The Model of Human Occupation Clearinghouse Department of Occupational Therapy College of Applied Health Sciences A User’ User’s s Manual for MODEL OF HUMAN OCCUPATION SCREENING TOOL (MOHOST) Sue Parkinson, OT (Versio (V ersion n 2.0) Copy Copyright right 2004 Kirsty Forsyth, PhD, OTR Version Versio n printed January 2006 Gary Kielhofner, DrPH, OTR, FATOA The Model of Human Occupation Clearinghouse Department of Occupational Therapy College of Applied Health Sciences A User’ User’s s Manual for MODEL OF HUMAN OCCUPATION SCREENING TOOL (MOHOST) Sue Parkinson, OT (Versio (V ersion n 2.0) Copy Copyright right 2004 Kirsty Forsyth, PhD, OTR Version Versio n printed January 2006 Gary Kielhofner, DrPH, OTR, FATOA Gary Kielhofner Copyright 2004 by Sue Parkinson, Kirsty Forsyth, and Gary Kielhofner.. All rights reserved. This manual may not be reproduced, adapted, translated or otherwise modified without express permission from the MOHO Clearinghouse. Score sheets, summary sheets and other forms which are provided as perforated pages in this manual may be reproduced,, but only by the single individual who purchased the manual and only for use in practice. reproduced These forms may not be reproduced for use by others. Each individual user must purchase a manual to have permission to use forms. Some forms from this manual may be available available in other languages. For access to any available forms, forms, please visit www.moho.uic.edu. www .moho.uic.edu. Any available translated forms will be posted under Additional Resources / MOHO Related Resources/Translated MOHO Assessments and available for download. The password to access and download translated forms associated with this manual is: Moho$t73 . A thera therapist pist must must purchase purchase this manual manual to have have access to this password. Only the purchaser of this English-version manual has permission to download and use translated forms. Restrictions regarding the use of forms within this manual also apply to use of downloadable, translated forms. Forms may not be available for all languages. Some full translations of this manual may be available for international sale or distribution through third parties; details on obtaining these resources may also be found at Additional Resources/MOHO Related Resources/Translated MOHO Assessments. The Model of Human Occupation Clearinghouse Department of Occupational Therapy For further evidence and resources related to this product, please visit our Web site at http://www.moho.uic.edu http://www.moho.uic.edu The MOHO Clearinghouse is a nonprofit organization. All funds generated are used to continue research and development of these resources. Thank you for your support and interest in the MOHO Clearinghouse products. MOHOST v.2.0: ACKNOWLEDGEMENTS We would like to acknowledge the UK Centre for Outcomes Research and Education, for co-ordinating some of the developments and research work. We also wish to acknowledge the good will of our managers and the invaluable contribution of so many colleagues, who have offered their encouragement, contributed their ideas, helped to pilot the assessment, written translations, offered case studies for the manual and participated in the research. In particular, we would like to mention: Dorothee Acker Helen Bailey Lynn Brownwood Sarah Cratchley Laura Di Bona Sharon Durose Marie Ahern Andy Barnett Diveena Cooppan Alison Critchley Sue Ducker Leigh Dyson Green Carolyn Atkinson Jo Batten John Cooper Simon Curle Angela Ross-Gamble Dimitra Efstathiou Mary Axon Andrew Baxter Debbie Cotgrave Anita Desikan Laura Dunphy Esther Evans Sarah Adam Eves Graham Tanya Harris H arris Kyliee Innocente Kyli Innoc ente Jessica Keller Keller Maggie Lee Melissa Mackinnon Rosie McConville Carole Merriman Laura Moston Civil Parkinson Katrina Reece Rachael MargaretFayerman Gray Ruth Hartwright Catherine Jones Denis Lacey Julie Leeson Sue Marshall Paulette McIntosh Rachel Miles Liz Newington Chet Patel Judith Rimell Denise Ferrett Tori Gregory Emma Haynes Layla Jones Ron Larty Chris Lucas Debbie Martin Louise McMillan Celia Millington Theresa O’Neil Tejal Patel Jayne Robinson Rachel Miriam Goodman Hanley Wendy Hill Aliza Kander Emma Lashbrook Wendy Lyons Gina McConnachie Jane Melton Sarah Morris Michelle Palmer Gemma Payne Angela Ross Gamble Karen Ruff Saffron Scott Sarah Skinner Helen Tilley Vicky Waud Mary Williams Keith Wilshere Joanna Sanday Shelley Seed Leanne Smith Carrie Tucker Jonathan Weir Weir Fiona Willis Katherine Wimpenny Ezra Schwartz Daksha Shah Nicki Snape Louise Twigger Richard Western Suzie Willis Janet Woodhouse Woodhouse Gemma Scott Rebecca Shaw Becci Thompson Laura Wain Karen Wheeler Emma Whelan Finally, we are indebted to Central and North West London Mental Health Trust; Finally, Trust; The The State Hospital, Carstairs; Gloucestershire Partnership NHS Trust; Coventry Teaching Primary Care Trust and Derbyshire Mental Health Services NHS Trust Trust for supporting the research process. MOHOST 2.0 MOHOST v.2.0: INTRODUCTION The Model of Human Occupation Screening Tool (MOHOST) has evolved slowly over a period of several years. My first attempt was, to say the least, lacking in scientific rigour. rigour. Despite this, it soon proved invaluable to me as a practising clinician. I was able to use it as a basis for sharing insights with clients and colleagues and for communicating the focus of my work to students and the wider multidisciplinary team. In fact, I might never have developed it any further if it hadn’t been for the generosity of Gary Kielhofner who encouraged me to think of the Model of Human Occupation as “community property”. He put me in touch with Dr. Kirsty Forsyth, and the improved design of the MOHOST owes as much to her enthusiasm as it does to her research skills. The layout layout has changed dramatically since we first started collaborating, but my original vision remains the same: to create a simple outcome measure covering a broad range of occupational performance. I work in an Acute Psychiatric setting and it would be fair to say that I meet chaos and disorder on a daily basis. So I was keen to base any new assessment on a model that could provide a stable framework and help me to look for clear patterns of behaviour. I turned to the Model of Human Occupation to provide the inspiration I needed because MOHO seems to me to explain not just the scope of occupational therapy therapy,, but the importance of occupational therapy and how it brings about change. I am aware, however however,, that not everybody shares this enthusiasm, and I know that the Model of Human Occupation’s terminology has proved a stumbling block for many of my British colleagues. My hope is that the MOHOST goes some way towards addressing this issue by attempting to use commonly understood terms as much as possible. This This hope has been strengthened by the experience I have had of working with many gifted occupational therapists whose work is largely intuitive. Many of them would ordinarily view manufactured models and assessments with a healthy scepticism and yet they have surprised me with their reports of the MOHOST being both useful and user-friendly. I would be delighted if the MOHOST proved to be of use to you in your work setting. MOHOST v.2.0 MOHOST v.2.0: TABLE OF CONTENTS 1. Theoretical Basis of the MOHOST ............. ............................ ............................. ........................... ............. 4 2. Contextual Issues ............. ........................... ............................. ............................. ............................ ......................... ........... 8 3. What Does the MOHOST Measure? ...................... ..................................... ............................ ............. 12 4. Content and Purpose of the MOHOST .................. ................................. ............................ ............. 15 5. MOHO Terminology and the MOHOST................. ................................ ............................ ............. 18 6. Administration .............. ............................. ............................. ............................. ............................. ......................... ........... 20 7. Links with Other MOHO Assessments ................... .................................. ............................ ............. 25 8. OCAIRS Questions - Getting to Know Know Your Client ................. ............................ ............. 29 9. Case Studies .............. ............................ ............................ ............................. ............................. ............................. ................. 31 10. Quick Guide to Treatment Planning....................... ...................................... ............................ ............. 51 11. Guidelines for Using the Rating Scale.................... ................................... ............................ ............. 54 12. Instructions and Expanded Criteria........................ ....................................... ............................ ............. 60 Appendix ............. ........................... ............................. ............................. ............................ ............................. ..................... ...... 87 MOHOST 2.0 Chapter One: THEORETICAL BASIS OF THE MOHOST: THE MODEL OF HUMAN OCCUPATION The MOHOST is based on concepts from the model of human occupation, which addresses motivation, performance, and organisation of occupational behaviour in everyday life. This section provides a brief overview of the elements of the model that are most relevant to the MOHOST. Those who wish to use the MOHOST are also encouraged to refer to the text, A model of human occupation: Theory and application (Kielhofner, 2002), since the MOHOST presumes that persons who use it are familiar with the concepts of this model. The model is based on the premise that occupational performance is a central force in health, well being, development and change. The The model views humans as dynamic, self-organising systems always unfolding and changing in time, and ongoing occupational behaviour is regarded as underlying this self-organisation. That is, is, as human beings engage in work, play and daily living tasks, they maintain, reinforce, shape and change their own capacities, beliefs, and dispositions. According to the model, a person’ person’ss occupational participation emerges out of a co-operation of the person with conditions of the environment. The Person The person is made up of the following elements: a) volition, b) habituation, and c) performance capacities VOLITION The model asserts that a universal need to act is uniquely expressed in each person’s occupational performance. The choices that persons make to act are seen as a function of the volition subsystem. Volition Volition is made up of values, personal causation, and interests. These pertain to what one holds as important, how effective one is in acting on the world, and what one finds enjoyable and satisfying. Personal causation, values, and interests are interrelated and together constitute the content of our feelings, thoughts, and decisions about engaging in occupations. 4 MOHOST v.2.0 Components: Personal causation: Personal causation refers to what persons believe about their effectiveness. It includes: a) knowledge of capacity, an awareness of and attitude toward one’s one’s present and potential abilities, and b) a sense of efficacy which includes the perception of whether and how one controls one’s own performance and achieves desired outcomes of performance. Values: What one sees as worth doing, how one believes one ought to perform, and what goals or aspirations one holds are all expressions of values. Also reflected in one’s values is the common sense that guides the kind of life that persons strive for. Values elicit strong emotions concerning how life should be and how one should behave. Interests: Interests reflect both natural dispositions and acquired tastes. Interests include: a) the disposition to enjoy certain occupations or certain aspects of performance, referred to as attraction, and b) preference, which is the knowledge that one enjoys particular ways of performing or particular activities over others. HABITUATION Humans acquire and exhibit recurring patterns of occupational performance that make up much of their everyday lives. These These patterns are regulated by habits and roles. The process of acquiring and repeating these patterns of occupational performance is referred to as habituation. Components: Habits: Habits allow occupational performance to unfold automatically. They preserve ways of doing things what we have learned and repeated. Habits are reflected in one’s: a) performance in routine activities, b) typical uses of time, and c) styles of performance (e.g., being slow-paced versus fast-paced). Roles: Occupational Performance also reflects the roles one has internalised. People see themselves and behave as spouses, parents, workers or students when they are in these roles. The roles one inhabits also create expectations Theoretical Basis of the MOHOST for certain kinds of occupational performance, and competence depends on being able to reasonably meet those expectations. Interweaving of Habits and Roles groups provide and define expectations for roles and constitute a milieu or social space in which those roles are enacted. The ambience, norms, and climate of a group give opportunities for and demand certain kinds of occupational performance. Habits and roles, together, allow one to recognise Occupational forms refer to the “things to do” within a features and situations in the environment and to behave automatically. automatically . Roles guide how one performs within social positions; habits regulate other aspects of an individual’ individual’ss routine and ways ways of per-forming per-forming occupations. occupations. Much of occupational behaviour belongs to a familiar round of daily life, and adaptive performance means being able to sustain a pattern which is both satisfying to oneself and which meets reasonable expectations in one’s environment. The MOHOST provides an opportunity to gather information about the roles that a person has internalised and about how the person carries out those roles. It also provides an opportunity to examine the daily routines in a person’s life. particular milieu. Occupational forms are recognisable, coherent, and purposeful aspects of performance that are sustained in collective knowledge. They generally are named such as “doing the laundry”, “playing poker”, “reading a book”, and so on. Consequently, an occupational form that is part of a group’s typical performance is something members will recognise and have language to describe. Performance Capacities The third element of the person makes possible performance in daily occupations. Perform Performance ance involves a complex interplay of musculoskel-etal, neurological, perceptual, and cognitive phenomena that make up a mind-brain-bodyy performance subsystem. The underlying mind-brain-bod capacities of a person as reflected in their performance capacities interact with environmental factors to allow the person to express skill in occupation. The MOHOST does not directly assess performance capacities. The Environment The environment influences occupational participation by: a) providing opportunities and resources, and b) creating conditions that constrain and make demands upon a person. The environment is conceptualised as having physical and social dimensions. The physical dimension consists of spaces and the objects within them. Spaces refer to both natural and fabricated contexts in which people behave. Objects also refer to both natural and fabricated fabricated things with which persons may interact. The social environment includes groupings of persons and occupational forms that persons perform. Social The environments in which one performs occupations are combinationsofthephysicaland social. social.These Theseoccupational settings are composites of spaces, objects, occupational forms, and/or social groups that cohere and constitute a meaningful context for performance. Occupational settings can include home, school or workplace, and sites for gathering, recreation, or resources (e.g., theatres, churches, clubs, libraries, museums, restaurants, and stores). A person’s person’s occupational behaviour is invited and shaped by these occupational behaviour settings. Skills Within occupational performance we carry out discrete purposeful actions. For example, making coffee is a culturally recognisable occupational form in many western cultures. To do so one engages in such purposeful actions as gathering together coffee, coffeemaker, and a cup, handling these materials and objects, and sequencing the steps necessary to brew and pour the coffee. These These actions that make up occupational performance are referred to as skills. Skills are goal-directed actions that a person uses while performing. In contrast to performance capacity that refers to underlying ability, ability, skill refers to the discrete functional actions. There are three types of skills: motor skills, process skills, and communication and interaction skills. Detailed taxonomies of the skills that make up each of the three types of skills have been developed as part of creating assessments of skill (See below for further information on these assessments). Fisher and colleagues have developed the taxonomies of motor and process skills that make up an Assessment of Motor and Process Skills. Forsyth and her colleagues have developed a taxonomy MOHOST v.2.0 5 Theoretical Basis of the MOHOST of communication/interaction skills which make up the Assessment of Communication/Interaction Skills. A teenager’s teenager’s occupational participation may be: Occupational Performance Occupational performance refers to the completion of an occupational form. For example taking a shower, riding a bike, going fishing, play cards, bake a cake, shining shoes, mowing the lawn, and painting a room. • Personal care • Being a student • Participating in sports Occupational Participation The teenager’s school attendance is primarily shaped by societal expectations and social roles assigned to the teenager. Occupational Participation is the engagement in work, play or activities of daily living that are part of the social context. Not just occupational performance -- it is doing things with personal and social significance e.g., volunteering, working part time, maintaining one’s one’s living What kind of sports the teenager plays is influenced by capacities, interests, and available opportunities in the environment. space or attending college. Level of Doing Occu Oc cupa pati tion onal al Par arti tici cipa pati tion on Groo Gr oomi ming ng on ones esel elff Working as a nurse Maintaining one’s apartment Socialising routinely with friends Occupational Pe Performance Brushing tee teeth Giving an injection Vacuuming the floor Playing scrabble Calibrating Reaching Sequencing Manipulation Speaking Reaching Sequencing Manipulating Reaching Sequencing Manipulating Walking Reaching Sequencing Manipulating Speaking Occupational Skill 6 Examples MOHOST v.2.0 Theoretical Basis of the MOHOST Occupational Identity Occupational Competence Our participation helps to create our identities. Occupational identity is defined a composite sense of who one is and wishes to become as an occupational being generated from one’s history of occupational participation. Occupational Identity includes: Occupational competence is the degree to which one sustains a pattern of occupational participation that reflects identity. identity. Competence has to do with putting your identity into action. Includes: • Fulfilling the expectations of ones roles and one own values and standards of performance, What things one finds interesting and satisfying to do, • Maintaining a routine that allows one to discharge responsibilities, • Who one is, as defined by one’s roles and relationships, • • What one feels obligated to do and holds as important, Participating in a range of occupations that provide a sense of ability ability,, control, satisfaction, and fulfillment, and • Pursuing one’s values and taking action to achieve desired life outcomes. • One’ss sense of capacity and effective One’ effectiveness ness for doing, • • A sense of the familiar routines of life, and • Perceptions of ones environment and what it supports Perceptions and expects. These are garnered over time and become part of one’s identity. Occupational identity reflects accumulative life experiences that are organized into an understanding of who one has been and a sense of desired and possible directions for one’ one’ss future. Occupational Adaptation Occupational adaptation is the construction of a positive occupational identity and achieving occupational competence over time in the context of the environment. MOHOST v.2.0 7 Chapter Chapt er Two: CONTEXTUAL ISSUES Integrating outcome measures into our practice It has been said of the MOHOST, that it doesn’t tell an experienced clinician anything more than she or he knows already. This is, in fact, one of its strengths. It can reveal fresh insights at times, and has been found to be especially useful in alerting students and recently qualified occupational therapists to those aspects of a client’s client’s occupational participation that require most attention. However, one of its prime functions is to document the knowledge that we hold clearly and systematically, providing a format by which we can communicate this knowledge to others. Moreover, Moreover, when a group of occupational therapists adopt the assessment, then the purpose of occupational therapy is promoted and the concerns of occupational therapists in the multidisciplinary team become more prominent. Integrating any outcome measure into our practice can be challenging. The better that we know our clients, the quicker and easier the MOHOST is to use. As with any new assessments, the MOHOST may take a little while to become accustomed to, and it may take 40 minutes to complete a MOHOST form for a client with complex needs when one is unfamiliar with the concepts involved. If this seems to be too much time, we might put this in perspective