ACOT Presentation 2019

The Rehabilitation Outcome Measurement System

HEATHER PICKIN, OT

Director, Clinical Services, Training and Research Rehabilition, Research, Education and

Evaluation Services Inc. (RREES)

Association of Caribbean Occupational Therapists

14th Biennial International Scientific Conference,

Christ Church, Barbados, November, 2019

Purpose

This presentation will outline the purpose of the

ROM System as developed by neuropsychologist,

Dr. J. Douglas Salmon, Jr./Rehabilitation Research,

Education & Evaluation Services

Its ease of use by a single rehabilitation professional – to

track a patient’s functional progress;

facilitate multi-disciplinary programme planning and/or modification of the individual’s

rehabilitation programme

Objectives

To present the merits of the ROMs System

To demonstrate its validity and reliability in depicting changes (perceived, physical and emotional) in Life Role Disability over time

To demonstrate it’s use in determining an individual’s capacity to perform normal life activities and/or when quality of life is the focus of rehabilitation

To show its usefulness to referral sources – providing back-up support when needed to explain lack of progress, need for multi-disciplinary/ psychosocial involvement, alternative treatment/assessment – or as evidence of progress and/or appropriateness of treatment termination.

What is the ROM System?

An internet-based software system to track, analyse, graphically-trend and report patient progress and rehabilitation outcome measures

A subset of the Assessment Process Model

Based on validated measures in WSIB (workers’ compensation) and MVA populations in Ontario

Intended for use by all rehabilitation professionals

Through ongoing research and development, ROMS will promote best-evidence practice at the clinic and industry levels

Mental and Physical Health Relationship

About 50% hospitalised heart patients have some depressive symptoms and 25% develop major depression (Miller, 2006)

Patients with Type 1 or Type 2 diabetes are twice as likely to experience depression (Anderson, Freedlan, Clouse & Lustman, 2001)

Rates of depression, self-reported medication abuse, an inability to concentrate, or having sleeping problems were higher among injured employees compared to the general working Canadian population (O’Hagan, Ballantyne & Vienneau, 2012)

Presence of an anxiety disorder is associated with having chronic physical illness, poor quality of life and suicidal behaviours. Mental disorders, especially depressive and anxiety disorders, are prevalent in the labour force (Sareen, et al., 2005; Sareen, et al., 2006)

* Mental Health Issues – Facts and Figures (Workplace Strategies for Mental Health

https://www.workplacestrategiesformentalhealth.com/mental-health-issues-facts-and-figureshttps://www.workplacestrategiesformentalhealth.com/mental-health-issues-facts-and-figures

Rehabilitation Assessment and Intervention Process Model

Pre-morbid Personality, Life Roles,

and Experiences

Physical/PsychologicalTrauma/Disease

Symptoms/Impairments Psychosocial andEnvironmental Stressors

Client Schemas and Perceived Barriers

Emotional AdjustmentCoping Status,

Post-morbid RolesActivity Level Subjective Recovery Strategy

Intervention Planning

Rehabilitation OutcomeCopy right © 1990, 2000

J. Douglas Salmon, Jr., Ph..D. and

And Marek J. Celinshi, Ph. D.

Clinical Management & ADL/Essential Job Tasks Link

Illness

Onset

Pre-condition

Functioning

ADL/Essential Job Tasks Criterion (Physical, Cognitive, Social-, Emotional)

Sporadic Active

Treatment

Rare Vocational

Rehabilitation

Measuring Progress Towards Max ADL & Essential Job Task Criterion

Sporadic System Outcome

Poorer rehabilitation outcomes

Increased mental health impairments

Increased family crisis and breakdown

Increased financial burden/crisis

Increased burden on other systems (hospital, welfare/social assistance, disability benefit, early pension)

Entitlement appeals often through costly and slow legal process

Return to Work Probability: The case for aggressive intervention and vocational management

Research shows that unemployment, particularly long termunemployment, can have a detrimental impact on mental health (WHOMay 2019)

*Probability of returning to work:

50% after 6 months

20% after one year

10% after two years

*Ontario Medical Association, Mental Illness and Workplace Absenteeism: Exploring Risk Factors

and Effective Return to Work Strategies, April 2002.

