Finding, Using and Documenting Evidence in School-Based Practice Occupational Therapy Association of California (OTAC) Annual Conference October 19-22, 2017 Julie Bissell, OTD, OTR/L, ATP Michaelann Gabriele, OTD, OTR/L Natalie Loera, MA, OT (NBCOT, CBOT in Process)
Learning Objectives 1. Articulate the importance of evidence and documentation of clinical reasoning in school-based practice. 2. Locate best available evidence for school-based practice. 3. Create evidence based reports, objective measurable goals, progress monitoring documentation and collaborative consultation plans. 4. Provide examples of data-driven services.
Documentation Overview Objective: Articulate the importance of evidence and documentation of clinical reasoning in school-based practice.
AOTA Code of Ethics Occupational therapy personnel shall [use], to the extent possible, evaluation, planning, intervention techniques, assessments, and therapeutic equipment that are evidence based, current, and within the recognized scope of occupational therapy practice. (AOTA, 2015a, p.2)
AOTA Standards of Practice An occupational therapist has overall responsibility for the development, documentation, and implementation of the occupational therapy intervention plan based on the evaluation, client goals, best available evidence, and professional and clinical reasoning. (AOTA, 2015b, p.4)
Individuals with Disabilities in Education Act (IDEA) The child s individualized education program (IEP) will provide a statement of the special education and related services and supplementary aids and services, based on peer reviewed research to the extent practicable (20 USC 1414(d)(1)(A)(i)(IV)).
What is documentation? Written Record KNOWLEDGE TRANSFERENCE Record of care
What is NOT documentation? www.dreamstime.com
Documentation Requirements Documentation must have the patient s name or other identifier. All documentation must be dated. All documentation must be signed with the provider s name and credentials. Documentation must be legible in ink. Errors should be corrected by making a single line through the error and initialing it. Errors in an electronic system should be corrected through an amendment, not by editing the original documentation. Only approved abbreviations may be used.
Language of Documentation Which language do we use???
AOTA Practice Framework (AOTA, 2014)
World Health Organization International Classification of Functioning, Disability and Health Child s Educational Need Foundations Core Body Skills Activities Participation Body Functions and Structures Environmental Factors Personal Factors
Language of Documentation Which language do we use???
Examples of OT Practice Models Acquisition Motor Learning Teaching and learning models are used. Direct instruction, engagement and repetition with knowledge of performance and results. Practice and master activities that are difficult. Cognitive Cognitive strategies are taught and real-time feedback shape performance. Compensatory Child is taught strategies to compensate for activities that are difficult and to find new ways to perform a modified activity. NDT Focus is on postural control, movement patterns and coordination to support functional outcomes. Sensory Integration Focus is on changing learning and behavior through concepts of neuroplasticity, adaptive response, child directed intrinsically motivated play and individualized sensory input. Psycho-Social Learning occurs in a social context. Children learn by observing the behavior of others and through social interaction.
Finding Evidence Objective: Locate best available evidence for school-based practice.
Evidence-Based Practice Performance Data
Tools for Appraisal Select Tools for Appraisal Effective Practice, Informatics & Quality Improvement (EPIQ) Critical Appraisal Skills Programme (CASP) AOTA s Evidence Exchange
Practicing Clinicians Data-Base Searching http://norris.usc.libguides.com/c.php?g=293771&p=1956687 http://norris.usc.libguides.com/ld.php?content_id=34955627
Search Engine and Data-Base Resources Guidelines for OT and PT in California Public Schools: Chapter 3 http://www.cde.ca.gov/sp/se/sr/r CINAHL Cumulative Index of Nursing and Allied Health Literature Cochrane Library http://www.cochranelibrary.com/ Systematic reviews Accessible through academic or hospital libraries or by purchase. ERIC https://eric.ed.gov/ Education bibliographic references and full-text articles Free Free medical journals Full-text articles in medical journals www.freemedicaljournals.com OT Seeker Systematic reviews and randomized controlled trials relevant to OT www.otseeker.com ProQuest http://www.proquest.com/libraries/academic/databases/
Documenting Evidence in School-Based Practice Objective: Create evidence based reports, objective measurable goals, progress monitoring documentation and collaborative consultation plans
Common Core State Standards
Common Core State Standards OT Reports, Goals, Documentation Link to Common Core Standards http://www.corestandards.org/read-the-standards/ Address WHAT a child needs to know not HOW to teach.
IDEA Requirements for Assessments OT Reports Document Compliance Assessments must be completed within the parameters of Education Code Section 56320;(20 USC 1412(a) (6)(B) and 1414 (b)(2)). Administered so as not to be racially, culturally, or sexually discriminatory. Materials and procedures shall be provided in the pupil s native language. Administered in such a manner that the child s behavior during testing is an accurate reflection of performance. Administered by trained and knowledgeable personnel in a valid and reliable manner and in accordance with instructions provided by the publisher of the assessment. More than one measure used (Interview, observation, standardized test)
The Report Communicate Findings Supported by Evidence Clinical Reasoning Provide data-driven, objective results (observations and standardized tests) separately from the analysis and interpretation. Include all suspected areas of dysfunction related to the unique needs of the child and OT domains of practice (OTPF). Interpret the educational relevance of the findings and discrepancies between test scores (prior and current) Identify and address needs related to access to education.