by asking ourselves as how long a standard kitchen assessment could take to do, compared with producing a standardised assessment of your client’s client’s overall occupational participation? Or without how long do producing we spend writing formative assessments ever a summative report? Notes that are written day by day are often relative in nature, with clinicians noting that clients are ‘more spontaneous’ or ‘less preoccupied’ but without any baseline information to measure this against. The MOHOST provides us with a format to overcome this weakness in note-writing, allowing us to be more accountable for our professional judgement. Of course, one could argue that it would be wrong to attempt to capture our understanding, in all its richness and depth, in a single assessment. In truth, however, however, the Model of Human Occupation has only ever sought to help 8 MOHOST v.2.0 us to manage complexity, never to reduce it (Kielhofner 2002). We ourselves are occupational beings, and we will always look for order and patterns to help us make sense of our world. We acknowledge acknowledge that we can never hope to fully control our lives or to mould the lives of others and, “each individual presents with a unique set of problems that needs to be addressed” (Chesworth et al, 2002, p.30). At the same time, we believe that we can benefit from a framework to inform our clinical practice and decisionmaking (Payne, (Payne, 2002), and should be mindful that, “It is not only directives from central government that are guiding us towards evaluating and improving the quality of our work as practitioners, it is also our own common sense. As health and social care professionals, we know it is good practice to routinely gather information on the results of intervention so that we can objectively evaluate our effectiveness and state the benefits of occupational therapy intervention. We also know that by finding out about the quality of our work we can strategically work towards refining our professional skills and improving our provision of care. The challenge is upon us all to find appropriate tools to measure the quality of our work” (Clarke et al, 2001, p.1). A theory driven, formal assessment like the MOHOST can therefore be used to deliver information about the effectiveness of our services and support us towards evaluating and improving the quality of our work as practitioners. Ensuring client-centred practice There are some clinicians who have registered their concern about using a therapist-rated assessment due to their fears that this might mitigate against client-centredness, and there has also been a great deal published about the challenge that client-centred practice presents (Hamell 2001). We all now recognise the value of working in partnership with our clients and know that we should strive to validate the expert opinions of service-users. In doing so, however, we sometimes need to remind Contextual Issues ourselves that this “does not negate the importance of professional expertise” (Kusznir & Scott, 1999, p.81). After all, client-centred practice includes taking a comprehensive perspective and providing clients with sufficient information so that they might make informed choices about their occupational lives (Law & Mills, 1998). Indeed, the essence of client-centred client-centred practice lies lies occupations that the client values and finds satisfying and meaningful. Being client-centred cannot only mean paying attention to clients who can communicate to us about their unique situation. We have often heard therapists indicate that they cannot apply the concepts of volition to their clients whose level of functioning is too low. This has always perplexed us since clients, not in the tools that we use but in the approach that we adopt. It has more to do with therapists being “motivated, hardworking, fun to work with, appreciative and even inspiring” and it is threatened when therapists make “unrealistic recommendations” (Kusznir & Scott, 1999, p.77). By using tools wisely to systematically analyse our findings, we are less likely to fall into this trap. who are least able to self-describe and self-advocate, most deserve careful assessment of their volition. Clientcentredness should extend to those clients who are unable to verbalize and/or be active in collaboration. Within MOHO there are ways to be client-centred and gather this important information volitional information. The therapist uses MOHO to understand the client’s view on the world, what matters to the client, what the client enjoys, and how the client feels about his or her abilities. This can be achieved through careful observation of the client’s volitionally relevant actions. An important aspect of MOHO-based therapeutic reasoning is its client-centred nature. MOHO is recognised as a model consistent with client-centred practice (Law & Mills, 1998). MOHO concepts require therapists to have knowledge of their client’s values, sense of capacity and efficacy efficacy,, values, roles, habits, performance The MOHOST works well with clients who are unable to identify their occupational needs, but it is also possible experience, and personal environment. MOHObased assessments are designed to gather information on and provide clients with opportunities to improve their perspectives on these factors. The client’s unique characteristics, in combination with the theory, guide the development of an understanding of the client’s unique situation. The The understanding of the client, in turn, provides the rationale ratio nale for therapy. Moreover, since MOHO conceptualises the client’s client’s own doing, thinking and feeling as the central dynamic in achieving change, therapy must support the client’ client’ss choice, action, and experience. to share its results with clients who are more articulate, enabling them to debate or confirm the results of the assessment and so clarify their occupational goals. The decision to show the assessment to clients rests entirely with the therapist. It will be necessary to balance the right of the client to access their clinical notes with the understanding that some clients may find it difficult to respond to the written word. Should the therapist deem that it would be useful for the client to see the assessment, then it is hoped that the MOHOST is worded in such a way as to facilitate this process. MOHO is, therefore, inherently a client-centred model in two important ways: Maintaining • It views each client as a unique individual whose characteristics characterist ics determine the rationale for and nature of the therapy goals and strategies, and occupational participation • It views what the client does, thinks, and feels as the central mechanism of change (Kielhofner 2002). In particular, the model includes a concept called volition (Kielhofner,, 2002). This is defined as motivati (Kielhofner motivation on to engage in occupations and is based on what we perceive to be interesting (interests) and valuable (values) and what we believe ourselves capable of doing (personal causation). This concept is particularly important for client-centred practice as it asks the therapist to fully understand the our unique focus of We can sympathise with Perrin, when she asks whether it would, “be true to say that we have been so preoccupied with assessment … that we are losing the art (and the heart) of what it means to use occupations in healing“ (Perrin 2001, p.129). This is particularly true when occupational therapists turn to psychological and medical assessments that do not assess occupational participation and also when they restrict their assessments to those based on the interview format. The MOHOST, however, can only be completed if the client is observed engaging in occupation. Information provided by carers and the multi-disciplin multi-disciplinary ary team can be used to confirm these observations, but one cannot assess a client with confidence without direct MOHOST v.2.0 9 Contextual Issues contact in an occupational setting. In this way, the MOHOST encourages occupational therapists to focus on their core skills. We agree with Nelson, that “what makes us unique is not that we document functional outcomes but that we use occupations as the method to achieve positive outcomes” (Nelson, 1997, p.22). This is also consistent with the belief that it is only right that “we should seek ways of measuring the effectiveness of our interventions in terms of enhanced engagement in occupation” (Creek, 2002, p.4). The MOHOST allows us to own an assessment process that is congruent with our professional focus. “Clinicians like MOHO because it gives them a theoretical understanding of occupation and tools for doing occupationally focussed practice, not just a way of thinking about occupation” (Forsyth, 2001, p.620), and 10 MOHOST v.2.0 the MOHOST allows clinicians to actively use MOHO theory in their occupation focused practice. The importance of this cannot be underestimated at a time when professionals have been pressured to become increasingly generic in their roles, leading to inevitable role-blurring and consequent stress and insecurity, (Bassett & Lloyd, 2001). Many occupational therapists are now attempting to reverse the tide of genericism and we are encouraged to spend “the majority of our time” using our core skills, (Craik 1998, p.391), but difficulties remain in explaining our role to others. The beauty of the Model of Human Occupation and the MOHOST is that they can provide us with the vocabulary to define the scope of our work so that we can communicate our occupational focus clearly and effectively. effectively. Contextual Issues References Baron K, Kielhofner G, Goldhammer V, Wolenski J (1999). A User’s Manual for the Occupational Self Assessment (OSA) (Version (Version 1.0) University Universit y of Illinois at Chicago. Bassett H, Lloyd C (2001). Occupational Therapy in Mental Health: Managing Stress and Burnout. British Journal of Occupational Therapy, 64(8), 406411. Kielhofner G (2002). A Model of Human Occupation, Theory and Application. (Third edition) Baltimore, MD: Lippincott Wiliams and Wilkins. Kusznir A, Scott E (1999). The The challenges of client-centred practice in mental health settings. In: T Sumsion, ed. Client-Centred Practice in Occupational Therapy. New York, NY: Churchill Livingstone. Law M, Mills J (1998). Client-centred occupational therapy. In: M Law, ed. Client-Centred Occupational Therapy. New Jersey: Slack. Chesworth C, Duffy R, Hodnett J, Knight A (2002). Measuring Clinical Effectivenessin Mental Health: is the Canadian Occupational Performance an appropriate measure? British Journal of Occupational Therapy, 65(1), 30-34. McLaughlin Gray J (1997). Application of the phenomenological method to the concept of occupation. Journal of occupational Science: Australia, 4(1), 5-17. Clarke C, Sealey-Lapes C, Kotsch L (2001). Outcome Measures Information Pack for Occupational Therapy. College of Occupational Therapy, London. Nelson D (1997). Why the profession of occupational therapy will flourish in the 21st century. The 1996 Eleanor Clarke Slagle Lecture. American Journal of Occupational Occupatio nal Therapy, Therapy, 51(1), 11-24. Craik C, Austin C, Chacksfield J, Richards G, Schell D (1998). College of Occupational Therapists’ Therapists’ position paper on the way ahead for research, education and practice in mental health. British Journal of Occupational Occupati onal Therapy, Therapy, 61(9), 390-392. Payne S (2002). (2002) . Standardised Standard ised Tests: Tests: an Appropriate Appropr iate Way to Measure the Outcome of Paediatric Occupational Therapy? British Journal of Occupational Therapy, 65(3), 117-122. Creek J, Bannigan K (2002). Occupation and activity – a discussion. Mentalhealth OT, 7(1), 4-6. Perrin T (2001). Don’t despise the Fluffy Bunny: a Reflection from Practice. British Journal of Occupational Occupatio nal Therapy, Therapy, 64(3), 129-134. Forsyth K (2001). What kind of knowledge will most benefit practice? British Journal of Occupational Therapy, 64(12), 619-620. Sweetman M (2001). Outcome oriented treatment planning in acute inpatient mental health. Occupational Therapy Therapy News, 9/10, 19. Forsyth K, sSalamy M,the Simon S, Kielhofner G (1998). A User’s User’ Guide to Assessment of Communication and Interaction Skills (ACIS) (Version 4.0) University of Illinois at Chicago. Trombly C (1993). Anticipating the future: assessment of occupational function. American Journal of Occupational Occupatio nal Therapy, Therapy, 47(3), 253-257. Halliday K (2001). Measuring the occupational performance of mental health clients – how hard should we try? Occupational Therapy News, 9/10, 21. Hammell K. (2001). Applying the Client-centred Philosophy. British Journal Jou rnal of Occupational Occupat ional Therapy, Therapy, 64(8), 418-419. MOHOST v.2.0 11 Chapter Three: WHAT DOES THE MOHOST MEASURE? The link with activities of daily living The MOHOST measures occupational participation of the client. Occupational participation has been defined as self care, productivity, productivity, and leisure. Some department call these activities of daily living (ADL). Self care, productivity productivity,, and leisure MOHOST ANAL ANALYSIS YSIS Motivation for occupation, pattern of occupation, communication & Motivation interaction skills, motor skills, process skills, environment MOHOST provides a framework for understanding why a client is not engaging in self care, productivity or leisure. The The MOHOST is a theory driven activity analysis that can be used in all areas of practice to understand the client’s client’s engagement in activities of daily living. ? What do ADL issues look like from a MOHOST perspective e.g., appraisal of abilities as part of “motivation for occupation”? MOHOST Self care Productivity Leisure Is the client appropriately appraising their own ability in self care skills and abilities? Is the client appropriately appraising their own ability in productive skills and abilities? Is the client appropriately appraising their own ability in leisure skills and abilities? Is the client over/under estimating their ability when engaging in self care activities? Is the client over/under estimating their ability when engaging in productive activities? Is the client over/under estimating their ability when engaging in leisure activities? Appraisal of abilities ? Is it important to consider the full range range of issues of self care, productivity and leisure leisure when rating a MOHOST? Yes, the MOHOST is a measure of OCCUPATIONAL PARTICIPATION and that means it should consider the areas of…………… Motivation for occupation, Pattern Motivation Pattern of occupation, Communication and Interaction skills, Process skills, Motor skills, Environment …………..in relationship to self care, productivity and leisure – as below 12 MOHOST v. v.2.0 What does the MOHOST measure? Motivation Motivati on for occupation How is the client motivated for self care, productivity, and leisure? Pattern of occupation How does the client organise their self care, procuctivity, and leisure? Communication and Interaction skills Does the client have adequate social interaction skills to complete their self care, productivity, productivity, and leisure? Process skills Can the client organise themselves within their self care, productivity, productivity, and leisure? Motor skills Can the client move themselves and objects around during their self care, productivity, productivity, and leisure? Environment Does the client have a supportive social and physical environment to allow for meaningful self care, productivity, and leisure? ? Can I still use group work as an observational setting for the MOHOST? Yes, many leisure/producti leisure/productivity vity activities are delivered in group formats within occupational therapy services. This This is an entirely appropriate setting to observe the client engaging in occupation. However, you need to make sure you are also data gathering in others areas of self care, productivity and leisure as well before completing the MOHOST ratings. ? So if I receive a referral asking for a “functional assessment” I can complete a MOHOST? Yes, we would encourage you to think through what you mean by “functional assessment” as this has various meanings within OT. OT. The The MOHOST would ask you to assess the person’ person’ss occupational participation, i.e. their ability to engage in self care, productivity productivity,, and leisure. This This includes considering dressing, grooming, cooking, home maintenance, taking care of others, paid employment, enjoyable enjoyable social activities and so on. ? What do I do if I receive a referral that asks for a “kitchen assessment”? You need to ask “what is my professional position?” Can an OT make sound judgements based on one kitchen observation? If the OT states that the person is able to function in a kitchen, based on a one-off observation in the OT kitchen and the person is subsequently found to not cook while at home – what would the consequences be? It is the OT’s judgement that would be scrutinised, not the referring agent and, therefore, it is the responsibility of the OT to decide what an assessment should contain. If you are asked for a one-off kitchen assessment – we recommend that you complete an assessment of the full range of self care, productivity and leisure as there are so many factors to take into consideration. For instance, if someone has just completed an afternoon (habits) football group with peers (leisure activity) – they may be more motivated (volition) to cook because they are hungry. If someone takes pride (values) in their appearance, however, seems reluctant to engage with you in the kitchen (volition) – the reluctance may be due to them being conscious of their body odour because they weren’t able to wash adequately (self care) in the morning in the ward due to the lack of shower facilities (physical environment). It may have nothing to do MOHOST v.2.0 13 with their kitchen skills, and so self care & leisure can influence the person’ person’ss ability to prepare food in the kitchen. To meet the referring agent’s concern, you will need to make a judgement about the client’s ability to feed himself/herself. The OT can complete the MOHOST (self care, productivity, and leisure) based on the person’s behaviour in the hospital environment. You will also need to know what the person’ person’ss daily life is like in the community i.e., how they construct their habits, what responsibilities they hold, how motivated are they to cook even though they have the skill, do they have enough confidence, skill, capacity to get food into their house, and so on, - how feeding themselves fits into their occupational participation. For example, if they have no responsibilities and an empty routine, they may lack motivation motivati on to do anything – even though they have the skills to cook in the OT kitchen. This assessment structure will provide the following information: Completed MOHOST in hospital (which may include observations of dressing, kitchen work, group work, discussion with nursing staff) In addition to.... Community proxy report Proxy report from someone who knows the client in the community Note: it may also be appropriate in some circumstances to complete a home visit in a MOHO format. develop case formulation Discharge recommendations The completed MOHOST will document how the person is participating in occupation in the hospital (self care, productivity,, leisure). Meanwhile, a proxy report of the person’ productivity person’ss life in the community can be used in order to predict the likelihood of participation on discharge (which is what the referring agent is probably looking for). So if a person participates well in their daily life on the ward, but a proxy report states that they don’t participate well at home – then reasons for this can be explored before discharge. Reflections may include……….is it the structure of the routine that helps them engage more in occupation in the hospital? … is it the verbal prompting of the environment? … is it the peer support and friendships formed in the ward that support the persons function? … is it because they have an OT standing over them! … is it because they are on medication and are medically stable and so on. If there is a major difference between the hospital MOHOST ratings and the community proxy report of the persons’ community participation prior to admission then the OT may decide to complete a full MOHOST within the community context of the person’s person’s life (within a home visit). This allows allows the persons abilities to be measured within within the community before discharge. discharge. Note: this structure is also effective in a day hospital situation when it would be appropriate to complete 2 MOHOST’s MOHOST’s – one in the day hospital and one in the community community.. 