Increasing likelihood of extended benefit exposure & deteriorating mental health and familial status

http://www.oma.org/pcomm/omr/apr/02returnwork.htm

“Clinical case coordination” through an integrated Clinical/ Vocational Model

Mental health interventions should be delivered as part of an integrated health and well-being strategy that covers prevention, early identification, support and rehabilitation (WHO 2019)

Access to evidence-based treatments has been shown to be beneficial for depression and other mental disorders (WHO 2019)

Use of the integrated ROMS approach can track progress, identify the need for programme modification and readiness for

return to work – potentially reducing the length of absence

A Solution

Rehabilitation Assessment and Intervention Process Model:Relating Concepts and Assessment Instruments

Pre-morbid Personality (RNSHI) Roles (RCL)

and Experiences (PPCLES)

Physical/PsychologicalTrauma/Disease (ITS)

Symptoms (RCL, R-SOPAC, RNHSI) Psychosocial andEnvironmental Stressors

(PPCLES)

Client Schemas and Perceived Barriers (RCL, RNHSI)

Emotional Adjustment(RNHS*, R-SOPAC)

Coping Status (R-SOPAC, )Roles (RCL)

Activity Level (R-ADLS)RNSHI Subjective Recovery Strategy

Intervention Planning

Rehabilitation Outcome

Assessm ent Tools Legend

RCL: The Rehabilitation

Checklist

PPCLES: The Pre/Post Condition Life

Event Survey

R-ADLS: The Rehabilitation Activities

of Daily Liv ing Survey

R-SOPAC: The Rehabilitation Survey of

Problems and Coping

RNHSI: The Rehabilitation

Neuropsychological and

Health Status Inventory

ITS: The Impact of Trauma Scale

Copy right © 1990, 2000

J. Douglas Salmon, Jr., Ph..D. and

And Marek J. Celinshi, Ph. D.

THIS IS WHERE WE WANT TO BE VS CURRENT “JAGGED LINE” APPROACH

Illness

Onset

Pre-condition

Functioning

Essential Job Tasks Criterion (Physical, Cognitive, Social, Emotional)

Integrated Active

Treatment

Vocational

Rehabilitation

ROMS Measures Progress Towards Essential Job Task Criterion

Review of Key Measures

The Rehabilitation Checklist (RCL)

The Rehabilitation Survey of Problems and Coping (R-SOPAC)

The Rehabilitation Activities of Daily Living Survey (R-ADLS)

Rehabilitation Functional Status Markers (R-FSM)

Now coding translation into 21 languages

Treatment Goal Applicable ROMS Tool

Identifying primary rehabilitation barriers (symptoms, psychosocial/ social determinants, employment)

Identifying main symptoms/ coping concerns & pre-existing symptoms (physical/cognitive/emotional domains)

Identifying Activity of Daily Living gaps/treatment needs

Identifying Occupational Demands gaps/treatment needs

Rehabilitation Checklist (RCL)

Rehabilitation Survey of Problems & Coping (R-SOPAC)

Rehabilitation Activities of Daily Living Survey (R-ADLS)

Functional Status Measures (FSM)

Use of Assessment Tool

Mental Health Concern ~ referral

Emotional rehabilitation barriers endorsed (especially priority)

Worsening emotional condition

Worsening physical condition , contrary to medical evidence

Fear towards workplace, driving, etc.

Marital/family problems

Dependence upon medication, alcohol/substances

Maladaptive Disability Perceptions: “Red Flag”

Fear of re-injury/worsening condition

Fear of dying

Extreme life role/overall disability ratings

Past/Future worsening condition

Poor self prognosis (contrary to diagnosis/es)

Life Roles - Disability Rating and Ranking

1. Household chores2. Relationship with friends3. Parental activities4. Volunteer work5. Relationship with spouse/lover6. Self-sufficiency (dress, transportation etc.)7. Sports/hobby participation8. Social participation9. Regular work10. Learning/Memory11. Modified work12. Overall disability

The Rehabilitation Checklist (RCL)

Purpose:

To identify patient perceived rehab barriers

To identify life role impairments

To identify pre-condition and future primary/secondary life roles

To identify client perceived physical and psychological change over time

To identify psychopathology risk factors

Administration Time: 5 - 10 minutes

Key Reliability Statistics:

