the efficacy of the application of new technology, to establish the effectiveness of assistive technology over time or to steer the development of new assistive technology.• Efficacy of an AT device = the effect resulting from its use in comparison to the effect claimed beforehand.• The nature of this effect may depend on the user(-population), the device and the use conditions.• Effectiveness on societal level is often considered in relation to costs; i.e., cost- effectiveness. The cost-effectiveness of the intervention is established by weighing the benefits against the costs. (Gelderblom, Witte, 2002)
    52. 52. AT IS TRICKY!AT is more complex than other areas to evaluate Outcome. This complexity originates from:a) the diversity in contributing variables - impact is dependent on characteristics ofthe end user, the context of its use and the type of AT. The functional effect of a wheelchair isdifferent to a AAC aidb) outcome being a multidimensional concept - User satisfaction, functionalindependence, societal and individual gains, increased social participation, enhanced normativesocial roles, the promotion and sustaining of employment and facilitation of activities of dailyliving may all add to the outcome of AT.c) the embedding of an AT device - AT is rarely used in isolation. How is it being usedin different domains of care?d) the goals to be reached with an assistive device can be diverse and highlyindividual
    53. 53. OUTCOMES• Establishing the effect of AT may • Family Impact of AT (FIAT) require more than one instrument depending on the type of question • MPT (Predisposition Assessment) underlying the assessment of • OT-FACT (Functional Performance) outcomes. E.g • SCAI (Costs)• Quebec user evaluation of satisfaction with assistive • Life-H (Social Participation) technology (QUEST) • IPPA (Individual Goals)• The Psychosocial impact of assistive devices scale (PIADS) • EuroQol & PIRS (Quality of Life)
    54. 54. AAC• Alternative Augmentative Communication• AAC is a form of AT• Some difficulties removed by focusing on the specific area of AT - communication.• But - Communication itself is complex!• Tools to measure language and cognitive performance - but most norm referenced. E.g. PPVT-R, WISC-R. Individual Goals make the most sense for individual/service outcomes.• Reading homework : Schlosser, 2000
    55. 55. http://www.communicationmatrix.org/
    56. 56. AAC TOOLS • COL Determines and defines the levels of competence using Lights 4 levels of compentency; Linguistic, Operational, Social, Strategic. • Five skill sets within each of these four areas are identified. Each skill set represents an increment of increased skill development toward mastery of a competency area. • Suggesting intervention and instruction to assist in the development of communicative competence using AAC systems • Measuring progress. Builds on communication matrix, GAS and good basis of AAC theory • Kovach, 2009
    57. 57. INTERAACT FRAMEWORK• The framework addresses communication ability levels (Emergent, Context-Dependent, and Independent) and provides the opportunity to transition dynamically through communication ability levels as well as throughout the lifespan.• Focus on interaction - functional communication• Communicative competencies “The development of communicative competence is essential to express needs and wants, share information with others, and develop social closeness with family and friends” (Light, Beukleman, Reichle, 2003)
    58. 58. F R A M E W O R K Use this guide to indicate the individual’s stage in life and identify important characteristics about his/her communication. These characteristics can help guide the individual to the most appropriate set of communication pages in their DynaVox device while maximizing interaction. E M E R G E N T C O N T E X T - I N D E P E N D E N T D E P E N D E N TYOUNG CHILD May be starting to follow directions within Understands general conversations and Understands communication the same as 2-6 routines and familiar activities. directions as well as same age peers. same-age peers. May be communicating most successfully using Understands picture symbols that represent Able to talk about a broad range of age-CHILD 7-13 facial expression, body language, gestures