14 MOHOST v. v.2.0 Chapter Four: CONTENT AND PURPOSE OF THE MOHOST The MOHOST aims to give a broad overview of occupational participation. It consists of 24 items, four for each of the following sections: therapeutic environment. The observations/interactions with the person are structured through the conceptual model of practice. • Volition V olition (or ‘motiv ‘motivation ation for occupation’) • Habituation (or ‘pattern of occupation’) • Communication and Interaction skills • Process skills • Motor skills • Environment The MOHOST is the most flexible of the MOHO assessments available to date as it provides a comprehensive evaluation of the person using a mixed data collection method. This This means that the MOHOST can be used with a wide ability range of people including those with verbal or non-verbal skills. It thereby allows the therapist to infuse client-centredness into practice even in challenging circumstances, acting as a basis for discussion with the person and the multidisciplinary team, to guide the aims of therapy and to set occupational goals. Most of the sections deal directly with the person’s participation in occupation. The last section is slightly different, in that it explores how the environment supports the person to participate in occupation. The items in all the other sections are concerned with different aspects of the person. When it comes to rating the environment, however, the therapist is not rating the person’s skill to manage their environment but the resources, opportunities, constraints and demands of the environment itself. It must be remembered that occupational participation is always contingent on the support that we receive from the environment and the inclusion of the environment section therefore puts a person’s occupational participation into context. It is intended to be a screening assessment for a broad range of occupational participation issues that are articulated by MOHO, by identifying that a person has a difficulty in any particular aspect of their occupational participation. The therapist may then decide to complete further, more specific assessments. The MOHOST may also be used alone, particularly when the occupational therapy service is under pressure and a review of the person’ss needs are required and/or when the reasons for person’ referral to occupational therapy are unclear and clients need to be assessed and prioritised. Having an equal number of items per section allows the therapist to compare the person’ person’ss relative strengths and to focus on those areas of occupational participation requir- The only limiting factors are that clients need to have regular contact and sufficient access to meaningful occupation in order to adequately gauge their level of performance, and that their performance is consistent ing further intervention. Thethe MOHOST’s value lies inassessment its ability toortake into account impact of volition, habituation and the environment as well. In this way, it makes plain that the focus of occupational therapy is more than the treatment of discrete skills and instead involves looking at the person and how they engage with the environment in order to complete self care productivity and leisure activities. over a period of time. The The therapist needs to be confident of having sufficient information in order to have a real sense of knowing the person. If the person is verbal and co-operativee it may be possible to collect the information co-operativ required in one or two sessions but getting to know a person often takes longer. For more challenging clients it can take up to a week (depending on regularity of access to the client). The MOHOST enables occupational therapists to formalise the knowledge that they build up about the person informally over a period of time, by systematically documenting their observations/interactions regarding how the person respond to occupation within a given MOHOST v.2.0 15 Content and Purpose of the MOHOST Aims of the MOHOST • To maintain a perspective that is unique to Occupational Therapy, using a conceptual model of practice focused on occupational participation (self-care, productivity, leisure). • To identify further more is needed andwhen to complement thedetailed existingassessment assessments in the MOHO toolbox. • To be straightforward and reasonably quick to use, allowing repeated assessment at regular intervals. • To use terms that will be understood by the multidisciplinary team. • To assess a representative sample of issues relating to the person and the environment as framed by the Model of Human Occupation, allowing their relative strengths to be demonstrated in a person’ person’ss profile. • Typical uses of the MOHOST • To be used in situations where accurate self-assessment may not be possible and lengthy interviews may not be appropriate (e.g. when the person may be too confused and lacking insight or too depressed and lacking concentration, or in settings where there is a high turnover of clients). To aid documentation by enabling occupational therapists to systematically record both their initial observations and their subsequent analyses (e.g. recording baseline assessment and changes in occupational participation (self-care, productivity, leisure). • To aid communication regarding the person’s needs and to analyse their relative strengths (e.g. prior to care-planning and treatment reviews). • To highlight the impact of volition (motivation for occupation) and habituation (pattern of occupation) as well as the more commonly assessed aspects of skills, making it explicit that the focus of occupational therapy needs to be broader than the teaching of discrete skills. 16 To help the multidisciplinary team to recognise when a person with florid symptoms is nevertheless able to participate in occupation well, or conversely, when a person with an absence of primary symptoms has disengaged from occupation. • To provide the answers to those questions commonly asked when a clinician is considering how best to approach a person who may be previously unknown to them, and thereby enabling any clinician to have a clearer understanding of the person’s current occupational participation (e.g. discharge planning, when a person is referred to another agency). • To help identify when further more detailed assessment would be useful (e.g. Volitional Questionnaire, Assessment of Communication and Interaction Skills, Assessment of Motor Process Skills). • To establish whether occupational therapy services are necessary, necessary, by reinforcing the occupational focus of occupational therapy. To analyse a person’s general occupational participation irrespective irrespective of symptoms or diagnosis or the treatment setting. • • MOHOST v.2.0 Purpose of the Ratings We believe that most therapists who take the time to complete the MOHOST will find that doing so is a good investment of time and energy. • The ratings provide an objective, theory-based, and succinct assessment of a client. This can contribute to occupational therapy & interdisciplinary decision making in treatment, discharge, placement, and other decisions. • The rating scale of the MOHOST reflects theory from the Model of Human Occupation and functions as a way of relating the information obtained in the assessment back to the theory. • The descriptive criteria serve as a visual profile of strengths and weaknesses of which the therapist should be cognisant when beginning treatment planning. The ratings, when completed, provide a visual profile of the person’s strengths and weaknesses and can serve as a ready index for quickly identifying these strengths and weaknesses. Content and Purpose of the MOHOST • The MOHOST provides a method of effective communication. In an era when occupational therapists are increasingly assuming indirect service roles such as in education, consultation, and supervision of direct service providers, clear and consistent means of communication are essential. The MOHOST provides a means of communicating a range of considerations for the occupational participation of the client. That is, the ratings can serve as an effective structure for providing consultation, education, and supervision. By consistently using the ratings, the therapist employs a consistent framework for communicating about the needs of a person and recommendations for services, structure, etc. Moreover, Moreover, by using the same framework across clients, therapists can readily point out similarities and differences of clients, justifying recommendations or specifications for services. • The ratings provide a means of measuring the person’ss occupational participation. When one uses person’ a tool capable of measurement, it is possible to measure the effectiveness of occupational therapy services. MOHOST v.2.0 17 Chapter Five: MOHO TERMINOLOGY AND THE MOHOST The words that are selected to describe therapy are very important and MOHO terms, like those of any other professional language, offer benefits and pose challenges. When the MOHOST was first conceived, the specialist terminology was not a particular issue. The sole intention was that it should be relatively quick and simple to use, so that it could be used on successive occasions to document progress. However, it soon became apparent that its simplicity made it an ideal tool for communicating the focus of occupational therapy to the wider multidisciplinary team, and for this reason it was decided to de-code the professional language used by the Model of Human Occupation. In this way: • Volition • Habituation becomes “ Motivation for Occupation Pattern of Occupation • Physicality “ Non-verbal skills • Temporal Organisation “ Timing It is not intended, however, that MOHO terms should be discounted altogether. altogether. Occupational therapists therapists have always used professional terminology, indeed they have acquired the professional languages of several disciplines and theoretical perspectives. The terms, “resuscitation”, “repression” and “reinforcement” respectively reflect medical model, object relations, and behavioural concepts. Such specialised terms terms are designed to support the flow of communication among practitioners. Complex conditions or procedures can be conveyed and immediately understood when such professional terminology is used. A common example of how a professional term can efficiently convey complex information and facilitate communication between professionals is medical diagnosis. The term, “Alzheimer’s dementia” conveys the following, rather complicated meaning: 18 MOHOST v. v.2.0 “. . . the development of multiple cognitive deficits manifested by both a) impaired ability to learn new information or recall previously learned information, b) one or more of the following deficits: i. language disturbance; ii. impaired ability to carry out motor activities despite motor function; iii. failure to recognise or identify objects despite intact sensory function; vi. disturbance in planning organising, sequencing, and abstracting. These cognitive deficits cause a significant impairment in social or occupational functioning and represent a significant decline form a previous level of functioning. It is characterised by a gradual onset and continuing cognitive decline. The deficits do not occur exclusively during the course of delirium” (DSM VI, 1994). Using diagnostic terms such as Alzheimers allows those who know the meaning of terminology to share common perspectives and to succinctly convey information. Similarly, MOHO terminology can be used to convey complex concepts to those who are familiar with the model. For example, the term, volition, denotes a complex idea about how persons are motivated toward their occupations. To To those who know its meaning, “volition” will convey several concepts. When someone refers to a “volitional problem” those who know the terminology can anticipate that the problem involves clients’ values, personal causation, and interests. They can further expect that the problem is manifest in how clients anticipate, choose, experience and interpret what they do. In this way, MOHO terminology can convey a great deal of information. The major disadvantage of all professional language is that everyone needs to have a common set of definitions for the words to be used to communicate effectively. It is, therefore, ineffective to use MOHO terms with colleagues and/or clients/relatives who will not understand what the words mean. Some MOHO terms such as “volition”, “personal causation”, and “roles” have meanings not readily understood. Other terms such as “interests” and “values” and “habits” contain meaning beyond but MOHO Terminol Terminology ogy are still consistent with ordinary usage. Still other terms, such as skill, have a meaning within the MOHO context (i.e., a quality of actual occupational performance), that may be quite different to everyday usage (i.e., underlying capacity). Therefore, therapists do have to be careful when and how they use MOHO terms, lest they confuse or mislead clients, lay persons, and other professionals. There are circumstances in which it is appropriate to use MOHO terms in communication. These These include: • Circumstances when the primary or exclusive audience is other occupational therapists, • Situations when clients are empowered by learning the MOHO concepts as a means of increasing understanding and control over their own circumstances, and • Settings where other professionals are receptive to becoming familiar with occupational therapy terminology. Certainly, the whole point of MOHO language is to facilitate communication of ideas between occupational therapists. This language can be particularly helpful when therapists are discussing clients, plans for therapy and so on. While clients ordinarily require that we communicate to them in everyday language, there are occupational therapists who encourage their clients to learn basic MOHO language and concepts. A couple of years ago the second author visited a private, community occupational therapy program, Reencuentros, Chile. In this setting clients are educated on the basic language and views of MOHO as part of their therapy. It was interesting to note that many of these clients (who have chronic disabilities) were quite interested to discuss their own “volition” with this visiting therapist. The authors have routinely used MOHO language with other professionals in practice contexts with good results. Other professionals are often quite willing, within reason, to acquire a basic understanding of one’s professional terminology. terminolo gy. Therapists have often noted to us that they have been surprised by how quickly teams pick up MOHO terms. More often than not, it is the therapist’s lack of confidence in using the terminology than resistance on the part of other professionals that prevents use of MOHO terminology in an interdisciplinary context. Nonetheless, therapists do need to be sensitive to the demands they put on other professionals for learning their terminology. It is important to decide which terms one would like interdisciplinary colleagues to understand and to take the time to explain them. As this example illustrates, one benefit of using MOHO language in a multidisciplinary context is that it conveys the fact that occupational therapy has its own concepts and approaches. Related to this, using MOHO language also denotes that the occupational therapist has a specific domain of interest and expertise. For example, a psychologist was apparently upset because she felt that occupational therapists were claiming motivation as their domain. She felt that motivation was a psychological term and area of expertise. The second author explained that occupational therapy’s interest in motivation was based on the concept, volition, and offered a brief explanation. Following this, the psychologist realised that her concerns with motivation and occupational therapy concerns were actually complementary rather than competitive or duplicative. Of course, most therapists will find it necessary to develop the facility of moving back and forth between using MOHO terminology and expressing MOHO concepts in ordinary language. This is not unique to occupational therapy. All professionals who wish to be effective in interacting with those who don’t share their expertise must know how to explain themselves in everyday language. Our intention is that the MOHOST will assist in facilitating this process. MOHOST v.2.0 19 Chapter Six: ADMINISTRATION When should I use the MOHOST and with whom? The MOHOST attempts to paint an overall picture of a person’ss occupational participation, irrespective of sympperson’ toms or diagnosis, as well as the level of support that the person receives from their environment. It enables occupational therapists to formalise the knowledge that they build up about people informally over a period of time, by systematically documenting their observations regarding how they respond to occupation. It can then be used as a basis for discussion with a person and the multidisciplinary team, to guide the aims of therapy and to agree occupational goals. As such, it is a valuable tool to use: • • • In the initial stages of assessment when planning treatment, To document change when progress is apparent, or alternatively when a deterioration in occupational participation is perceived, or In discharge-planning, when referring the person to a new service. Its objective focus is of particular value when clientcentred practice is most challenged, being ideally suited for use with clients who are unable to tolerate lengthy interviews, i.e., clients who may have difficulty evaluating or articulating their own abilities because of lack of insight, or concentration or verbal skills. Such clients are also likely to experience a wide range of impaired performance capacity, capacity, and this is another reason to consider using the MOHOST MOHOST,, because of its broad scope and ability to summarise information succinctly. These same qualities mean that the MOHOST can also be useful when the occupational therapy service is under pressure, when the reasons for referral to occupational therapy are unclear and clients need to be prioritised. Clients with medical problems do not necessarily have any occupational challenges, and once this has been established, it enables therapists to concentrate their efforts on those clients who are most in need. Therapists need to use their own professional judgement as to when to use the MOHOST. In some acute 20 MOHOST v. v.2.0 settings the MOHOST could well be used to document the progress of certain clients every two weeks, but to use the MOHOST any more frequently would be impractical. In those situations where clients are making daily progress, it is impossible to know with any certainty that the changes are going to be maintained, and the MOHOST can only be used when the therapist can confidently predict how the person is going to respond. When change is too rapid, or a person’s occupational participation is unpredictable then it becomes more difficult to use the MOHOST, although the first author has frequently used two assessments to document client’s typical “good” and “bad” days. The occupational therapist may have particular difficulty using the MOHOST if their own observations of a person are consistent but these are not corroborated by discussion with carers and the multi-disciplinary team. In most cases it will be possible to reach a consensus as to how the person participates in occupation and the therapist’s role is to clarify this in order to provide a consistent treatment approach. However, there may be times when no agreement is reached and on these occasions the therapist must ask themselves whether or not the occupational therapy itself is the reason for the person’s changed presentation. The The demands and the support of occupational therapy may be responsible for the changed presentation, either because it nurtures enhanced occupational participation or perhaps because it highlights areas of difficulty that the person is adept at masking in other settings. The The occupational therapist can still complete the MOHOST ratings, but needs to make it clear in the MOHOST summary that the ratings reflect occupational participation as witnessed in the therapeutic setting and may not reflect the level of participation seen e.g., on the ward or in the home environment. The therapist could then make recommendations that would support the person’ person’ss occupational participation in other environments. To summarise, as its name indicates, the MOHOST is essentially a screening tool: Administration • Assessing for areas of occupational participation requiring further assessment and intervention, and • Discussion with carers and the multidisciplinary team regarding their observations, • Assessing the person referred to occupational therapy to determine whether occupational therapy is essential or not. • Reading case notes, and • Completing other formal assessments. It is not an assessment that can be used to screen referrals before the occupational therapist has begun the process of getting to know the person. How is the information gathered? The MOHOST has been designed to provide a perspective that is unique to occupational therapy by documenting those skills that can only be assessed when a person is engaged in occupation. It is therefore dependent on the person having regular contact and sufficient access to meaningful occupation and assumes that occupational therapists will not be working in a wholly generic role. It is also assumed that the occupational therapists will always have some directand contact with to theconfirm person their and will be using discussion case notes professional observations. Occupational participation is inherently client-centred; it allows the person to demonstrate their commitment and involves the possibility of them making long-term occupational choices. Some activities utilised by therapists are short-term and therapist-led (Quizzes, Anxiety Management, Reminiscence, etc.) and by using the MOHOST it becomes apparent that these activities offer insufficient opportunities to adequately assess occupational participation. E.g., it can be difficult to observe a person’s organisational skills when they attend a discussion-based group that is organised for them. Although the MOHOST is primarily an assessment based on observation, it does allow the therapist to draw upon a variety of different sources of information, in order to fully reflect their knowledge of the person. The criteria is “getting to know your client” and this may be done through: • Informal observation in open settings, • Formal observation observation in 1:1 and group settings, • Discussion with clients regarding their motivation, interests, roles, and routines, Occupational therapists report significant advantages in completing the MOHOST in conjunction with other colleagues or carers, or even with the clients themselves. In doing so, the therapist is able to validate opinions and build rapport at the same time as educating others about their focus of intervention and the value of occupation. However, it should be recognised that the therapist will have to exercise professional judgement in whether to share the assessment form with the client or not. The occupational therapist has a duty to check out their assessment with the person in the manner which will be most appropriate. This may involve completing the assessment with the person, but when their skills are limited due to reduced volition, or communication and interaction, or processing abilities, then the therapist may decide to delay sharing the form and confine themselves to verbal feedback & dialogue. The therapist therefore has several options: • To complete the MOHOST with the person, • To complete the