Cronbach alpha* for Total Rehab Barriers: .85

Cronbach alpha for Life Role Disability: .82

Factor Analysis support for Rehab Barriers subscales

Note: Cronbach’s alpha is a measure of internal consistency or reliability or how well a test measures what it

should. 0.9 < a = Excellent; 0.8 < a < 0.9 = Good

The Rehabilitation Checklist (RCL)

Validity Summary:

Sound Life Role & Overall Disability correlations with Oswestry

Supported relationship between subjective estimate of return to work and presence of psychopathology

Supported relationship between subjective estimate of return to work and presence of psychopathology

Sound convergent/divergent validity relative to various psychological measures & R-SOPAC

3 established cut-off scores for psychopathology predictions

Number of subjects for reliability/validity data:

Workers Compensation = 294

Motor Vehicle Accidents = 100

Report Usefulness

RCL graph depicts change in Life Role Disability over time

RCL graph depicts change in client perceived physical and emotional change over time as well as anticipated future

change

Rehabilitation barriers are presented on the Rehabilitation Progress and Outcome Summary Report

The RCL User’s Manual provides examples of intervention strategies for selected rehabilitation barriers/problem areas (page 3) and selected Life Role Disability (page 4) - as identified in part 3 of the RCL

Rehabilitation Checklist

The Rehabilitation Survey of Problems and Coping (R-SOPAC)

Purpose:

To measure client perceived symptom problem intensity and ability to cope with varied physical, cognitive and emotional symptoms

Coping aspects are recognised as generally being more sensitive to change than symptom intensity, especially beyond acute treatment phase

To identify psychopathology risk factors

Administration Time: 5 - 10 minutes

Key Reliability Statistics:Test - re-test reliability: .91 - .93Cronbach’s alpha full scale: .87Cronbach’s alpha subscales: .77 - .92 (most above .80)Factor Analysis support for scale structures

R-SOPAC Report Usefulness

Key summary graphs of the measure are provided in the

ROMS Progress & Outcomes Summary Graphs

Full R-SOPAC Report provides back up support when needed:

to help explain lack of progress,

need for multi-disciplinary/psychosocial involvement/assessment,

further evidence of progress, or

appropriateness of treatment termination

Rehabilitation Survey of Problems and Coping (R-SOPAC)

of Activities of Daily Living (R-ADLS)

Purpose: For all disability groups with any single/combination of physical, cognitive, emotional

symptoms From acute care to community reintegration

To identify activity of daily living (ADL) limitations To identify symptoms responsible for ADL limitations

To evaluate changes in functional abilities secondary to various disabling conditions

Helps target treatment and treatment modalities Respondent may be patient, significant other or for objective measurement may be based

on professional assessment

Administration Time: 5 – 10 minutes (longer if English literacy is weak or other reading impediments)

Key Reliability Statistics:Cronbach alpha whole scale: .96Cronbach alpha subscales: ..83 - .95Split-Half whole scale: .74Split-Half subscale: .79 - .92 (only one under .80)

The Rehabilitation Activities of Daily Living Survey (R-ADLS)

R-ADLS ~ Validity Summary

Strongly correlated with Oswestry Total (.66) and Oswestry subscales

Strongly correlated with Neck Disability Index (.68) and NDI subscales

Soundly correlated with Rehab Checklist Life Role Disability (.49)

As expected more highly related with symptom coping measures than symptom intensity measures

Number of subjects for reliability/validity data: 175 motor vehicle accident

R-ADLS Report Usefulness

Key summary graph of the measure is provided in the ROMS Progress & Outcomes Summary Graphs

R-ADLS Summary Report and R-ADLS Overall Domain Report are highly relevant when disability status/benefits are determined by the individual’s capacity to perform normal life activities &/or when quality of life is the focus of rehabilitation

Individual Domain Reports provide back-up support when needed to explain lack of progress, need for multidisciplinary/psychosocial involvement/assessment, further evidence of progress or appropriateness of treatment termination

Rehabilitation Activities of Daily Living Survey (R-ADLS)

Functional Status Markers (R-FSM)

The Rehabilitation—Functional Status Markers (R-FSM) is an unique tool which allows the user to graph and depict a client’s physical capacities relative to specific pre-morbid job demands.

The specific job demands may be gathered through a formal Physical Demands Analysis (PDA), or through less formal means such as client and/or employer survey.

The client’s physical capacities may be measured utilizing any accepted protocol at the discretion of the user.