Use and Beware of the Template Check boxes, drop down menus, and narratives? Can you distinguish between patients? Can you complete the report quickly? Are you providing evidence to support clinical reasoning? www.hexblot.com http://mods.curse.com
Case Scenario 4th Grade Student with Autism in General Education Jack is a fourth grade student who was recently diagnosed with autism after suspected mental health concerns. His teacher noticed he was not engaging with other students, often had his head on his desk, did not independently start or complete his work and rarely engaged in play at recess. He was referred for an OT assessment.
Case Scenario (Continued) Data-Driven, Strength-Based OT Assessment Record Review (Multidisciplinary reports) Observations (Across settings at school) Interview (Teacher, Parent, Child) Standardized Tests Data from child (strengths, performance) Information from teacher and parent
Case Scenario (Continued) Findings, Interpretation Hypothesis Record Review (Multidisciplinary reports) Strengths in nonverbal ability, needs in verbal processing. Observations Leans on desk, observed to look sleepy, retreat from play equipment (soccer, hand ball, kickball, basketball). Interview (Teacher, Parent, Child) Reluctance to participate peers, does not finish work. Sensory Processing Measure (Teacher observation of sensory behavior) Standardized Tests Data from child (strengths, performance) BOT:2 Average FM Precision, Below Average Manual Dexterity, Balance Poor Upper Limb Coordination) Test of Handwriting Skills:Revised (THS:R) Poor letter formation. Ayres Clinical Observations: Poor prone extension, balance, praxis Information from teacher and parent (Does not independently begin or complete school work, plays video games, sedentary, cannot ride a bicycle.)
Components of a Measurable Goal WHO Student DOES WHAT Observable Behavior WHEN Annual Goal (Benchmark Objectives) GIVEN WHAT Conditions (Qualify Variables) HOW MUCH Criteria and Mastery (Quantify) MEASUREMENT Performance data
Sample Goal To support educational goals, by 10/11/17, Jack will engage with another person (Teacher, Instructional Assistant) in a sensory break task incorporating heavy work against resistance with his choice of the sensory break (Examples: bouncing a basketball, shooting hoops 10' tall basket overhand, playing tether ball, swinging, climbing playground structure) and persist for 5 minutes without leaving the activity and without prompt, 2 of 3 observations as measured by teacher data taken over a two week period.
Form a Hypothesis Write a Measurable Goal GOAL COMPONENT EXAMPLE WHO WHEN By 10/11/17, Jack will DOES WHAT Observable Behavior (Choose ONE not several) engage in a sensory break task incorporating heavy work GIVEN WHAT (Qualify) Conditions with another person (teacher, Instructional Assistant), without prompt HOW MUCH (Quantify) Criteria Mastery persist for 5 minutes 2 of 3 observations over two week period MEASUREMENT teacher data collection
Check the Goal - Monitor Progress Data Collection Table to Match Goal DATE 1. 2. 3. ACTIVITY PROMPTS TIME COMMENTS, RESPONSE
Critique a Goal GOAL COMPONENT WHO WHEN DOES WHAT Observable Behavior (Choose ONE not several) GIVEN WHAT (Qualify) Conditions HOW MUCH (Quantify) Criteria Mastery MEASUREMENT EXAMPLE RATE 1= GOOD 0= MISSING POOR
Qualify Conditions - Measurable Goals Identify Variables 1. Where? (Classroom, e.g. circle time, center time, playground) 2. With Whom? (OT, Teacher, 1:1 IA, small group?) 3. Level of support needed (prompts- type, visual cues)
Quantify the Goal Make it Measurable Choose a System for Measuring Progress 1. Increasing or decreasing frequency of behavior 2. Increasing or decreasing duration of behavior 3. Increasing range of behavior 4. Decreasing the need for assistance/prompts
Benefit and Problems with Percentages When NOT to use percentages: 1. Opportunities not well defined. Child will write legibly 80% of the time. What does this mean? 2. Limited opportunities infrequently occurring behavior 3. Fluctuating opportunities - 1 of 2 opportunities = 50% 4 of 10 = 40% Benefit of using percentages: When opportunities are well defined a percentage provides an accurate objective measure. For example, copying letters of the alphabet from a model - 17 out of 26 in one minute = 65% (baseline), 22/26 = 85%
Session Notes in School-Based Practice Completed immediately following the session or within 24 hours Child name, date of service, total treatment time IEP goal addressed Description of service provided linked to frame of reference Child response with an example Plan for continued care Signature and credentials of provider (or electronic signature)
Client Response Cues Falls/bumps Quantitative Data Time Assistance Trials
Description of Service 1. Focus on the skill set not the activities 2. Use language that reflects frame of reference 3. Use evidence (literature, child, past clinical experience) Activities with heavy work input included in treatment to elicit an adaptive response in postural control to support posture at a desk and arousal level (readiness to learn).
Plan for Continued Care Continue Plan of Care? A specific skill to address in the next session: Visual scanning or bilateral motor coordination A particular objective measure: manual muscle testing An activity to implement: Address cognitive sequencing skills in a construction activity An issue for further consideration: consult with teacher or parent about a new behavior or home exercise program An outside referral: Adapted physical education or speech and language referrals
Enjoy Finding, Using and Documenting Evidence! Performance Data