MOHOST with a carer or another member of the multi-disciplinary team, • To complete the MOHOST alone and discuss the main findings with the person, • To complete the MOHOST alone and use the findings to frame future interactions, and • To complete the MOHOST alone and share the analysis with the person when appropriate. How long does it take to gather the information? The MOHOST recognises that a therapist’s knowledge of a person is built up over a period of time, and its scope is such that it would be almost impossible to gather all the information in a single therapeutic contact. A period of a week might provide adequate time in acute settings where progress is being monitored frequently. In community settings, however, or when the person’s occupational participation is more settled, the assessment could be made over the period of two weeks or more. When progress has plateaued, as it may have done e.g. with MOHOST v.2.0 21 Administration people who have dementia, then longer periods of time may even be possible. The length of time that it takes to gather the information is perhaps not important, so long as the occupational participation observed has been relatively consistent for the whole period. How do I decide which form to complete? There are four forms provided in this manual 1. MOHOST Form 2. Multiple MOHOST Form It should take ten to twenty minutes to write up the assessment itself, once the therapist has become familiar with it through regular use, although the assessment may take 40 minutes to complete if the person’s needs are complex or unclear. uncle ar. However, all assessments take longer to complete when first attempted and it may take half a day to read through the manual before starting to use the assessment. This may cause a degree of dismay to a busy therapist, but if the person’s person’s needs can be articulated and clarified in the process then the effort is worthwhil worthwhile. e. Also, research has shown that the time taken to complete a MOHOST decreases dramatically after it has been used for the first 5 times. Motivation for Occupation ss e c c u s f o n o ti ta c e p x E tiy li b a f o l a is a r p p A Pattern of Occupation s e ic o h C st e r e t n I tiy li b ta p a d A e itn u o R 3. MOHOST Data Sheet Single Observation Form 4. MOHOST Data Sheet Multiple Observation Form a) MOHOST Form This form allows an assessment of all 24 items – 20 relating to the person and 4 relating to the environment. It is the MOHOST form that is recommended, enabling the occupational therapist to document the person’ person’ss abilities within the context of their environment. If the person’s abilities are similar across different environments then one MOHOST assessment can be completed. If, however, however, the person performs differently in Communication & Interaction Skills lls i k s l a b r e -v n o N tiy il b is n o p s e R s le o R n io ss e r p x e l a c o V n o it a sr e v n o C Process Skills s p i sh n o it a l e R e g d le w o n K tiy li b o m & e r tu s o P g in lv o -s m le b o r P n ito a is n a g r O g in im T Environment: _____________ Motor Skills rt o ff e & h g n e rt S n o it a n i rd o o C s e c r u o s e r l a ic s y h P e c a p s l a ic s y h P y g r e n E s d n a m e d l a n ito a p u c c O s p u o r g l ia c o S a) Occupational Participation in Day Hospital F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R b) Occupational Participation in Home Environment F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 22 MOHOST v.2.0 Administration different environments the occupational therapist should complete separate MOHOSTs for each environment. It is purely observational and can be completed after a single intervention, concentrating on individual behaviours that are representative of the items assessed in the MOHOST. For example, it assesses whether the person ‘manipulates tools and materials easily’ instead of assessing the general skill of ‘Co-ordination’. As such, it is ideal for use by occupational therapy support staff to use in For example a person’s occupational participation may be different in the home as opposed to their work environment, perhaps because the work environment is more stressful, or perhaps because a parent tends to be over-protective in the home environment. Or a person’s occupational participation may be perceived as being very different in hospital as compared to their home. order to discuss their observations with the occupational therapist. Occupational therapists should, of course, provide training in the Model of Human Occupation and supervise the use of the rating scale until the support staff become confident in its use. All single observations completed by support staff need to be countersigned by qualified staff. 2. Multiple MOHOST form This form is used to document multiple MOHOST assessments. It is particularly useful if the client is engaged with services over a long period of time. Their change of occupational participation can be easily tracked. It is also helpful to visually track a person who is repeatedly admitted into a service. The most common query raised by support staff relates to the environment section and can be expressed as: ‘Why do I continue to rate the environment when I usually observe the person in the same situation each time?’ The occupational therapist will need to explain that the conditions of the environment can still vary and 3. MOHOST Data Sheet Single Observation Form Form the example is given below of how the occupation of gardening can vary even though the garden remains the same: This form has been included in the MOHOST manual in response to the growing demand from occupational therapists for a form that would help them to gather information about their clients in preparation for completing a MOHOST Form. However, it should be emphasised that the single observation form is not an outcome measure on its own and does not have the advantages of the MOHOST form in being able to capture the whole of the therapist’s knowledge of a person. The MOHOST Form provides a summative assessment of a person’s occupational participation, summarising the wealth of information that exists, whereas the single observation form provides a snapshot/single observation of the person doing an occupation and as such gives a formative assessment. • One day the physical space may be unbearably hot and so the physical space is not as comfortable, • There may be sufficient physical resources for everyone to get involved with the task of pricking out seedlings, but there are insufficient garden forks for everyone to use when digging is required, • The social group may be generally very supportive, but one day another person may enter the garden and disturb the others, or • The person may usually enjoy the occupational demands but they may prefer certain activities and may particularly dislike e.g., weeding. Example use of environment section t n e m n o ir v n E Space offers stimulus and comfort N/S F A I R The garden is bare at the moment Resources allow safety and independence N/S F A I R Kneeling stool was provided Social interaction provides support N/S F A I R Needs of others in the group conflicted Demands of activity match abilities/interests N/S F A I R Satisfaction expressed with planting MOHOST v.2.0 23 Administration 4. MOHOST Data Sheet Multiple Observation Form This form allows occupational therapy staff to record multiple ratings from sigle observations on one form and is often used to give a snap shot record of progress over 5 days. 24 MOHOST v.2.0 Chapter Seven: LINKS WITH OTHER MOHO ASSESSMENTS Other Assessments that Cover Similar Areas The MOHOST is similar in content area to the OCAIRS, OPHI-II & OSA and so one might suppose that they would not normally be used in conjunction with the MOHOST. MOHOST. However, if the client is conversational, or perhaps progresses to being so, then these assessments create invaluinvaluable opportunities for dialogue with the client in which to fully explore their motivation for therapeutic goals. This would make them the assessments of first choice in many instances. Being based on the interview process, however, they may be less easy to administer regularly at repeat intervals. The MOHOST offers greater flexibility and the chance to use a single assessment with mixed ability clients. Occupational Circumstances Assessment Interview and Rating Scale (OCA (OCAIRS) IRS) The OCAIRS is a semi-structured interview that provides a structure for gathering, analysing, and reporting data on the extent and nature of an individual’ individual’ss occupational participation. It can be used with a wide range of clients, and would be appropriate for any adolescent or adult client who has the cognitive and emotional ability to participate in a short interview. The OCAIRS provides a structured and theoretically based means of developing interview skills in evaluation and treatment. behaviour settings, and • A life history narrative designed to capture salient qualitative features of the occupational life history. It is designed to give the interviewer a means of understanding the way a client perceives her or his life to be unfolding. The The OPHI-II can be used with adolescents and adults who have a range of impairments. Occupational Self Assessment (OSA) The Occupational Self Assessment (OSA) is designed to capture clients’ perceptions of their own occupational competence. It also allows clients to indicate personal values and to set priorities for change. As such, the OSA is designed to give voice to the client’s perspective and to give the client a role in determining the goals and strategies of therapy. Having gained a broad overview of the client’s abilities using the MOHOST, the therapist may decide to examine specific aspects of occupational performance in greater detail. The The MOHOST would more commonly be used in conjunction with the following MOHO assessments, which include b) Observational Assessments, c) Self Report Assessments, and d) Occupation Focused Interviews. Observational Observation al Assessments Occupational Performance History Interview-Second Version (OPHI-II) Assessment of Communication and Interaction Skills (ACIS) As a historical interview, interview, the Occupational Performance History Interview-Second Version (OPHI-II) gathers information about a client’s past and present occupational adaptation. The The OPHI-II is a three-part assessment that includes: The Assessment of Communication and Interaction Skills (ACIS) is a formal observational tool designed to measure an individual’s individual’s performance in an occupational form and/or within a social group of which the person is a part. The instrument aims to assist occupational therapists in determining a client’s ability in discourse and social exchange in the course of daily occupations. The ACIS has been developed for use in a wide range of settings. Observations are carried out in contexts that are meaningful and relevant to the client’s lives. The occupational therapist then completes a 20-item rating form. • A semi-structured interview that explores a client’s occupational life history, • Rating scales that provide a measure of the client’s occupational identity, occupational competence, and the impact of the client’s occupational MOHOST v.2.0 25 Links with Other MOHO Assessments Data can be combined with observations from other settings to give a more complete picture of the client’s skills in communication and interaction. The National Institutes of Health Activity Record (ACTRE) The Assessment of Motor and Process Skills (AMPS) The NIH Activity Record (ACTRE) was developed as an outcome measure for a study of patients with rheumatoid arthritis. This instrument provides a 24-hour log of a patient’s activities and is an adaptation of the (Fisher, 1994) represents a fundamental and substantive re-conceptualisation in the development of occupational therapy functional assessments. The AMPS is a structured, observational evaluation. The AMPS is used to evaluate the quality or effectiveness of the actions of performance (motor and process skills) as they unfold over time when a person performs daily life tasks. The daily life tasks included in the AMPS are both personal & domestic activities of daily living. The tasks included in the AMPS manual vary in difficulty from simple to complex, with the easiest tasks being less difficult than many self-care tasks, including dressing and toileting. Occupational Questionnaire (described later in this appendix). The ACTRE aims to provide details on the impact of symptoms on task performance, individual perceptions of interest and significance of daily activities, and daily habit patterns. Specific information gathered covers frequency and/or percentage of time spent in role activity and resting, frequency of rest periods during activity, frequency and/or percentage of time with pain and fatigue and time of day or activity with which it occurs. It also covers volitional concerns such as interests, meaning, enjoyment, and perception of personal effectivene effectiveness. ss. Volitional Voli tional Questionnaire The Occupational Questionnaire (OQ) Traditionally, it has been difficult to assess volition in clients who have communication and cognitive limitations due to the complex language requirements of most assessments of volition. The Volitional Questionnaire is an attempt to recognise that while such clients have difficulty formulating goals or expressing their interests and values verbally, verbally, they are often able to communicate them through actions. The The client is observed in a number of occupational behaviour settings so that a picture of the person’ss volition and the environmental supports required to son’ support the expression can be identified. The Occupational Questionnaire (OQ) is a pen and paper,, self-report instrument which asks the individual to paper provide a description of typical use of time and utilises Likert-type ratings of competence, importance, and enjoyment during activities. activities. The OQ asks the client client to complete the instrument in two parts. First, he or she completes a list of the activities he or she performs each half-hour on a typical weekday. After listing the activities, the client is asked to answer four questions for each activity. The questions ask the client to rate whether he or she considers the activity to be work, daily living tasks, recreation, or rest, and to consider how well he or she does the activities, how important they are to him or her her,, Assessment of Motor and Process Skills (AMPS) Self Report Assessments Interest Checklist Although the Interest Checklist was developed prior to the introduction of the Model of Human Occupation, both the instrument and the theory have strong ties to the occupational behaviour tradition. The Interest Checklist has been modified and utilised extensively over the years in studies based in the Model of Human Occupation because of this tool’s utility in identifying clients’ past and present interests and the degree of attraction clients express towards those interests. 26 MOHOST v.2.0 and how much he or she enjoys doing them. Role Checklist The Role Checklist is a self-report checklist that can be used to obtain information about the types of roles people engage in and which organise their daily lives. This checklist provides data on an individual’s perception of his or her roles over the course of their life and also the degree of value, i.e., the significance and importance that they place on those roles. The The Role Checklist can be used with adolescents, adult, or geriatric populations. Links with Other MOHO Assessments Occupation Focused Interviews Work Environment Impact Scale (WEIS) Worker Role Interview The Work Environment Impact Scale (WEIS) is a semistructured interview designed to gather information about how individuals with disabilities experience and perceive their work settings. The The focus of the interview is the impact of the work setting on a person’s person’s performance, The Worker Role Interview (WRI), is a semi-structured interview designed to be used as the psychosocial/ environmental component of the initial rehabilitation assessment process for the injured worker. The The interview is designed to have the client discuss various aspects of his or her life and job settings that have been associated with past work experiences. The WRI combines information from an interview with observations made during the physical and behavioural assessment procedure of a physical and/or work capacity assessment. The intent is to identify the psychosocial and environmental variables that may influence the ability of the injured worker to return to work. satisfaction and well-being. An important concept underlying this scale is that workers are most productive and satisfied when there is a “fit” or “match” between the worker’s worker’s environment and the needs and skills of the worker. Hence, the same work environment may have a different impact on different workers. It is important to remember that the WEIS does not assess the environment. Rather, it assesses how the work environment impacts a given worker. MOHOST v.2.0 27 Links with Other MOHO Assessments The MOHOST covers all the major concepts in MOHO and as such it may be useful when a) The client group is non verbal verbal or has a range of abilities, b) It is your first contact with with the client and/or, and/or, c) It is unclear where where the source of the difficulty is, and/or d) There is a need to understand how a specific difficulty affects a range of occupational occupational issues. Having completed the MOHOST, the therapist may then decide to assess specific aspects of performance in more depth. Motivation for Occupation VQ Observational assessment that focuses on volition Pattern of Occupation NIH Activity Record Identifies habitual Communication and Interaction Skills ACIS Observation assessment that focuses on communication and interaction skills Process Skills Motor Skills Environment AMPS Observational assessment that focused on motor and process skills Interest Checklist Useful to identify interests routines into relationship pain and fatigue OQ Identifies routine in relationship to volition OQ Identifies routine in relationship to volition Role Checklist Identifies past, present and future roles in connection with Role Checklist Identifies past, present and future roles in connection with importance importance WRI Interview about the worker role WRI Interview about the worker role WRI Interview about the worker role OTPAL Observation and interview for student role OTPAL Observation and interview for student role OTPAL Observation and interview for student role SSI Interview for student role SSI Interview for student role 28 MOHOST v.2.0 WEIS Interview about the work environment NB: Several tools cover more than one area of occupational functioning SSI Interview for student role Chapter Eight: OCAIRS QUESTIONS - GETTING TO KNOW YOUR CLIENT Although the MOHOST is primarily an assessment based on observation, it does allow the therapist to draw upon a variety of different sources of information, in order to fully reflect their knowledge of the client. The criteria is simply “getting to know your client” and this may be done through: • Informal observation in open settings, • Formal observation observation in 1:1 and group settings, • Discussion with clients regarding their motivation, interests, roles, and routines, • Discussion with careers and the multidisciplinary team regarding their observations, • Reading case notes, and • Completing other formal assessments. If all your clients are verbal and can all comply with an interview format it is more appropriate to use the OCAIRS and NOT the MOHOST, unless outcome measuresare required at frequent intervals. ✓ Use the MOHOST and the OCA OCAIRS IRS in a service if the service has clients of mixed ability: If you have a client group who have mixed abilities it may be more appropriate to use both assessments. With clients who are more non verbal then a MOHOST can be used and the method of data gathering is observational and proxy report. ✓ If the clients are not conversational but will give you some verbal information then a MOHOST ✓ is appropriate andreport. information is gathered by observation, proxy The OCAIRS questions in this chapter can also be used to support the MOHOST data gathering method for clients who can respond to questions in part. It is assumed that the occupational therapists will always have some direct contact with the clients and will be using discussion and case notes to confirm their professional opinion. Use the MOHOST in a service if the service has clients who do not have verbal skills: If the occupational therapist reasons that it is appropriate to ask questions as part of the data gathering method it is recommended that the questions in this chapter be used. Originally there were no recommended questions within the MOHOST, as we preferred the therapist to use the questions that were most comfortable to the situation and the client. We discovered, however, that occupational therapists were looking for guidance regarding ✓ occupational interviewing and we have, therefore, provided the following recommended questions. It should be stated though that these are only recommended questions and can be changed in how they are phrased as long as they elicit similar kinds of information from the clients. The questions in this chapter are the same questions used within the OCAIRS interview. The benefit of using these questions are that at the end of the interview the OT will be able to rate both the MOHOST and the OCAIRS. OCAI RS. The following are guidelines regarding when to use the OCAIRS and the MOHOST: Recommended Questions – See Appendices ✓ Use the OCAIRS if all your clients are conversational: If your clients cannot give you information about themselves verbally through conversation it is recommended that you use the MOHOST and gather information by observation and proxy report and NOT use the OCAIRS questions in this chapter. I. OCAI OCAIRS RS QUESTIONS QUESTIONS – Mental health settings settings II. OCAIRS QUESTIONS – Forensic settings III. OCAIRS QUESTIONS – Physical settings/Older Adult Mental Health It should be noted that these are recommended questions and SHOULD be adapted and rephrased to communicate effectivelyy with the client as long as they are eliciting the effectivel same information. MOHOST v.2.0 29 OCAIRS Questions It should also be noted that it is often easier to start with questions regarding the client’s pattern of occupation and proceed gradually to questions regarding motivation for occupation. There are three different formats that can be used and the choice is made through personal preference. 