Monday, July 4, 2011

How accurate are our assessment results?

I've been thinking a lot lately about the huge responsibility we have when assessing people's daily living skills.

I took my 5 year old son to a medical appointment to be assessed. The session went very poorly - he really does not do well in new environments, with strangers, following an unpredictable schedule of tasks, with no ability to remove himself from the situation. I felt that the clinician saw a very inaccurate picture of who he is, and what his issues are.

I was incredibly concerned when the clinician made some statements generalizing what she saw in that one small office to other environments, especially because this was not consistent with what I had actually observed in similar environments to the ones she was talking about.

As a mama bear protecting her cub, I was enraged. Fortunately, I waited to express myself.

Reflecting on the experience, I realized that the clinician was really not acting very differently from myself in my role as an Occupational Therapist. I have routinely been asked to perform assessments, and make predictions about how a client will do in an environment different from where the assessments were performed.

OTs are often asked the question - what level of support will a person require upon discharge? Our answer to this question is difficult for many reasons, including:
  • Not very much time to do the assessment. I have been fortunate in that I have worked in environments where I had time to be thorough with my assessments. Many times, I would be almost done the assessment, and decide to do one last assessment to clarify something. During that one last assessment, I learned a critical piece of information that changed how I viewed all the other assessment results. If I had been rushed and not able to do that last assessment, I would have had a very different picture of the client's abilities.
  • We often do not get to see clients in their natural environments. It is very hard to make a prediction of how a person will do in an environment that you have not seen him or her in.
  • Community supports are constantly changing and evolving, so it is hard to stay on top of what supports might be available. This is even more difficult to stay on top of when you are working in an inpatient environment.
  • There are very few standardized assessments, with clinical value, that have enough research to interpret and support their results. Also, assessment results are inaccurate if a person is unwilling or not able to fully participate for any reason (such as my son's experience).
What can we do about this? In the program I work in, we make recommendations around the areas that we feel the person may have difficulties e.g. likely to have difficulties budgeting. We suggest supports that we feel would be likely to be helpful, but we generally refrain from saying that a person required a specific level of care due to that deficit. Our reasoning is that we do not have all the information on the possible supports available, and we are passing on our assessment reports to the case worker who may have other ideas. However, on many teams, the OT is expected to make specific recommedations re: level of care.

I once received an OT report from an inpatient OT where she stated that the client required 24-hour supervision because the client required monitoring of taking her medication. Well, here in Winnipeg, Home Care can visit a client's place to monitor medications. I cannot really blame the OT for not knowing that. When I worked as an inpatient OT, I do not think I knew that. However, there is a big difference for the client between being in a Residential Care Facility providing 24-hour care and living independently in an apartment with Home Care coming in once a day to provide medication reminders.

Seeing a person in his or her home environment is incredibly important. I remember meeting with one man in his home. When you talked with him, he had all the correct answers, yet there were reports he was not doing well. His place was very untidy. He cooked with lots of oil on high heat, with piles of things stacked by the stove. He showed me his "dosette". The labels were in Chinese and he does not speak Chinese, and he was unable to explain how it worked. Very scary considering the incredibly high levels of medications he was on. He had physical difficulties and was unsteady on his feet, yet he could barely move around the piles of things in his apartment. He needed to get up multiple times each night to go the bathroom, yet the way to the bathroom was obstructed with things. Someone from the hospital had ensured he had a walker, which he was unable to use in his apartment. Whenever possible, we need to do home visits, and we need to advocate for this in our programs as many programs still do not support home visits due to the time involved.

We need to really listen to what the client is saying. We also need to seek out friend and family perspectives. I think that perhaps I have not done this enough. Sometimes it seems like enough to just complete the assessments while trying to juggle the rest of our caseload. Talking to friends and family also means having to navigate privacy concerns and ensuring the necessary paperwork is done.

We need to continue to seek out assessments that are backed up by research. I feel we need a significant increase in partnership between clinicians and researchers in this area. I believe this is a major deficit area of our profession right now, and if it is not addressed, it will jeopardize the future of our profession.

After the appointment with my son, I thought about this for a long time. Then I wrote a nice long note to the clinician to explain my observations, and my concerns with the generalizations she made. I hope she reads it.

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