The R-FSM manual provides guidelines and references with regards to acceptable measurement practices.

The ROMS Progress & Outcome Summary Graphs identifies the percentage of occupational physical demands actually met by the client. [Note: it will not reflect the stamina, work pace and consistency of performance required of a full work day or work week – a Situational Work Assessment would be needed]

Another summary graph depicts the percentage of overall total scores of all functional domains in relation to the overall total scores of all physical demands.

FSM Usefulness for referral source

Key summary graphs of the measure are provided in the ROMS Progress & Outcomes Summary Graphs

Individual FSM Report is highly relevant when return to work is a primary rehabilitation goal and/or disability

status is determined by an individual’s ability to perform pre-morbid work tasks

ROMS Outcome Graphs

Model Advantages

Advances maximal clinical/functional/vocational progress in integrated/comprehensive manner

Clearly identifies residual symptom barriers, ADL and occupational shortfalls

Facilitates demonstration of patient motivation

Case Study I ~ using the R-ADLS

Joan is a 57 year old single unemployed woman with a complex medicalhistory, incl. multi-trauma/abuse experiences.

Sustained a head injury in a motor vehicle accident twenty-four years ago withresidual cognitive impairments (inc. poor short term memory, planning andorganisational skills).

Recently diagnosed with cancer and is on the liver transplant waiting list whilecontinuing to having ongoing tests and chemotherapy; and borderline diabetic(type 2)

She reported low mood, weight gain and anxiety when stressed, along with lowself-esteem and confidence; consequently she has few social contacts.

She lives alone in subsidized housing, receiving monthly disability benefitincome which barely covers her rent, utilities, food and basic needs; withnothing left for recreational/social activities.

Non-restorative sleep due to pain and discomfort resulting in fatigue, has lefther unmotivated to initiate and sustain a meaningful daily routine; her homebecame cluttered and disorganised adding to her stress and anxiety.

OT Intervention

Functional issues and goals were identified: e.g. to improve planning andorganisational skills and effect change in household management, reducingclutter, nutrition/diet and meal planning, tracking income/expenses/budgetingand saving, filing medical documents/bills etc., maintaining a daily exerciseplan (walking and cleaning).

Establishing contact with other resources inc. Community Support Services(Psychologist, Social Worker, Dietician, Chiropodist, Healer etc).

Assistance indentifying issues client needed to raise with her healthpractitioners – making lists and keeping notes, appointment dates.

Reviewing volunteer options based on client interest; readiness affected byhealth status (ongoing symptoms, new medications, multiple hospitalappointments, cataract surgery).

Facilitating applications or recommendations for assistive devices throughgovernment and charitable funding sources e.g. replacement RTS and longhandled devices, community gym membership, funding for light therapy lamp,cell and internet services, organisational tools. With funds saved she was ableto purchase a tablet.

The R-ADLs graph shows the functional gains made since OT intervention wasinitiated between April 2015 and November 2016.

RADLS Outcome Measure

“Joan”: Higher scores reflect improvement towards pre-condition baseline

Case Study - II: Susan & Family

Susan is a 42 year old single parent with 6 children. Her 5 youngest live with her in a 5 bedroom rented house.

Susan copes with various health related issues on a daily basis:

Physical = fibromyalgia/chronic back, hip, knee pain, digestive problems (mucusmembrane), poor mobility (uses scooter)

Emotional/Cognitive//Mental health = grieving traumatic death of ex-husband, abusewhen she was a child, poor coping skills, query past addiction issues or difficulty managingpain medication, difficulty with confrontation, poor attention/distractible, guilt as a singleparent and being spread thin with her own health issues therefore she demonstratesavoidance behaviours (less discipline, less structured routines & responsibilities, lessadvocating for herself or personal leisure activity, etc.)