30 MOHOST v. v.2.0 Chapter Nine: CASE STUDIES Case Study 1: Joy with thanks to Leigh Dyson Green Joy is in her early twenties. She was diagnosed with bipolar disorder at the age of 16 having become acutely ill while taking some exams. Joy’s parents were divorced when she was 10 years old. Her mother has schizophrenia and used to have frequent admissions to hospital and consequently Joy spent most of her early childhood living with her grand parents. They both died when she was a teenager and she went on to spend the weekdays living with her father and his new family, and the weekends with her mother and her older brother who is also known to the mental health services. The occupational therapist hasJoybeen involved with Joy for 12 months, and first met when she was elated in mood and had been admitted on a voluntary basis to hospital. The The local hospital had no beds available and so Joy had been transferred to to a nearby town, which which was an unsettling experience in an already extremely unsettled life. The one point of stability in Joy’s life was her clerical work. She had worked full-time with the same firm since leaving school. While Joy was in hospital, however, the company went through a restructuring process, which meant that Joy would no longer be working with the same team. She felt unable to face the changes and although the occupational therapist liased with the company to facilitate part time work, it soon became apparent that Joy was unable cope with the transition or manage financially on hertoreduced income. The occupational The therapist worked to help Joy to explore alternatives to work and also supported Joy in her decision to live independently. Joy coped remarkably well with the changes and the MOHOST was used to document Joy’s Joy’s progress. Motivation for Occupation When unwell Joy tends to overestimate her capabilities but in general Joy has low expectations of herself. She retains hopes for the future but requires reassurance regarding her skills. She has had few interests beyond drinking socially with friends and meeting young men, but has recently joined a gym and she has started to have driving lessons and has requested further support to develop new interests. Given support, Joy stays engaged and listens to advice, but she also experiences conflicting values. For instance, she knows drinking alcohol is likely to have a detrimental effect on her mental health, but she wants to have what she sees as a “normal young person’s lifestyle”. This This involves going back to full time employment, as she believes that by keeping busy she can maintain her mental health. She views her current unemployment as a chance for her to plan her future, and has enrolled on a vocational course. Pattern of Occupation Joy copes well with a structured routine and has initiated three different jobs through the volunteer bureau, demonstrating loyalty and commitment. If anything, she tends to be overacti overactive, ve, and the occupational therapist frequently has discussions with Joy about the need to maintain a regular sleep pattern. Joy continues to find that adapting to change is a little anxiety provoking, and requires encouragement, but is generally very responsible and can be relied upon to carry out planned tasks. She derives a lot of pleasure from her voluntary work and role as a friend and she keeps regular contact with her family. family. Communication and Interaction Skills Joy has no assessed deficits with communication skills. She worries about when to disclose her illness and what to say, say, but she discusses this appropriately with her therapist. She is also able to assert her own needs, and when a friend moved in to stay with her on a temporary basis Joy was able to clearly state the terms on which this arrangement was made. She has also been very supportive and has shown considerable maturity towards a friend who was having problems, and she enjoys the social nature of her voluntary work. Process Skills When last employed, Joy had been distractible and had required continual supervision, but her process skills are now much improved. She is able to seek out and retain relevant information, and shows a level of general aware MOHOST v.2.0 31 Case Studies ness that is within the norms of her peer group. Once she has a plan, she is able to sustain her concentration and to follow the plan through independently. She is also organised and neat, e.g., after a discussion on how best to maintain her correspondence she organised it into a file. Joy continues to have difficulty problem solving, however,, and she seeks out reassurance and advice from however family, friends and mental health workers. independently in a rented flat. Initially Joy found that her sudden independence was a lonely experience. Gradually, however, she has become used to living alone and has learnt to appreciate her new found freedom. She now says she could not go back to living with either parent. She is financially secure, having been awarded a Disability Living Allowance Allowance and receives some practical support from her father. Her family relationships continue, however, to be a source of stress, - the family dynamics were the main reason for Joy wanting to live independently. Not only is Joy’s mother frequently unwell but her father can also be somewhat over protective and controlling. Joy is coming to terms with her relationships with her parents and looks to her friendships for support instead. Unfortunately, she can be easily influenced by peer pressure. She does, however, find satisfaction in her chosen activities which are now all within her capabilities. Motor Skills Joy has no deficits with her motor skills, skills, which which are are within the norm for her age. Environment With practical help and support from the occupational therapist, Joy has moved out of her mother’s home to live MOHOST Analysis of Strengths & Limitations Joy’s main strength strength is her determinat determination. ion. She has proved to be be responsible responsible and has carried through agreed plans. She is also prepared to work at being more adaptable, and she is able to change and learn new skills. She is caring and sensitive to the needs of others, but can sometimes be overwhelmed by the views of others and she finds problem solving difficult. She needs to seek reassurance and advice over basic decisions, and finds it difficult to see the future in the long term. Her main focus is on the here and now. Summary of Ratings Motivation for Occupation s e c c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A Pattern of Occupation s e ic o h C st e r e t n I tiy il b ta p a d A e itn u o R Communication & Interaction Skills lls i k S l a b r e -v n o N tiy li b is n o p s e R s le o R n io ss e r p x E l a c o V n o ti a sr e v n o C Process Skills s p i sh n o it a l e R e g d le w o n K tiy li b o M & e r tu s o P g in lv o -s m le b o r P n ito a is n a g r O g in im T Environment: Motor Skills Community rt o ff E & h t g n e rt S n o ti a n i rd o o C s e c r u o s e R l a ic s y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n ito a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 32 MOHOST v.2.0 Case Studies The assessment tool was helpful in three ways. Firstly, it showed that Joy has made good progress towards an independent and balanced lifestyle; that her process skills and communication & interaction skills are much improved and that she has the willingness and perseverance necessary for success. Secondly, it clearly identified those areas of occupational competence requiring further work, e.g., developing interests and independent problem-solving strategies. Thirdly, it reinforced the importance of the occupational therapists role in providing an alternative source of support and encouragement to explore more stimulating and appropriate alternatives for her future employment. With the intervention of her occupational therapist Joy’s mental health has gradually became stronger and stable. Joy will, however,, require ongoing support to enable her to realise however her long-term goals. Case Study 2: Jessie with thanks to Sarah Morris Jessie is in her nineties and still lives in her own house. She is well known in her neighbourhood, having worked with her husband to teach generations of children to swim at the local swimming pool. Her husband died a number of years ago and so she lives alone now, now, receiving some support from a niece who lives just around the corner. Her two daughters are also supportive and one lives fairly close but the other is further afield. She has no statutory support. Jessie was referred to the Day Hospital following concerns expressed by her family that she was throwing food away and wandering around the local area looking for her mother’s house. The doctor who visited her at home found that her house was in good order and immaculately tidy. Jessie herself was neat and clean, but it was clear from the looseness of her clothes that she had lost a considerable amount of weight. Alzheimers disease was diagnosed and the occupational therapist became involved in order to assess Jessie’s ability to manage independently. Jessie proved able to bath, wash, dress and make a hot drink without any problems but these achievements needed to be seen in the wider context and so the occupational therapist used the Model of Human Occupation Screening Tool Tool (MOHOST) to summarise her observations. These are detailed below. Motivation Motivat ion for Occupation Jessie is often overly confident about her abilities, without being aware of her limitations. She is a lively character, has a strong belief in her own abilities, and generally anticipates successful outcomes. She participates in most activities at the day hospital with enthusiasm and is generally willing to try anything. She likes to keep active and obviously values social company, and she has always been house-proud so her domestic responsibilities give her a clear sense of purpose. Unfortunately, Unfortunately, she tends to lack realism when she sets out to do things, so sometimes makes inappropriate choices. Pattern of Occupation Jessie is on the go all the time and she rarely sits down when on her own. She has maintained a daily routine of getting up, bathing, and dressing, but without support she neglects preparing or eating regular meals. For this reason, a home help service was arranged to assist and prompt with cooking and Jessie had difficulty accepting this initially, as she believed herself to be perfectly capable. Eventually she adjusted to the new routine and became more accepting of help. She also adapted well to the Day Hospital environment. She remains keen to maintain her domestic role and most of her time is spent in domestic activity. There are times, however, when she still believes her mother to be alive and adopts inappropriate role behaviour because of this. Communication and Interaction Skills Overall, Jessie has good communication and interaction skills. Her non-verbal interactions are always appropriate and she can put on a good social front even when disoriented to time and place. She chats readily and is mostly appropriate, but she may jump from one topic to another. She can also confabulate at times and her conversation can be repetitive. Moreover, Moreover, the pace of her conversation is very fast and when she becomes agitated or distressed she tends to speak quite loudly. She has been known to make derogatory comments about other clients but these are infrequent and for the most part she is very friendly and sociable. She has even made a new friendship since she started to attend the Day Hospital. MOHOST v.2.0 33 Case Studies able to make a hot drink safely and dress herself independently.. Her energy levels are more questionable independently as she clearly finds relaxing difficult and enjoys always being on the go, but her daughter reports that she has always been very active and so her energy levels now are only congruent with her past. Process Skills Jessie relies heavily on her previous knowledge of activities and she is clearly disoriented and confused at times. Although she is well oriented to her home environment she often believes that she does not live there. She then wants to return to her mother’s mother’s and has difficulty retaining information given to reorient her. Her concentration is also quite poor and she becomes easily distracted, making it difficult to complete tasks independently. Her organisational skills are better, (as demonstrated by her ability to keep tidy), but she sometimes has difficulty finding objects and has a history of losing money. She also has difficulty thinking through problems and without firm direction she sometimes make rash decisions. Environment The risks that Jessie faces by staying in the same environment need continuing assessment. Jessie values the freedom of living independently and her home is comfortably furnished. She is mostly disoriented to time and person rather to place, and benefits from being in familiar surroundings. She is also financially secure and has no unmet needs that would be remedied by further resources. As to social support, her daughters and niece continue to provide what help they can. They They are unable to be with her 24 hours a day but Jessie is well known in the local community and when she wanders, people have always brought her home. Finally, although Jessie Motor Skills Jessie is a highly independent lady lady.. She has good posture and mobility and can, as she says, “walk for miles”. Her co-ordination and strength are equally good, and she is MOHOST Analysis of Strengths & Limitations Jesse is highly highly motivated motivated to be occupied occupied but her pattern pattern of activity activity is repetitive repetitive and she requires assistance to organise her routine. She is a good communicator despite being confused and her motor skills are excellent. Continuing assessment is required to assess the risks of staying in her own home and to ensure that her occupational needs are met. Summary of Ratings Motivation for Pattern of Communication & Occupation Occupation Interaction Skills ss e c c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A s e c i o h C ts e r te In y itl i b a t p a d A e itn u o R lls i k S l a b r e v n o N y ti li b si n o p s e R s e l o R n io ss e r p x E l a c o V n ito a sr e v n o C Process Skills Environment: Motor skills Community s ip h s n ito la e R e g d le w o n K g n i v l o sm e l b o r P n o it a si n a rg O g n i m i T tiy li b o M & re tu s o P tr ffo E & th g n e tr S n ito a in d r o o C s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 34 MOHOST v.2.0 s d n a m e D l a n o it a p u c c O Case Studies enjoys her domestic responsibilities, they clearly do not meet all her social, leisure and relaxation needs. The Day Hospital remains a crucial factor in supporting Jessie. Completing the MOHOST enabled the occupational therapist to see where Jessie’s strengths and weaknesses were. This in turn had an impact in the planning of Jessie’ss therapy, Jessie’ therapy, ensuring that the occupations she carries out help to hold her concentration and maintain her remaining problem-solving skills in addition to meeting her social needs. The MOHOST was also used to provide evidence that Jessie can sustain relationships and adapt her routine with help, and that she is able to function in a new environment and orient herself to the Day Hospital. This gave the team hope that she would be able to adapt to new accommodation should this become necessary in the future. However, the decision was made that Jessie should be supported at home with a large care package as she so obviously values her domestic responsibilities and feels positive about staying in her own home with the support of her local community. community. Case Study 3: Brendan with thanks to Kylie Innocente Brendan is a 36 year old Afro-Caribbean male who was diagnosed as having Schizophrenia when he was 19. He has had multiple admissions to secure and acute wards, averaging an admission every year for the last 15 years. He lives in supported housing with three other residents. He reportedly has a good relationship with his parents. His mother is on an Older Persons mental health ward and his father lives at home. He also has a 26 year old brother and a 41 year old sister with whom there is no apparent contact. It has been noted that his maternal Aunt is in a psychiatric hospital in Jamaica and has been resident there for ‘some years’. His most recent admission was precipitated by a rapid deterioration in his mental state. He was running up and down the stairs of his house, holding his head and yelling, “I want to kill myself”. He was observed looking into the mirror and grimacing throughout the day and staring at pictures of Christ. There was reported enuresis and he was urinating and vomiting on the floor and in drawers of his room. Brendan described experiencing command hallucinations to kill himself, and evidence of thought insertion and withdrawl were noted. In addition, he was experiencing visual hallucinations stating that he could see the Devil and “all things evil”. Admission was at his request and Brendan stated that he did not want to return to his home as someone was bothering him. His care manager denied any conflicts with other residents. A risk assessment revealed that he was at risk to himself and others. Risk behaviour has ranged from personal neglect and reports that he wanted to kill himself in addition to stabbing patients and strangers with cutlery cutlery.. Brendan was given an atypical anti-psychotic medication and the MOHOST was used to assess his progress over a period of time. It was chosen because it could be used in collaboration with the multi-disciplinary team and could be based on observations only, with no invasive questioning being required at a time when Brendan was acutely mentally unwell. Brendan was observed both on the ward and also in the Therapy Centre that served his ward and two others in the hospital. a) The first MOHOST was completed when Brendan was floridly psychotic before any medication was prescribed. b) Two months mo nths later, a second MOHOST was completed. By this time Brendan was consenting to take the maximum dose of anti-psychotic medication and was consistently attending his selected group programme. c) The third MOHOST was completed after another two months when Brendan was close to being discharged from the hospital. Motivation Motivat ion for Occupation Appraisal of ability a) Brendan wanted to be admitted because he recognised that he felt unable to cope, but could not identify the skills that he needed to work on. [R] b) He would often say, say, “I am no good”, and was unable to see positive achievements. [R] c) Verbal Verbal prompting from clinicians was still required to maintain his confidence about the efficacy of his skills. [I] MOHOST v.2.0 35 Case Studies Expectation of success a) Brendan did not express his feelings. [R] b) Brendan wanted to make some achievements but was ambivalent about whether he would be able to cope. [I] c) Brendan was positive about his decision to move into supported accommodation. [F] Interest a) Brendan could only tolerate therapy sessions for five minutes at a time. There was no other evidence that he was engaging in any other activity apart from smoking cigarettes and making coffee. [R] b) Brendan was able to express his interests but did not always engage in them, e.g. Brendan identified being interested in sports and relationships with women. [I] c) The The nursing team reported that he was consistently talking about his achievements and expressing pleasure in the tasks he was engaging in. [F] Choices a) Brendan appeared unable to act on choices regarding routine activities of daily living and was dependent on nursing staff for self-care including dressing. [R] b) Brendan became involved in selecting the groups he wanted to attend at the Therapy Centre. He also planned to buy some new clothes but did not do so despite offers of help [I] c) Brendan had set the goal of wanting to move into supported accommodation, and he was motivated motivated to engage in relevant groups. Some verbal prompting was still required in order to achieve goals. [A] Pattern of Occupation Routine a) All of his daily routine was structured by the acute admissions ward e.g. breakfast, medications, lunch and evening meal. All engagement in routine was through verbal prompting from nursing staff. [R] 36 MOHOST v.2.0 b) Less prompting was required to attend to the routine on the ward and at the Therapy Therapy Centre. [I] c) Brendan adapted fully to the ward routine, and attempted groups without prompting although he still expressed some uncertainty about the timings. [A] Adaptability a) Brendan was unable to tolerate conflicts between other patients on the ward. He would become agitated, screaming and then urinating in his bedside cabinet and crying. [R] b) Brendan was able to adapt to the changes in his therapy programme and became less disturbed by changes on the ward environment. [I] c) Brendan appeared more able to tolerate change but a visit to his new accommodation highlighted a residual difficulty. It took a further visit and encouragement from staff, for him to feel comfortable. [A] Roles a) Brendan’s Brendan’s only role was that of being a patient. [R] b) As before. [R] c) Brendan demonstrated a strong sense of belonging in the hospital and valued being known and belonging to the Therapy Therapy Centre, but prompting was required to enable him to take on new roles. [I] Responsibility a) Brendan was unable to take responsibility. He had been evicted from his home but did not want to retrieve any any of his belongings. belongings. All decisions were were made by professionals involved in his care. [R] b) He continued to avoid responsibility by stating he was tired. It was clear to the occupational therapist he was adopting