objects and common actions (e.g., run, appropriate topics in exible ways. and/or behaviors (either socially appropriate paint, eat). behaviors or challenging behaviors). Combines single words, spelling, phrases and Starting to understand more abstract picture complete messages together to create novel TEEN May have a few messages that (s)he symbols (e.g., think, big, hot, few). communication about a variety of subjects as 14 -21 communicates well and/or often using symbols would others of his/her age. or any methods listed above. Uses symbols and objects spontaneously to communicate basic needs and wants. Changes the way words and phrases areYOUNG Frequency and reliability of both understanding combined based on the communication partnerADULT and expression varies from day-to-day and/or Uses a combination of communication methods (e.g., pictures, objects, pointing/gestures, speech and situation. 22-50 activity-to-activity. vocalizations) to express messages. Literacy skills on par with same-age peers.ADULT Pictures seem to increase both comprehension and expression. Beginning to combine two or more symbols to Social interaction skills, environments, and 50+ create longer and/or more complex messages. activities are similar to others of his/her age. Attempts to communicate are most frequent in motivating situations or favorite activities. Communicates best in routines and regarding Participates in age-appropriate environments familiar topics. and activities. If using picture symbols, use one picture at a time to communicate messages. Bene ts from help to initiate social interaction Actively participates with communication partner and/or take additional turns in conversation. when communication breakdowns occur. May be beginning to use clear and simple symbols (including objects, photographs and Bene ts from help to participate in interactions in picture symbols) in motivating situations and/or new environments and with new people. favorite activities. May continue to bene t from the help of his/her Bene ts from help from his/her communication communication partner to narrow down choices, partner to communicate successfully navigate pages, interpret body language/gestures (e.g., narrowing choices, page navigation, as these skills develop. interpreting gestures/body language). Literacy skills developing (e.g. letter names and May be starting to show interest in social sounds, site words, spelling of simple words). interactions, especially in speci c situations. Note: “ Children’s natural actions and behaviors are the only prerequisites to AAC...Early behaviors and skills facilitate the gradual development of more complex communication skills, including language” (Cress & Marvin, 2003). We believe that this is true of individuals of all ages. Note: Because these characteristics cover a broad range Note: These individuals interact daily in all environments As a result, the communication system should of skills, many AAC users fall into this category. in flexible ways at age level. embrace growth and development. 150117 *Adapted from Patricia Dowden, Ph.D., CCC-SLP, University of Washington, Communicative Independence Model. InterAACt framework Dynamic AAC Goals http://www.dynavoxtech.com/training/toolkit/ details.aspx?id=32
    59. 59. BLACKSTONE’S SOCIAL NETWORKS• Social Networks, created by Sarah Blackstone and Mary-Hunt Berg (2003), provide a unique way to explore communication partners and environments. A team of individuals, including AAC users, identify individuals that fit into the following categories: life partners/family members, close friends, acquaintances, paid workers and strangers.• Intervention strategies can then be developed based on the Social Networks identified. For example: • Many AAC users have few people in the “close friends” circle. In such cases, the team can work together to provide vocabulary and teach interaction skills that will help this circle to grow. • More and more AAC users are active in their communities. To develop or reclaim these important social roles, individuals need to be able to interact with a variety of people. The Social Networks program may identify “strangers” such as store clerks, bankers, or other community workers that an AAC user wants to be able to talk to.