Physical/Social Environmental = house clutter presents tripping hazards, disorganisedspace and morning routine (getting stuff ready and out for school, etc.), less personal andshared space for homework, activities, family time; no method of organising and keepingtrack of schedules, due dates, appointments, etc.; disruptive and abusive childhood → norole model for current parenting, coping with trauma (contributes to avoidance/indulgenceparenting behaviours); negative interactions with both public health services andIndigenous health services → she has been neglected or turned away from public healthservices, children put into foster care for 1.5 years from NCFST to child services →conversations with OT led to preference for smaller, community services

Case Study II ~Reason for Referral

Client would like a more organised home, healthier shared space

Client would like assistance with accessing relevant community resources

Client would like advocacy/assistance with accessing health

services

Neuropsychological assessment and counselling for 10 year old

Poor literacy for 6 year old (all children are somewhat behind in school as they spent a year and a half in foster care (disrupted school year and learning)

Case Study II ~The Parent

Strengths: creative, resourceful, able to identify needs (but not plan or follow through), children are strong, resilient, well behaved, interested in school, want to be a part of the family. Parent and children have a robust set of interests and engage in therapy (difficulty with follow through, commitment to a plan).

Barriers: health issues, overwhelmed with 5 children (older children often take on parenting role for younger ones when mother not well which puts strain on relationships, expectations, personal time/responsibilities), unpredictable pain (difficulty to make a plan and stick with it, difficulty adapting to change), poor budgeting skills (relies on ODSP and several social assistance programmes for income →multiple incomes at different times + poor planning and organisation skills = difficulty keeping track of what’s coming and what’s going →difficulty saving)

Case Study II ~ The Children

Child 1: 6 years old (f) Identified Issues: Poor literacy, poor sleep hygiene Strengths: social, open to trying new things

Child 2: 10 years old (m)

Identified Issues: cognitive issues present – poor sustained attention, difficulty with some studies, poor social skills outside of school (difficulty making friends)

Strengths: likes structure, routine, engaged in classroom work (in school – difficulty focusing in the home - distractible)

Child 3: 12 years old (f) Main goal: enroll in activities of interest, social, life skills Strength’s: encourages family time, takes initiative in finding solutions, enjoys physical activities and creative arts

(dance, martial arts, crafts)

Child 4: 14 years old (f) Main goal: engage in family responsibilities Strengths: takes responsibility for her own activities (routine, school deadlines, etc.), currently involved in NCFST

counselling

Child 5: 16 years old (m) Main goal: engage in work and enroll in post-secondary studies Possible emotional strain/grieving from loss of father

Strengths: Independent, helps with getting younger brother to/from school, activities, routines

OT Intervention

Client Goals Identified:

Better planning, organisation and follow-through

Better routines for children (sleep hygiene, reading/homework time, getting to school on time and alert, results in personal and shared activities and builds better relationships through common interests)

Get children and herself involved in individual and community activities (routines, engagement, social and interest development)

Long-term – get back to work (Advocacy role)

Get back on social housing waitlist (application, get new birth certificates, OHIP Cards)

Issues that arose during treatment

Cyber bullying 12 year old from group of school friends → resulted in physical altercations with parents and older siblings

During move, older children were looking after younger children – poor bedtime routine, late morning, means all children are late in getting to school, all children are tired at school, frustrated and fighting in the home

Client had several falls or other reasons for hospital admission

Eviction from initial rental, packing, move and flooding in new accommodations (harassment from old landlord, new accommodation has 4 rooms for 6 people – disrupted children’s routines with different bedtimes, activity times, etc.)

ODSP was temporarily suspended as taxes were incorrectly filed by a free service.

Father passed away → brought up a lot of old feelings Ongoing fluctuating pain and children getting sick (home with the flu, etc.) resulted in several cancellations

and delayed timelines

Case Study II ~ Issues Addressed

Initial interview – goals laid out in diagram to better visualise: Goal → Action → Perceived Outcome

Identify triggers for and against action

Practice breaking down the problem and applying solution focused therapy – establish the goal/barrier → explore potential solutions → Choose best option → establish how, what, when, where → provide support and encouragement to work towards goals – reduce distraction, role play, discuss issues/concerns that prevent working towards a goal (potential triggers for old bad habits)

Daily log to find best time for action and any changes that could lead to a more organised day and better routines (energy levels, least pain, least busy with children)

Daily goals → weekly goals → practice, practice, practice! Identifying how goal was met, why goal wasn’t met, what can be done next time to improve outcome → varying the levels of support and assistance to achieve goals

Adapted PGAP program – with R-ADLS outcome measures to track progress

Gather forms and applications to access resources - Welcome Policy (help low-income families access City-operated recreation programmes), City of Toronto activities, Status Card, Birth certificates and Health cards)