the patient role. [R] c) He began to take on extra responsibilities responsibilities and would clear up after himself, and make tea for others. However, if someone else would offer to do these tasks, he would relinquish the responsibility. [A] Case Studies Communication and Interaction Skills Non-verbal skills a) Brendan’s affect was frequently observed to be incongruent with the environment. e.g. laughing tohimself and hyper posturing. [R] b) Brendan still had difficulty controlling his body language. Unusual posturing was attributed to Tardive Dyskinesia and incongruent laughter was still observed but to a lesser extent. [I] c) The incongruent laughter stopped and the dyskinesia was controlled. However, he would shake one’s hand in greeting too hard and for too long and kiss female staff two or three times on the cheek which was not his usual behaviour. [A] Conversation a) Brendan would occasionally respond to a greeting with a monosyllabic answer but otherwise only expressed distress, e.g., screaming at the auditory hallucinations he was experiencing. [R] b) Brendan was now able to engage in a limited and basic conversation if questions were put to him by others. Prompting was still required to keep a dialogue. [I] c) He became able to initiate conversation, discussing current affairs and world events. However, there were times when he would self isolate and ignore any attempts to engage in conversation. [A] Vocal expression a) Brendan was able to express himself when upset. However,, his verbal expression was loud, pressured However and mumbled. [I] b) Despite his conversation having improved, Brendan was still observed to be mumbling with pressured speech. [I] c) His pressure of speech and volume had decreased. Mumbling continued due to Tardive Dyskinesia, but conversation could be followed. [A] Relationships operative) behaviour to other clients, offering his cigarettes and making cups of tea on occasion for female clients. [I] b) Brendan developed a friendship with another client who had cooked a meal for him and they wentout walking together in the local area. He was also observed to be supportive to female clients. [A] c) It became apparent that the people initiating friendships with Brendan were requesting money, tobacco and clothing from him. Brendan’s lack of assertivenesss led to him being vulnerable. [I] assertivenes Process Skills Knowledge a) Brendan was observed to have difficulties handling objects that were not familiar to him, e.g. in an art class he was utilising the felt tip pen the wrong way around. [R] b) Brendan was still observed to be confused when engaged in an activity and verbal prompting and modelling of tools for the task were required in order for tasks to be completed. [R] c) Prompting was still required to complete tasks, e.g. in baking, Brendan would know how to prepare the ingredients but would help to follow the recipe. [I] Timing a) Brendan was not orientated to time or place. Verbal prompting was required for all tasks other than making a cup of coffee. [R] b) Brendan began to enquire about his Therapy Programme in advance, e.g. he asked questions of whether he needed to bring certain items with him on a community visit. [A] c) It was observed that Brendan continued to have difficulties with forward planning more than a few steps at a time but this had a minimal impact on his occupational functioning. [A] Organisation a) Brendan would always look for assistance for any task before attempting independently. independently. [R] a) Brendan was observed to demonstrate friendly (co- MOHOST v.2.0 37 Case Studies b) Brendan was observed having difficulty searching for objects, e.g. in an art group, he was observed to knock items over and he became quickly frustrated when he could not find a paintbrush. [I] c) Brendan maintained his improvement. [I] objects but consistently used too much force to open doors and they would swing around into the wall, on one occasion hitting another client. [I] b) As before. [I] c) Brendan improved but remained inconsistent in how he moved and transported objects. [A] Problem-solving a) Brendan would disengage from a task before a problem arose. Instead of turning some music down, he once put his hand to his ears and sat there until another patient turned it down. [R] b) Brendan was now engaged in tasks long enough to encounter problems or difficulties. He reported that he found it useful to talk with a staff member about his concerns before his blood tests. [I] c) It was clear that some deficits remained in all of his executive functions. [I] Motor Skills Posture and mobility a) Brendan always walked head down with his hands in his pockets, and was reluctant to take his hands out of his pockets even to make a coffee. [I] b) Brendan began to walk with his hands out of his pockets and his head upright, but this behaviour fluctuated throughout the day. [A] c) Brendan exhibited fluid and agile movements. [F] Co-ordination a) Brendan was able to co-ordinate and manipulate movements but not without substantial difficulties. Tardive Dyskinesia made his movements gross, rigid and tremulous and when making a coffee, there would be milk, coffee and water spilt on the tabletop. [I] b) As before. [I] c) Brendan demonstrated excellent bilateral coordination and reactive reflexes. [F] Strength and Effort a) Brendan was able to grasp, move and transport 38 MOHOST v.2.0 Energy a) Brendan had difficulty maintaining energy. energy. He was observed to fall asleep in groups and would say ‘tired’. Thiswaslinkedtothesedativeeffectsof medication. [I] b) Brendan was consistently reporting to be tired and would disengage from activities as a result. This information was fed back to the medical team and his medication was decreased as a result. [I] c) Brendan no longer reported feeling tired and demonstrated an ability to engage in tasks for up to two hours. [F] Environment Physical space a) Brendan’s environment (acute admissions ward and the Therapy Centre) provided the structure and support that he required at this time. [A] b) As before. [A] c) Brendan began to explore his local community community.. He personalised his bedroom space and reported to be feeling safe. However the ward would not be able to meet his needs for much longer. [A] Physical resources a) Brendan often threw away the possessions he had. [R] b) Brendan began to utilise more resources and was given time to leave the ward environment. [I] c) Brendan was living off a daily budget that was meeting his needs and was independent in transport use. He had stopped throwing away his possessions and was keeping the ones he had. [F] Case Studies Social groups a) Brendan sought only to perform habitual tasks such as smoking cigarettes and making coffee, which were not affected by his reduced ability. However, his personal care needs were overwhelming and he was unable to attend to them without physical assistance. [R] a) Brendan was unable to engage in groups. [R] b) Brendan occasionally received the support of his peers. One client volunteered to teach him to cook, and Brendan accepted. [I] c) Brendan continues to have some social support from fellow clients but very little from his family. [I] b) Brendan stillindependent found activity tiring[I] and was reluctant to become of staff. c) The groups and activities offered to Brendan appeared to meet his interests and needs. [F] Occupational demands a) Motivation for Occupation ss e c c u S f o n ito ta c e p x E y itl i b A f o l a isa r p p A Pattern of Occupation Communication & Interaction Skills y ti li b si n o p s e R y ti li tse r te In sc e i o h C e n ti u o R a t b p a d A s lli k S l a b r e v n o N s e l o R n io ss e r p x lE a c o V n ito a rs e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy li b o M & re tu s o P g n i v l o s- n o ti a sn i a g r O g n i m i T Environment: Motor Skills m e l b o r P Hospital tr ffo E & n ito a n ir d o o C th g n e tr S s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n o it a p u c c O s p u o r lG ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R b) c) Motivation for Occupation Pattern of Occupation Communication & Interaction Skills Process Skills Environment: Motor Skills Community F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R MOHOST v.2.0 39 Case Studies It is clear that Brendan made significant gains. However, he continued to lack confidence in his own abilities and was thought likely to have initial difficulties coping with change in the future. It was noted that his process skills did not improve at the same rate as other skills and in this respect the MOHOST reflects the chronicity of Brendan’s condition. ‘Relationships’ was the only item to receive a reduced rating and this perhaps reflects the increasing awareness of his vulnerability by the multidisciplinary team. The ratings for the environment might also have decreased if Brendan had not been discharged, as they would have been unable to keep pace with his increased ability to utilise resources. The median rating of ‘A’ suggests that Brendan requires supervision, albeit verbal prompting, to engage and sustain commitment to tasks and activity activity.. He was referred to 24-hour residential home for people with long and enduring mental health problems, where it was hoped that he would be able to improve his ability to form relationships and build a more supportive social network. programme of activities including lunch and breakfast cookery, baking, computing, wood sculpture, art, pottery, quizzes and bowling games. The The MOHOST was used to evaluate his skills prior to discharge and used as a basis for discussing the possibilities for independent living in the future. Motivation Motivat ion for Occupation Case Study 4: Mark Prior to discharge, Mark was more aware of his strengths and limitations. He was able to maintain a positive attitude and belief in his ability to live independently and he was also realistic in recognising that he would require support. He consistently set goals for himself in occupational therapy that were appropriate for his level of ability and then worked methodically to complete them. Within the hospital environment, he was always keen to try new activities and he reported finding them invaluable in helping h elping him to recover. re cover. Ordinarily, however, however, his interests had always been solitary and consisted largely of computing, walking, doing jigsaw puzzles, and writing music. with thanks to Katrina Reece Pattern of Occupation Mark is in his early 40s. He had his first psychotic episode in his late teens leading to three admissions to hospital in quick succession and a diagnosis of schizophrenia. He met his wife in hospital and the marriage lasted for 5 years. During this time they had a son, but Mark no longer has any contact with them due to having had an injunction taken out against him, the circumstances of which are not known. After he split up with his wife, he had a period of living independently but states that this was not successful. He therefore returned to living with his parents, and gradually lost contact with the mental health services. On the ward, Mark followed a routine that was balanced and structured, but without occupational therapy intervention he would have continued to have difficulty in organising his routine to meet any responsibilities. The change in his pattern of occupation demonstrated his adaptability and this was also evident in his ability to accommodate changes to group times and appointments. However,, the drawback to this relaxed attitude manifested However itself in a lack of commitment to any major roles. He had no employment role, very little contact with his family When his parents divorced, Mark moved to live in staffed accommodation in a different part of the country. Since this time he has had three further admissions to hospital when he has been detained involuntarily. During his last admission he was preoccupied with delusions of a religious nature and had difficulty interacting with others. He did not believe that he should have been brought into hospital, but was nevertheless very co-operative and willing to engage. One of the reasons he gave for attending occupational therapy was to increase his confidence in managing activities of daily living. He attended a varied 40 MOHOST v.2.0 and a poor sense of belonging. He could demonstrate responsibility for set tasks in therapeutic groups, but he found it difficult to exercise responsibility in the group home, where much was done for him. Communication & Interaction Skills Mark’s communication and interaction skills were partially intact. He was able to sustain conversation with staff but he was generally self-isolating and was rarely observed initiating conversation. Once approached, however, he was assertive and articulate. Indeed, his relaxed manner sometimes seemed incongruous with the situation and his eye contact could be so full as to make Case Studies situation and his eye contact could be so full as to make him appear to be overly familiar at times. Yet he did not pursue relationships, and in many ways seemed to lack interest in other people and to be entirely satisfied with his own company. Motor Skills Mark had no problems with motor skills other than becoming short of breath on exertion. He walked fluidly, fluidly, had a good range of movement and no evident problems with strength and effort. It was also encouraging that he was willing to incorporate more physical exercise into his routine. Process Skills Mark was able to obtain and retain information and select tools appropriately. appropriately. He could plan ahead, sustain intense concentration and was very methodical, preferring to complete one job before moving on to another. He needed assistance organising himself in order to carry out multiple tasks, (e.g., necessary for cooking and baking), and he demonstrated some difficulties in making decisions if problems arose. In general, although he recognised that he needed help, he was not sufficiently reflective enough to predict what it was that he needed help with. Environment Mark’s progress needs to be seen within the context of a relatively supportive hospital environment where Mark can readily access the facilities he needs and is reasonably comfortable. The nurses support him to take his medication as prescribed and Mark appears to enjoy the opportunities that he has for social interaction. He particularly enjoys the activities available in occupational therapy and sets projects for himself on the computer. computer. Analysis of Strengths & Limitations Mark has been well-motivated to attend occupational therapy and would like to work towards living independently. At present, he has very limited roles and although living independently might inevitable fill this gap, he would need some assistance in organising his responsibilities and making decisions. decisions. There would also be a risk of him being isolated without structured support. Summary of Ratings Motivation for Occupation s sc e c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A Pattern of Occupation s e c i o h C ts e r te In y ti il b a t p a d A e itn u o R Communication & Interaction Skills lls i k S l a b r e v n o N y ti il b si n o p s e R s e l o R n io ss e r p x E l a c o V n o ti a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy li b o M & e r tu s o P g n i v l o sm e l b o r P n o it a si n a g r O g n i m i T Environment: Motor Skills Hospital tr ffo E & h t g n e tr S n o ti a in d r o o C s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n o it a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R MOHOST v.2.0 41 Case Studies The MOHOST provided a useful structure to help the occupational therapist analyse Mark’ Mark’ss abilities. Using the MOHOST required the whole occupational therapy team to gather the information, including technical instructors and assistants, and once completed it ensured that the team focussed on those aspects of functioning requiring the most attention. This was particularly helpful for a student on placement with the occupational therapist. However, the occupational therapist was aware that Mark had not been functioning as well when he was living in the community, so she completed another MOHOST based on proxy reports of his functioning prior to admission. This highlighted that Mark’s functioning was markedly different prior to admission, as even though he had been living in staffed accommodation the environment was not as conducive to his good mental health. The accommodation was some distance away from a town and there were no shops or community facilities nearby. nearby. The staff were not able to monitor Mark’s medication and so it was likely that his health would rapidly deteriorate if he returned to live there. Nor were they able to influence his budgeting, with with the result result that Mark had experienced financial difficulties difficulties and could no longer afford to use the internet on his computer computer.. Over the years, the relationships with other residents had also become more acrimonious so the whole environment was affecting Mark’s mental health in a negative way. When Mark was first assessed, he had seemed so willing to engage and so able to express himself, that other assessments had been used, including self assessments and interview formats. However, it soon became clear that although Mark had sufficient insight to set himself long-term goals, he was less able to identify the specific objectives necessary for success. The MOHOST lent objectivity to this task and also led to the consideration of further therapist-rated assessments: the Assessment of Communication and Interaction Skills, (ACIS), and the Assessment of Motor Process Skills, (AMPS). Summary of Ratings Motivation for Occupation ss e c c u S f o n ito ta c e p x E y itl i b A f o l a is a r p p A Pattern of Occupation s e c i o h C ts e r te In y ti li b a t p a d A e n ti u o R Communication & Interaction Skills s lli k S l a b r e v n o N y ti li b si n o p s e R s e l o R n io ss e r p x E l a c o V n ito a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy il b o M & e r tu s o P g n i v l o sm e l b o r P n o ti a si n a g r O g n i m i T Environment: Motor Skills Group Home tr ffo E & h t g n e tr S n ito a in d r o o C s e rc u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n o it a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I A I R R R R R R R R R R R R R R R R R R R R R R R R So the MOHOST allowed the occupational therapist to present her findings in a convenient report format for the multidisciplinary team and to the staff at Mark’s accommodation, and to gather her thoughts to give clear feedback to Mark. Mark was soon ready to be discharged and no alternative accommodation was forthcoming in the short-term. He accepted that the structure of the hospital had made a significant impact on his recovery recovery and the team remained 42 MOHOST v.2.0 concerned that independent living would not provide him with the structure he needed. Mark decided to return to live in familiar surroundings for the time being and a community psychiatric nurse was also appointed to support Mark in taking his medication. A community occupational therapist was allocated to give him extra support to meet his goal of living independently. She planned to use the MOHOST on a repeat basis in order to review Mark’s progress in the future. Case Studies Case Study 5: Sophie Sophie was referred to a community team via her GP. GP. An initial assessment was completed and was written up in two formats a) a narrative home visit report, b) a MOHOST Form. The narrative home visit report provides a detailed account ofform Sophie’s needs is complemented by the MOHOST which givesand a brief summary. Homevisit Narrative Report Referral & Reason for Assessment: The referral was received from Sophie’s GP Dr. Smith. The referral stated that Sophie was now reporting “difficulties with coping and mobility”. It also stated that Sophie has early dementia and has a previous medical history of osteoarthritis and congestive heart failure. The reason for the assessment, therefore, was to assess Sophie’s engagement with everyday activity and make recommendations to support Sophie to feel like she can important for Sophie to always present herself well. She took great care of her appearance, liked to be “well turned out” and had her hair set once a week. She enjoyed spending time with her daughter and family family.. She was particularly close to her granddaughter and they had previously spent time together every Saturday out in the community.. She also enjoyed board games and knitting. community She used to volunteer at a local sheltered housing complex where she made soup and meals and she was involved in church events; running charity events for the woman’s guild. Information from Sophie’s Sophie’s husband and daughter: “cope and manage her mobility” issues and support with other potential unidentified difficulties engaging in activity. They both confirmed the above information from Sophie and so it could be concluded Sophie is an accurate historian. They stated that Sophie’s activity levels fell when she retired five years ago. There has been a gradual deterioration over a 12 month period. She has been sitting in her chair all day doing very little since her recent hospital admission 6 months ago. This admission was to review Sophie’s mental state – at this time she was diagnosed with dementia. ________________________________________________ Sources of Information for Report: Current Mental/Physical Health: This report is a compilation of information gathered on a home visit (Sophie, Sophie husband & OT present) and a telephone contact with Sophie’s Daughter. A: Current Mental Health Evidence based assessment used to gather data: Parkinson S, Forsyth K, Kielhofner G (2005) The Model of Human Occupation Screening tool (MOHOST), version 2.0, Model ofofOccupational Human Occupation Clearinghouse, Department Therapy,, College Therapy of Applied Health Sciences, University of Illinois at Chicago. ________________________________________________ History of Activity: Information from Sophie: She was previously a very active person. She worked behind the bar of a local pub for 20 years before her retirement five years ago. She enjoyed the social aspect of her job and felt that