    60. 60. APPENDIX
    61. 61. THANKS• Gary Derwent, Royal Hospital for Neurodisability, Putney• The ACE Centre, Oxford
    62. 62. FURTHER INFORMATION• Email: will.wade@nhs.net twitter: willwade• Citeulike references: http://citeulike.org/user/willwade/tag/outcomes
    63. 63. • A. L. Fawcett (2007). Principles of Assessment and Outcome • Johnson, M and Elias, A (2002) East Kent Outcome System for Measurement for Occupational Therapists and Physiotherapists: Speech and Language Therapy East Kent Coastal Primary Care Theory, Skills and Application. Wiley, 1 edn. Trust• Bovend’Eerdt, T., Botell, R. & Wade, D. (2009). Writing SMART • Johnson, M (1997) Outcome Measurement: towards an rehabilitation goals and achieving goal attainment scaling: a interdisciplinary approach. British Journal of Therapy and practical guide. Clinical Rehabilitation. 23. 352-361. Rehabilitation, 4 (9) 472-478• N. Patricia Bowyer EdD OTR/L BC & S. M. Cahill MAEA OTR/L • Miller, A (2000) Multidisciplinary outcome measurement: is it (2008). Pediatric Occupational Therapy Handbook: A Guide to possible? British Journal of Therapy and Rehabilitation 7 (8) Diagnoses and Evidence-Based Interventions. Mosby, 1 edn. 362-365• Brock, K., Black, S., Cotton, S., Kennedy, G., Wilson S., & • Lowing, K., Bexelius, A., Carlberg, E., (2009) Activity focused Sutton, E. (2009) Goal achievement in the six months after and goal-directed therapy for children with cerebral palsy – Do inpatient rehabilitation for stroke. Disability and Rehabilitation. goals make a difference ? Disability and Rehabilitation. 31(22): 31(11), 880-886. 1808-1816.• P. Enderby, et al. (2006). Therapy Outcome Measures for • McDougall, J., Wright, V. (2009) ICF-CY and Goal Attainment Rehabilitation Professionals: Speech and Language Therapy, Scaling: Benefits of their combined use for pediatric practice. Physiotherapy, Occupational Therapy. Wiley, second edn. Disability and Rehabilitation. 31(16): 1362-1372• Playford, E.D., Siegert, R., Levack, W., Freeman, J. (2009) • C. Unsworth, et al. (2004). ‘Validity of the AusTOM scales: A Areas of consensus and controversy about goal setting in comparison of the AusTOMs and EuroQol-5D’. Health and rehabilitation: a conference report. Clinical Rehabilitation. 23, Quality of Life Outcomes 2(1). 334-344.• Turner-Stokes, L. (2009) Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clinical Rehabilitation. 23. •• Ferguson, A., Worrall, L., Sherratt, S. (2009) The impact of communication disability on interdisciplinary discussion in rehabilitation case conferences. Disability and Rehabilitation. 31(22): 1795-1807.
    64. 64. AAC/AT REFERENCES• R. Andrich, et al. (1998). ‘A model of cost-outcome analysis for • H. Day, et al. (2002). ‘Development of a scale to measure the assistive technology’. Disability & Rehabilitation 20(1):1–24. psychosocial impact of assistive devices: lessons learned and the road ahead.’. Disabil Rehabil 24(1-3):31–37.• Blackstone, S. & Hunt Berg, M. (2003). Social networks: A communication inventory for individuals with severe • Hill, K., 2004. Augmentative and Alternative Communication and communication challenges and their communication partners. Language: Evidence-Based Practice and Language Activity Verona, WI: Attainment Company. Monitoring. Topics in Language Disorders, Vol. 24, No. 1, pp. 18-30.• L. A. Cushman & M. J. Scherer (1996). ‘Measuring the relationship of assistive technology use, functional status over time, and • Light, J. (1989). Toward a definition of communicative competence consumer-therapist perceptions of ATs.’. Assistive technology: the for individuals using augmentative and alternative communication official journal of RESNA 8(2):103. systems. Augmentative and Alternative Communication , 5 , 137-144.• L. Demers, et al. (1999). ‘An international content validation of the Quebec User Evaluation of Satisfaction with assistive Technology • I. Schraner, et al. (2008). ‘Using the ICF in economic analyses of (QUEST)’. OTI 6(3):159–175. Assistive Technology systems: Methodological implications of a user standpoint’. Disability & Rehabilitation 30(12-13):916–926.• M. J. Fuhrer (2001). ‘Assistive technology outcomes research: challenges met and yet unmet.’. Am J Phys Med Rehabil 80(7): • R. Wessels, et al. (2002). ‘IPPA: Individually Prioritised Problem 528–535. Assessment.’. Technology & Disability 14(3):141–145.• G. J. Gelderblom & L. P. de Witte (2002). ‘The Assessment of • R. Wesselsa, et al. (2000). ‘IPPA, a user-centred approach to Assistive Technology Outcomes, Effects and Costs’. Technology and assess effectiveness of Assistive Technology provision’. Technology Disability 14(3):91–94. and Disability 13(1):105–115.

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