Look up recreation programs that are of interest to each child – create a calendar to avoid conflicts in time/transportation

Collect one to two bags of clutter from the house and donate/dispose per week

Case Study II ~ issues addressed

Create chores list for children to become more involved in household activity

Look at different free activities for client – Art Therapy for Grieving and Loss

Life skills training for parent: practice calling ahead to confirm time, place, etc. to avoid issues or wasted visits, practice active listening with children (12 year old does not feel that she is heard or involved in family decision making), practice independent goal setting and follow through with plans (includes handling situations as they arise and re-organising time for reaching goals), using checklists and daily planners, how to break down a problem (sift through info, overcome anxiety by breaking up the issue and solution into little chunks, rationalising fears, role playing conversations to be more comfortable when handling the situation).

Child 5: apply for Status card to allow for additional tuition funding for post-secondary school

Child 3: Understanding healthy friendships and toxic friendship, how to handle personal information to avoid “making it easy for cyber bullies” (not to share passwords, what to post, what is personal), how to handle confrontation on the school grounds

Child 1 and 2: set up bedtime routines that involve reading together and writing stories (literacy, shared time, better sleep)

Case Study II ~ Goals Met

House is much less cluttered despite less space/rooms after the move

She is using a large calendar to keep track of everyone’s activities, appointments and deadlines – one column for ongoing goals she sets for herself

Client better initiates breaking down goals into steps, identifying triggers and how to overcome these barriers; better at asking for help and advocacy; She feels she is better at following through; She feels supported and understood

Children are working towards consistent routines (reading time, bath time, bedtime)

Children are doing better in school after IEP meetings and learning plans Chores list: 12 year old involved in devising chores list – active participant,

ownership of role “Language, Volume, Reaction to negativity from others” Mantra set –

children reminding others to be respectful

Client is linked with hospital advocate to avoid previous negative interactions with health care staff during hospital visits

Case Study II ~ New/Continued Goals

Organise space/rooms to give children their own space Continue to get kids involved in extra-curricular activities (time-management and

meeting deadlines, preparing ahead and following through, accessing Welcome policy, City of Toronto, summer camps)

Get Status Card to assist with funding of oldest child’s post-secondary school Continue to attend IEPs for updates on progress Continue to de-clutter and create spaces for personal time and shared activities.

Monitor time vs me time (health activities in the home) Continue to re-enforce daily routines including sleep hygiene; Get children involved in household activities (life skills, reduce strain on mother)

Ensure services are involved and working properly (CCAC housekeeping, CMHA, Scarb Centre counselling)

Get CCAC dietician involved Dentists Create a budget and savings plan

Case Study II

Barriers to successful interventions

Client has difficulty assessing own capacity to commit to weekly goals (distractible, avoids activity with potential conflict, collaborative goal setting, commits however slips into old habits of avoidance or distractibility and declines assistance for things she feels she can do independently)

e.g. Welcome Policy forms to be submitted (filled out with OT, agreed to post but avoided) → no funding for activities →avoids calling to organise free activities, avoids assistance → children disengaged and increased conflicts in the home →children not engaged in chores (what’s in it for me?)

Client becomes overwhelmed/distracted (crisis, poor planning ahead and dealing with things as them come up or too late) and does not ask for help, does not maintain consistent contact with OT

OT Tools, concepts and frameworks relied on:

Motivational interviewing (OARS – especially rolling with resistance and active listening)

COPM (Canadian Occupational Performance Measure) Goal setting – to capture client’s self-perception of performance in everyday living, over time (similar to the RADLS)

PGAP program (Progressive Goal Attainment) – logs, breaking down goals into achievable steps – using the logs to know when to book sessions (identify patterns of activity, mood, pain flare up, medication side effects, her personal time, etc.)

CBT concepts to encourage continued change behaviours

Working closely with the CAMH case worker so that goals, resources, timing for appointments are well aligned – reduces overlap or missed areas/gaps

Completing the R-ADLS

References

RCL: 54 page manual

R-SOPAC: 111 page manual

R-ADLS: 61 page manual

ROMS Measures Psychometric Overview (provided)

ROMS graphs samples, process & recovery curves (provided)

Rehabilitation Research, Education and Evaluation Services (www.rrees.com)

➢ rrees.com/roms/

➢ rrees.com/docs/r_fsm_manual.pdf

Thank You