a lot of the “regulars” at the pub were like friends. Since retirement she has felt isolated. She is extremely house proud, always had high standards On the visit Sophie was observed to be responsive and co-operative; she reported that her mood has been low for 6 months and that she no longer took any interest in activities that were once meaningful. Sophie identified the source of her low mood to include a) her inability to mobilise out of doors, b) her recent hospital admission (6 months ago), c) a flood incident in the flat above. She states she is not coping with any activities that were previously meaningful to her. Sophie’s daughter feels her current low mood is due to social isolation since retiring and having reduced mobility ascending/descending stairs due to painful and swollen feet. There is a podiatrist involved which has improved the situation, however, Sophie still reports pain. Sophie’s social isolation has worsened recently because Sophie is not taking as much care of her physical appearance and now would not want anyone to see her in an unkempt state. of cleaning and ran the household very efficiently efficiently.. It was MOHOST v.2.0 43 Case Studies B: Current Physical Health C: Daily Routine Sophie needs a zimmer frame to mobilise around her environment. She was observed to mobilise in her flat independently and safely using this frame. She has not gone outside for the past 12 months due to inability to ascend/descend stairs. She was observed to have swollen feet, with hyper-extended big toes which Sophie stated were painful. Podiatrist and Physical Therapist are involved. She wears glasses, although states she is able to read without them. She reports deteriorated eyesight since cataract operation. She stated has hearing aids which she was not wearing on the visit. She was answering questions appropriately and followed the conversations so could hear people talking adequately. adequately. ________________________________________________ Sophie’s husband states Sophie rises at 9am when the home care assistant attends. She goes through her morning routine then has breakfast at 9.30am. She sits in the lounge chair watching TV all day and evening. The The homecare assistant attends at 1pm to carry out domestic tasks. She then attends at 10pm to support Sophie with her night routine. Sophie states she is not happy with this routine but can’t “be bothered to do anything”. Current Engagement in Activity: A: Physical Environment Sophie was observed live in(no a 2rails) bedroom, first floor 100 flat. External access is by to 2 steps into building, yards paved corridor then 16 steps broken half way with a landing (with rail right side ascending). The physical condition of the flat was well maintained. It is centrally heated and connected by a telephone. D: Roles i) Self Care Sophie’s self care routine happens entirely within her bedroom. Sophie does not a) strip wash at the bathroom sink, b) use shower, or c) use perch stool due to lack of confidence in her balance. Sophie states to wash herself she has an established routine and sits on the bedside commode. The care assistant (arranges needed objects to support of mobility) and provides Sophie verbal encouragement (tolack (to support lack of confidence). lack and her daughter both state she has the skills to dress herself independently on the commode. Grooming herself is very important to Sophie and she states she is currently unable to set her hair and no longer has access to the hairdresser. B: Social Environment Sophie was observed on the visit to: Sophie states she has had a Home carer for the last 3 months who attends 3 times per day, seven days a week. Sophie states she has not been enjoying the company of her granddaughter recently. Sophie lives with her husband and he states he is in good health. He states he is frustrated with his wife’s lack of engagement in activities and her perception that he isn’t completing tasks to her standards. Sophie’s daughter states she and her husband live close by.. They both work full time but by b ut Sophie’ Sophie ’s daughter attends a ttends every evening to support. She has 2 teenage children a son and a daughter who now only attend sporadically. Sophie has asked friends to no longer come round. She states she doesn’t want them to see her unkempt. 44 MOHOST v.2.0 • Independently transfer on/off 16” high commode using zimmer frame with a safe technique. • Independently transfer on/off 16” high toilet, using 2” raised toilet seat & right wall grab rail, with a • • safe technique. Bed transfer not observed. Sophie did not want to attempt shower transfer as she is not currently using shower and is comfortable with her current arrangement of strip washing at bedside. ii) Productivity Cooking: The kitchen was observed to have a gas cooker with overhead grill, microwave, electric kettle, continuous surfaces and a table and chairs. Case Studies Although she stated she previously enjoyed cooking for the sheltered housing volunteer position, her husband now does all the cooking and hot drinks. She states she has “no interest” in cooking now although does occasionally help prepare meals with her husband. She feels she can’t do this now and feels she won’t be able to do this independently. They have a diet of toast in the morning, banana and bread for lunch and a cooked meal in the evening. Sophie states she doesn’t eat the vegetables because her husband doesn’t prepare them well enough. Sophie’s husband feels that Sophie still has the skill, supportive environment and previous habits to cook but she is not motivated to do so. He is frustrated by his wife’s lack of engagement with cooking. Task on Visit: Hot Drink Sophie stated she wouldn’t be able to manage to complete the activity. She did, however, managed to make the hot drink independently with the following skill level, Sophie’s daughter is particularly concerned that Sophie is not engaging with previously leisure activities. Her daughter states she feels that this is the key for supporting her mother to “re-engaging life again”. E: Goals Sophie was unable to identify any goals for the future. Sophie feels very pessimistic about her ability to return to a meaningful life. She states she feels “hopeless” about the future. F: Readiness for change Sophie’s current situation is not supportive of her mental Sophie’s or physical health. The following are issues which indicate that although Sophie wants to change her circumstances, she is not ready to independently change and therefore requires further extended occupational therapy input. • Motor Skills: She was unsteady at intervention. time and slow, however, physically managed without She demonstrated some stiffness and reduction in strength. She appeared to lack energy & sat at regular intervals during the activity. that were meaningful to her and cannot identify any goals, develop plans and follow them through. • Although socially isolated by not being able to ascend/descend external stairs, Sophie stated that she is not prepared to consider moving to alternative accommodation on the ground floor. They have been buying their council flat and moving would be too large an upheaval. • Now has carer support and developed strong habits and dependence on this support. Process Skills: Sophie managed to use knowledge, plan and organise organ ise the activity. She did, however, have difficult difficultyy problem solving. Laundry/Cleaning, Shopping: These activities are completed by the home carer and Sophie’s husband. They are happy to continue to support, however, however, Sophie feels these activities are not completed to “her standards”. Volunteer Job: Sophie has not been involved with her volunteer job for 3 years. She states she misses the social contact and the feeling of “being useful”. iii) Leisure Sophie could identify interests that she engaged in in the past. She specifically identified the social aspect of these interests as being enjoyable and satisfying. Sophie now appears to have reduced leisure opportunities. She could identify specific TV programmes programmes that she enjoys watching. She receives a weekly visit at home from the church. She could not identify anything else that Sophie lacks motivation to engage in doing activities G: Occupational Therapy View (see MOHOST Ratings) Sophie gives the impression of a been person given up on life. Sophie has previously an who activehas woman. She has had a reduction in activity in the past 5 years since retiring and this has further reduced in the past 12 months and was accelerated within the last 6 months following a hospital admission. This This situation was brought about primarily by a difficult transition from working to retirement, physical limitations and pain when mobilising. This has been compounded by the identification of the start of a dementia process. Motivation Motivat ion for Activity Currently Sophie lacks motivation motivation to engage in previously held meaningful activity. Specifically, she has difficulty she does that brings her enjoyment. MOHOST v.2.0 45 Case Studies appraising her own abilities leading to being dependent on others. She doesn’t expect success in the future, which leads to fear of failing and not meeting her high standards. She cannot identify any activities that bring her enjoyment and is unable to set goals for the future. These These characteristics create a situation where Sophie doesn’t make choices to do activity apart from basic self care. Environment Pattern of Activity H: OVERALL RECOMMENDATION Sophie has had substantial role loss over the last five years, which has lead to an empty routine, a poor sense of belonging and avoidance of previously held responsibility. responsibility. She demonstrates an unwillingness to agree to changes in her current routines and ways of doing activities. Sophie’s current situation is not supportive of her mental Sophie’s or physical health. Although Sophie wants to change her circumstances, she is not ready to independently change and therefore requires further extended occupational therapy input. Sophie’s physical environment is problematic as her flat is Sophie’s accessed by stairs and she cannot ascend/descend them. This will not be easily resolved. Her social environment is very supportive, however, however, carers are not supporting the development of Sophie’ Sophie’ss engagement. Skill for Activity NAME: Kirsty Forsyth GRADE: Senior I LOCATION: Edinburgh Community Rehabilitation Team Sophie has adequate communication and interaction skills, however is now having challenges maintaining relationships. She has physical difficulties with balance, stiffness, strength and energy. energy. She has adequate processing skills but has difficulty with problem solving. cc. GP, PT Summary of MOHOST Ratings Motivation for Occupation ss e c c u S f o n ito ta c e p x E tiy li b A f o l a is a rp p A Pattern of Occupation s e c o ih C ts e r te In y ti il b a t p a d A e in tu o R Communication & Interaction Skills lls i k S l a b r e v n o N y ti il b si n o sp e R s e l o R n io ss e r p x E l a c o V n o ti a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy li b o M & e r tu s o P g n i v l o sm e l o rb P n o it a si n a g r O g n i m i T Environment: Motor Skills Home tr ffo E & h t g n e tr S n o ti a in d r o o C s e c r u o s e R l a c i sh y P e c a p S l a ic s y h P y g r e n E s p u o r G l s d n a m e D l a n o it a p ia c o S u c O F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 46 MOHOST v.2.0 Case Studies Case Study 6: Grace The single observation MOHOST can be used by the occupational therapist and/or support staff to document observations of one occupation – that leads up to the completion of a MOHOST. The following case study of Graces illustrates this. Grace, a 79 year old woman, was admitted to an acute care hospital following a chest infection. She was unable to cope at home and couldn’t complete any of her activities of daily living. The occupational therapist received a referral once Grace was medically stable – three days after admission. The occupational therapist completed a “functional assessment” which included a) Community occupational participation (discussion with Grace; discussion with Graces’ son) b) Ward occupational participation (information from multi disciplinary team; personal care assessment; kitchen assessment). This allowed for a triangulation of information - OT observation; information from client; information from a community source. This This enabled the OT to have multiple perspectives on the client’s (ward and community) occupational participation and, therefore, strengthened the likelihood of being able to develop a professional judgement around the client’ client’ss safe discharged into the community. A) Community Occupational Participation Information from Grace about her home life Grace was orientated and keen to engage in conversation. She was smartly dressed. Grace stated she lives in a sheltered housing complex with a 24 hour warden for 6 once a week and otherwise has a strip wash at the sink. Grace feels it s very important to be clean and “not smell”. She particularly likes to have her jewellery and her make up on when visitors come to see her. She has a hairdresser who visits her flat once a week (Saturday afternoon ready for the dance at night). Grace was very keen to get home “asap” as she hates hospitals and feels it puts a burden on her son to visit. Proxy report (Information from Grace’ son about Grace’s Grace’s home life) Contact was made with her son via telephone. Her son states prior to admission Grace was not able to complete her morning routine of dressing and getting breakfast due to chest infection. She had also missed her tea dance the Saturday before admission – which is very unlike her. Her son confirmed the above information and is keen his mother is discharged soon. He states she is like a “fish out of water” in hospital. He states his mother’s mother’s home help is very supportive and praised the warden of the sheltered housing complex who apparently makes regular contact with all residents. B) Ward Occupational Participation (used in MOHOST ratings) Information from multi disciplinary team about how Grace is performing in ward Physiotherapists state that Grace can walk independently Physiotherapists using a stick. The stick is not used for support, however, but gives Grace the confidence to walk. Nursing staff states her medical condition has stabilised. years, that she is very settled there and has many good friends. There is bingo on Wednesday nights and tea dancing on Saturday nights in the lounge area and Grace regularly attends these events. She has a wide circle of friends and usually has visitors every day to her flat. This is important because Grace hasn’t been outside in 5 years and is reliant on the social life within the complex and friends visiting her. Grace states her “legs are poor” but she can manage with a stick. She has to make breakfast for herself (tea and toast) and a sandwich for her evening meal. A home help visits everyday to make a main meal for her at lunchtime and also does her laundry laundry,, shopping and cleaning. Grace is appreciative of this help but doesn’t feel her home help cleans as thoroughly as she did. Grace is helped in and out of the bath by her daughter in law MOHOST v.2.0 47 Case Studies C) Single observation form to document personal care assessment: Client: Grace Assessment environment: Ward bedside Date of birth: 79 yrs old Occupation being assessed: Dressing/personal hygiene Hospital number: 9999999999 Date of assessment: 24th April 2005 F AI R N/S Facilitates participation in occupation Name of Assessor: K Forsyth Allows Inhibitsparticipation participationin inoccupation occupation Restricts participation in occupation Not Seen Designation: o Rating Comments N/S F A I R Accurately assesses abilities N/S F A I R Mostly pleased with progress N/S F A I R Requires encouragement at times Identifies preferences/is goal-oriented N/S F A I R Chooses clothes, wants to dress for son’s visit Maintains routine habits (ADL) N/S F A I R Underlying habits are evident N/S F A I R Some frustration because she is out of home routine N/S N/S F F A A I I R R Absorbed in activity until completion Very willing N/S F A I R Occasionally appeared unhappy with Occasionally progress N/S F A I R Talked about plans for discharge N/S F A I R Occasionally slow to respond Relates to and co-operates with others N/S F A I R Always respectful and sociable Chooses/uses equipment appropriately N/S F A I R No problems identified Maintains focus throughout task/sequence N/S F A I R Mostly able to maintain focus Works in an orderly fashion N/S F A I R Benefits from some minor prompts Modifies actions to overcome problems N/S F A I R Beginning to anticipate difficulties Mobilises independently ls il k S Manipulates tools and materials easily r to Uses appropriate strength and effort o M N/S F A I R Managing transfers more easily N/S F A I R Some difficulty managing buttons N/S F A I R Mostly able to grip items securely Maintains energy and appropriate pace N/S F A I R Tires after five minutes t Space offers stimulus and comfort n e m Resources allow safety and independence n o ir Social interaction provides support v n E N/S F A I R Ward area was noisy and distracting N/S F A I R Chair a bit too high N/S F A I R Appreciative of small support provided N/S F A I R Able to dress in the way she wanted to n ito Shows pride/seeks challenges a itv Shows curiosity and demonstrates interest o M n ito a Remains settled/copes with disruption/change p u c c O Becomes actively involved with task/group f o n r e tt a P Fulfils responsibilities in the session n o it a c i n u m m o C lls i k S ss e c o r P n Uses appropriate non-verbal expression ito c a r Initiates and sustains appropriate communication te In Uses appropriate vocal expression & Demands of activity match abilities/interests Summary [written in contemporaneous notes] Grace has high standards of personal hygiene and personal appearance. It is important to her that she wears makeup, jewellery and has her hair set regularly. regularly. Grace managed 48 x Signature of Occupational Therapist: Area to Evaluate Shows awareness of strengths & limitations Occupational Therapist OT Support Staff MOHOST v.2.0 to wash and dress herself without support. She displayed adequate motivation, routines, process skills within the ward environment. Only areas of concern included managing her buttons and ensuring she could take regular rests due to fatigue. Case Studies C) Single observation form to document kitchen assessment: Client: Grace Assessment environment: OT kitchen Date of birth: 79 yrs old Occupation being assessed: Cup of tea and toast Hospital number: 9999999999 Date of assessment: 24th April 2005 F AI R N/S Facilitates participation in occupation Name of Assessor: K Forsyth Allows Inhibitsparticipation participationin inoccupation occupation Restricts participation in occupation Not Seen Designation: x o Signature of Occupational Therapist: Area to Evaluate Shows awareness of strengths & limitations Occupational Therapist OT Support Staff Rating Comments N/S F A I R Kept within the boundaries of her ability N/S F A I R Very excited she completed task N/S F A I R Keen to find out if she could manage N/S F A I R Strong preference re task progression N/S F A I R Strong habits evident with task N/S F A I R Frustrated she was not in own kitchen N/S F A I R Engaged in activity until completion Fulfils responsibilities in the session N/S F A I R Understood expectation and fulfilled this Uses appropriate non-verbal expression N/S F A I R Appeared tired throughout N/S F A I R Appropriate communication N/S F A I R Clear expression Relates to and co-operates with others N/S F A I R Negotiated task appropriately Chooses/uses equipment appropriately N/S F A I R Appropriate Maintains focus throughout task/sequence N/S F A I R Remained focused Works in an orderly fashion N/S F A I R Very precise organising tools Modifies actions to overcome problems N/S F A I R Very active in overcoming challenges Mobilises independently lls i k Manipulates tools and materials easily S r to Uses appropriate strength and effort M N/S F A I R Stick got in the way several times N/S F A I R Some difficulty manipulating knife N/S F A I R Appropriate Maintains energy and appropriate pace N/S F A I R Needed regular rests throughout t Space offers stimulus and comfort n e m Resources allow safety and independence n o ir Social interaction provides support v n E N/S F A I R Adequate maneuvering space N/S F A I R Chair available for rests N/S F A I R Rapport established N/S F A I R Pleased to have time off the ward n ito a Shows pride/seeks challenges itv o Shows curiosity and demonstrates interest M Identifies preferences/is goal-oriented n Maintains routine habits (ADL) o ti Remains settled/copes with disruption/change a p u c Becomes actively involved with task/group c O f o n r e tt a P n o it a c i n u m m o C lls i k S ss e c o r P n ito c Initiates and sustains appropriate communication a r te In Uses appropriate vocal expression & Demands of activity match abilities/interests Summary [written in contemporaneous notes] Grace is very particular about her routine around making breakfast. She is very precise and organised within the tasks. She doesn’t like clutter or messiness and cleared her tools regularly. Grace was able to make tea and toast independently. The main concern is that she needs regular rests throughout the activity. She did, however, realise this limitation and initiated regular rests herself. Grace states she has a table and chair in her kitchen to allow her to have rests. MOHOST v.2.0 49 Case Studies Prior to discharge, the standard MOHOST form was used to summarise the information above: Summary of MOHOST Ratings Motivation for Occupation ss e c c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A Pattern of Occupation s e c i o h C ts e r te In y itl i b a t p a d A e itn u o R Communication & Interaction Skills lls i k S l a b r e v n o N y itl i b si n o p s e R s e l o R n io ss e r p x E l a c o V n ito a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy il b o M & e r tu s o P g n i v l o sm e l b o r P n o it a si n a g r O g n i m i T Environment: Motor Skills Ward tr o ff E & h t g n e tr S n ito a in d r o o C s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n o it a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R Grace is able to take care of her basic needs within the ward environment. This This level of occupational participation in the ward (see MOHOST ratings) is consistent with the ability she needs to have in order to be discharged to her home environment (see report of home abilities from Grace and her son). She is keen to return home quickly 50 MOHOST v.2.0 and her son is supportive of this. The occupational therapist recommended discharge when her home help could be reinstated. The OT also contacted her son and warden of sheltered housing complex to inform them of Grace’s fatigue. Chapter Chapt er Ten: Ten: QUICK GUIDE TO TREATMENT PLANNING e g a r u o c n e l a rb e v e v i G S E I G E T A R T S k c a b d fe d n a t n e m • L A N O I T A P U C C O S M R O F r e ff o t a h t s n o it a p u c c O f o e e r g e d h g i h a ss e c c u s le ib g n ta • S IM A . T . O p o o T e c n e ri e p x e o t s e it i n • S T P E C N O C • t a th y ti v it c a d e d a r G d n a t n e d fi n o c e b o T e d i v o r p d n a ts c tra n o c e e r g A d e iv e c r e p s e g n lle a h c tiy il b a t e s to d te a itv o m d n a n ito c rp te in e r r ffe O d n a ts n e v e f o fl e re r fo s ite i n n d a l a si a r p o p T a e g a r u o c n e d e c n la a b te ita o g e N ts in a trs n o c l ta n e m n o r s,l a o g l a n o it a p u c c o d n a tss e r te in e v a h to ss e n e r a w a th te tia li c fa o T e r a t a th s n ito a p u c c O / n o sr e p e h t y b d e lu a v n ito c fa its a s e d i v o r p n e e w t e b e c n a l a B • in ta in a m to le b a e b w e n f o n o it a l u m i st • ss e c c u S f o n ito ta c e p x E tiy l a e r t u o g n tis te r fo s e l u e d h c s y ti v it c a • -i v n e t d a n th a s l n ia ito c a o s p t u c c e c fl Oe r e • y itl i b A f o l a is a r p p A tu r o p p o • -f l e s ss e c c u s n ito ta e r • • S M I A S ’ T N E I L C u rt o p y rl a e l c e s e th t n e m u c o d s n o it a p u c c o d l e h ly s u io v e r p d n a e itv c u d o r p a e v a h o T e c i o h c e t tss e r te in o m o r p o T s e c i o h C e r tu c u trs a g itn r o p p fsu o le b a p a c e d i v o r p o T d n a g in r tio n o m n tio a lu a v -fe l e s • y lt e v o n r e h ti e g n ri e ff o st s e r e t n i s u o i v e r p e t a l • e n it u o R y ti v it c u d o r p g in p o c r a le c d n a e itn u o r n a c t a th s n ito a p u c c O tiy r ila i m fa r o r fo s e u c r ffe O to g in d r o c c a d e d a r g e b e k a t o t e l b a e b o t s, e i g e t a rt s d n a tiy li ib s n o p s e r -r o p im e h t te • • o m o r p o T n i d e g a g n e y l e v it c a e b t n e tim m m o c f o e c n ta n o ti c a r e t n i -i s n o p s e r e h t d n a e itm w o ll a t a h t s n o it a p u c c O d e ir u q e r tiy li b s tiie n tu r o p o p T o te tia li c fa itly i b is n o p s e r d e fe r a e lc le o r e itv i sp o d n a k c o a T b e d i v o r p • y itl i b si n o p s e R s ite i n s n o i st e u q n e p o tu ro p p o r ffe O sl li k S l a rb e V n o N g iln l e d o m d n a n o it c e fl e rfl e s r o f l a sr a e h e r l ta n e m • g n ri a sh g n rii u q e r s sk a T r ffe o t a th s n ito a p u c c O rk o w m a e t d n a • n o it a c i n u m m o c ss e ss o p o T • s le o R n io ss e r p x e fle s • g in k ta r fo g n si u n o a ti c i n u m m o c • s e l o r l a n o it a p u c c o t n e m e lv o v in d n a e t a ti li c a F • • e c n a r le to e c e g n ta a r p u e o c c c n a e d o n T a y ti il b a t p a d A to sr e ir a b e r lo p x E • • s n o it a p u c c o e li h w h rt o w s e lu a v d te p e c c a in h ti w -f l se e g a r u o c n E ts p m o r p • u im s t a h t s n ito a p u c c O • • st e r e t n I e r u si e l d n a rk o w d n a sr d e in m e r e iv G s le o r w e n g in p lo e v e d lls i k s n ito c a r te in & e v i rt e ss a d e g n a a r r u u o io c v n a e h o e T b • lf e s e b to , e c n a m r fo r e p n o a ti c i n u m m o c to le b a , e itv r e ss a & e r a w a s e it i n u rt o p p o d e d a r g t c ta n o c l ia c o s r fo s p u o r g r fo g n rii u q e r s e tii v it c A n o tii t e p m o c y h tl a e h • e v a h d n a fl e s ss e r p x e s ip h s n ito la e r e itv is o p e t a ri p o r p n p a io s e t s a r ti e li p c x e a f -fl o e T s • n ito a sr e v n o C ro g e e r g a d n a • • l a n o it a p u c c o r o f y r a ss e c e n s e ri a d n u o b r a e l c t e S s le u rd n u sr e h t o h ti w ra e p o o c e t o m o r p o T f o e lu a v e th d n a n ito n o ti c a r te in l ia c o s • n o ssi e r p x E l a c o V MOHOST v.2.0 s p i sh n o it a l e R 51 Treatment Planning S E I G E T A R T S sk ri p o l e v e D s e i g e t a rt s t n e m e g a n a m s ite i itv c a t c u trs n o c e D • L A N O I T A P U C C O S M R O F e v it a e r c d n a l a c ti c a r P • S M I A S ’ T N E I L C S M I A . T . O S T P E C N O C 52 n o it a m r o f n i t n e d i v o r e p a v l o T e r • e g d le w o n K r o f s e it i n u rt o p p o d e d a r g n ito it e p e r e s U • • t n ie r o t a h t s n ito a p u c c O g in k a -m n io is c e d • , e d g le w o n k e h t e v a h o T d n a r a le c n o ti • r ffe o t a h t s n ito a p u c c O y ti v it c a s sk a t t n e n o p m o c d n a s n o ti u l o s n o s u c o F d n a e itm in n o sr e p e h t r e ff o d n a e g a r u o c n e o T o t e l b a e b o t sl li sk ts p m o r p te ia r p ro p p a • g in im T MOHOST v.2.0 s n ito a p u c c o te le p m o c t u o h g u o r h t ,y lt n ie c ffi e d n a ly e itv c e ff e sl a o g c i sti l a e r g in lv o sm le b ro p e tS d il u b t a h t s n ito a p u c c O e c a p s e g d le w o n k s u io v e r p n o n e p e d in c a fa n g te o m o r p • • n o it a si n a g r O s e it i n u rt o p p o d e d a r g e si c r e x e l a c si y h p r o f o T g n i v l o sm e l b o r p t n e d e d i v o r p o T d n a t n e m ip u q e s, d i a • l a r e n e g g n i d u l c n i g n i v l o sm e l b o r P n ito a c u d e e g a r u o c n e o T a id n r -o o c d n a th g n e trs y g r e n e d n a n ito a tp a d a • y ti il b o M & e r u st o P sr u o i v a h e b l a p f o n it o g n i v il y li a d f o s e it i v it c a itc s e m o d d n a l a n o sr e P sr fe s n a tr d n a tiy li b o m e r a t a h t s n ito a p u c c O • , litiy b o m e h t e v a h o T e t a ri p o r p p a a p u c c o g n sii t c a r s e i v iti t c a t u o y rr a c o t n o it n ito a v r se n o c rd a g e r k c a b d e e f e v iG s e u iq n h c te e c r fo d n a ly fe a s g in v li liy a d f o d e d ra g te tia li c fa o T e l b a e b d n a y lt n e d n e p e d n i c o n o s m r fo l a n ito a g in c n o ito d c n a n t u f n l e a m n n ito o a ir v n p p e u c u c e h t f o t c e ff e e th g in • g in x la re e b to d e iv e c r e p a n r e tl a n i s n o it a p u c c O • liy a d lly ia c e p s e , ty tiv c a ts n e m n o ir v n e e itv • s e tii itv c a g in ilv • tr ffo E & h t g n e tr S & fe a s a e d i v o r p o T -t la u itm s ly te ia r p ro p p a • y g r e n E e c a p S l a c si y h P w e n o t e r u s o ts n e m n o ir p x v e n e h c i h w s n o it a p u c c O f o e s u e is im x a m h tc a m d n a s e c r u o s e r t n e m n o ir v n e g in l ia c o s t u o b a r a le c e B s c i m a n y d l a r u tl u c n d a • d n a y g r e n e s,t s e r e t n i n a e m in s n ito a p u c c O e l b a li a v a e m it • t n e m n o ir v n e n a in e ilv o T n o ti a x la to ss e r se e i n te g tfi o te e m a s o tr a r d p s re o n c T a in d e d a r g te tia li c a F • y tl n e i c fi f e fl e s e c a p o t • n o it a n i rd o o C in e r to sr e e r a c e lv o v In • • h it y lt w e e n p d o n c e o t p e d e l n b i a s e m b e l o b t o d rp n a o r T o t n e m n o ri p f n v o e h c e t n e v o r p h c a e T t x te n o c e h t in s e u iq n • r e ff o t a h t s n o it a p u c c O • e itv c ffe e n te io tia ta li is e h t d n a e c n a m r o rf e • • l a n o tia is n a g r o d n a g in n n la p st n i a rt s n o c e th n i h it w s g itn t e s l ia c o s l fu g in • d n a e lb a rt o f m o c , e f a s si t a th , g n tila u itm s ly te ia r p o r p p a s e c r u o s e r f o n ito ra d y n - li a a s sc e r u o s e r te a u q e d a h ti w p u c c o w o ll a o t rt o p p u s a e t e m e b o t sl a o g l a n o it n o it a p u c c o -i n u m m o c t n a c fi i n g si e t h ti tia w li tly n e d n e p e d in d n a o x T e o a th T c o l ta n e m n o r e t iv o n m e is s o r d p n ly a a o l n T a a • • • e g a r u o c n lo e p s e c r u o s e R l a ic s y h P s c o fa n r ti e s p u o r G l a i c o S s d n a m e D l a n o it a p u c c O Treatment Planning The preceding chart gives a brief outline of the role that the MOHOST and the Model of Human Occupation can play in treatment planning; giving examples of how the general aims of an occupational therapist and a client will be influenced according to the particular skill deficits identified. It is intended to be of particular use for students and those therapists who are unfamiliar with the Model of Human Occupation. The example aims, goals, occupational forms, and strategies are not intended to be comprehensive and neither are they meant to be prescriptive. Wherever possible, aims should be re-worded as specific objectives in order to serve as measurable targets. These will state clear timeframes, behaviours and contexts, including the degree of support required and any conditions that need to be observed. It is recognised, however, that occupational therapists may not always be working in settings that afford them the degree of control requisite for preparing specific objectives. Given Given that time is often at a premium in these settings, the chart may provide a useful aid to highlighting those aims that require the most attention depending on the type of deficit experienced. For instance, although every client undoubtedly needs the opportunity to experience success, (this being at the heart of what occupational therapy is about), it becomes meaningless in treatment planning if it is written indiscriminately for every client. Also, if a client’s main deficits affect their motivation for occupation (volition), then it makes little sense to work on those aims related to performance issues until their motivation motivati on is addressed. The connections between skill items and strategies becomes even more indistinct, in that it is quite plain that the first strategy, i.e., ‘giving verbal encouragement and feedback’, is fundamental to all good therapy, irrespective of the underlying issues that require treatment. The chart, however, may still be useful in helping a whole team to focus in on the essential processes that we need to consider for clients with particular skill deficits. This would help to ensure that a consistent approach is maintained, and provide a clear focus for therapy. Ultimately, we must remember that, “Good therapy never substitutes generalised principles for detailed knowledge of the individual’ individual’ss situation. Rather, knowledge of each client should infuse any general principles with local meaning”, (Kielhofner & Forsyth, 1997, p.109). Reference Kielhofner G, Forsyth K. (1997) The Model of human Occupation: an Overview of Current Concepts. The British Journal of Occupational Therapy, 60(3), 103-110. As to recording the client’s goals, the occupational therapist needs to discuss this with the individual in order to gain a clear understanding of how they relate to the MOHO framework. Once agreement is reached then the best course of practice is generally to record these goals using the client’s exact words, in order to retain the client’ss understanding and commitment. client’ Similarly, there can be no standard formula for deciding on the most appropriate occupation to use in therapy. Certain occupations might appear to be more suitable than others, but a therapist must primarily be guided by the client’s interests and values. MOHOST v.2.0 53 Chapter Eleven: GUIDELINES FOR USING THE RATING SCALE Deciding which rating to assign is a professional judgement, informed by the data gathered by the on his or her occupational participation. In addition, a rating of “I” indicates that the person has a significant occupational therapist difficulty meeting theArequirements demands of his or her culture/context. rating of “R” or reflects an aspect of the person or the environment that restricts occupational participation. The MOHOST uses a 4-point rating scale. Assigning a rating requires the therapist to use the information gathered to make a professional judgement about the item that is being rated. This professional professional judgement requires that the therapist to clearly understand the item being rated, the rating system, and the information gathered. (See page 23 regarding how to handle conflicting data.) Rating system The 4-point rating system: • F - Facili Facilitates tates occupational participation • A - Allows occupational participation • I - Inhibits occupational participation • R - Restricts occupational participation For each item, the therapist is required to assign a rating of F, A, I, or R as an indication of how the client participates in occupation and how well the environment supports the client. The first twenty items refer to aspects of the client’s occupational participation and the last four to aspects of the environment that underpin occupational participation. As such, the environment section is slightly different, in that it refers not to occupational participation per se, but to the level of support that the environment affords, according to the opportunities and resources that are available, the constraints and the demands. However, the meaning of each the rating scale is the same across all items. That That is, a rating of “F” is an indication of appropriate, satisfactory occupational participation, where the person’s occupational participation reflects acceptable functioning in his or her culture/context. A rating of “A” indicates that there are times when the client continues to have a few difficulties participating in occupation due to a noticeable albeit small remaining awkwardness, or that occupational participation is put at risk and that the client remains vulnerable due to the effect of this item. A rating of “I” indicates that the client is experiencing difficulties in this area and that this has a major impact 54 MOHOST v. v.2.0 If in doubt about how to remember the value of ratings scale, one may find it helpful to think about how much therapeutic intervention is required to sustain occupational participation. • F - No outside support required • A - May benefit from occasional support • I - Requires support and/or encouragement • R - Unable to manage despite support Finally,, it is important to bear in mind that the MOHOST Finally is designed to measure a broad range of occupational participation with a wide range of individuals. In particular, it is designed for clients who have challenges engaging in their occupations. Therefore, “F” does not represent excellence and it is quite possible that an average person who is functioning adequately in his or her life will receive mainly ratings of “F” with perhaps a few “A” ratings. A client who received such a ratings profile would not be expected to require the services of an occupational therapist, whatever their diagnosis might be. On the other hand, there are some clients who experience problems with occupational participation to such a degree that they are likely to receive “R” for most items, with the odd “I” or even “A”. It is extremely important that the therapist use the rating scale with this in mind. This continuum includes the most chronically disorganised, decompensated individuals to the client who has many strengths and who could generally be described as a good all-rounder all-rounder,, - no more than this. Criteria Statements The meanings of the ratings F, A, I and R are constant across all items. Assigning these ratings require clinical judgements that are complex and may involve different considerations depending on the content of a given item. Guidelines for Rating Scale To make this process easier, broad criteria are written next to each item that the therapist should consider in assigning ratings as well as a page-to-view list of behavioural criteria in the manual. Therapists should not spend long periods of time pouring over the criteria. The important decision to make is whether to assign a rating of F, A, I, or R. The criteria exist to aid this decision. A therapist who has become familiar with the assessment would not be expected to be frequently returning to the manual to refer to the meanings of ratings for individual items. A single criteria statement has been included directly on the assessment in order to simplify the process of assigning ratings, but therapists should be clear about the differences between the ratings and the criteria statements. Criteria statements are provided to clarify for therapists the typical way in which a rating of F, A, I, or R is typically manifested for any given item. For example, for the Motivation for Occupation item ‘Expectation of Success’, a rating of “I”, is typically or most likely to be seen when an individual has difficulty sustaining confidence about overcoming obstacles or alternativ alternatively ely,, is overly confident. On the other hand, for the Pattern of Occupation item ‘Routine’, a rating of “I”, is typically or most likely to be seen when an individual has difficulty organising routines to meet occupational responsibilities without support. For both items, a rating of “I” means that the item allows participation in occupation. The criteria Posture & Mobility F walking reaching bending transfers When making a rating, the therapist should begin by looking in the criteria column. The therapist may decide to underline aspects of the criteria statement on the assessment that best describe the factors influencing their client’s occupational participation. This may act as a handy indicator of the most appropriate rating. More than one part of a criterion statement can be underlined for any item. Once the appropriate descriptive criteria have been underlined, the therapist can look to the rating scale points, F, A, I, or R to assign a rating. The underlined statements provide help to identify the appropriate rating for a client. In the example below, below, two parts of a criteria statement have been underlined next to the rating of “I”. A therapist would circle the rating “I” after having checked these descriptive statements. I Stable, upright, independent, flexible, good range of movement (possibly agile) Generally able to maintain posture and mobility in occupation, independently or with aids Unsteady at times despite any aids, slow or manages with difficulty R Extremely unstable, unable to reach and bend or unable to walk A stability alignment positioning balance may not be all-encompassing and it is quite possible that a therapist may recognise some uniquely different characteristics in their client that still warrant a rating of “I”. The criteria statements are provided to assist the therapist in narrowing down the options as to which rating to assign, but above all else the therapist needs to pay attention to the fundamental meaning of the rating scale. Comments: If the specific criteria on the assessment do not entirely match the client, then a therapist who is unfamiliar with the MOHOST may wish to check the expanded set of criteria in the manual for further assistance. By scanning from top to bottom, one can locate the statements thatbest describe the client. For the example below, the therapist mentally places a tick against those criteria that describe the client and thus confirms a “I” rating. MOHOST v.2.0 55 Guidelines for Rating Scale Posture & Mobility F = Faci Facilitates litates occupational participation Stable, upright, independent, flexible, good range of movement (possibly agile) • good rotation and flexion of the spine • maintains balance with ease, keeping the body stable without support • • positions self in relation to objects so that movements are most effective reaches safely in all directions A = Allows occupational participation Generally able to maintain posture and mobility in occupation, independently or with aids • movements are awkward at times • moves slowly or hesitantly at times • reaching objects requires effort • slight stoop or leaning, awkward gait I = Inhibits occupational participation Unsteady at times despite any aids, slow or manages with difficulty • may need some help with domestic activities of daily living • some unsteadines, shuffling or lurching • stooped or leaning posture leads to some instability • uses aids for support or furniture to prop self upright, may use wheelchair effectively effectively • uses excessive movements or has difficulty bending and reaching ✓ ✓ ✓ R = Restricts occupational participation Unstable, unable to reach or bend, unable to walk • dependent on others to help with domestic activities of daily living due to lack of posture/mobility • moving results in unacceptable delay or effort • poor trunk control, risks falling or other danger due to poor stability or positioning • unable to mobilise independently or reach objects independently When more than one rating has criteria statements that describe the client one with the most statements that match, because the number of criteria statements is not the same for each However, as in the next example, it may be possible for the criteria statements to suggest a rating of either “A” or “I” because the therapist identifies some criteria statements that allow occupational participation and also some criteria statements that inhibit occupational participation. If the therapist is confident that a particular rating truly represents the client’s functioning then this rating should be made irrespective of any criteria that match. For example, the therapist therapist may decide that even even though several statements that could indicate a “A” “A” rating are applicable, the person’s occupational participation remains inhibited and so the person should still be given a “I”. It is especially important to refer back to the ratings rating. (The therapist may have identified more matching statements next to the “A “A”” rating simply because there are more statements statemen ts next to “A” “A” than there are against agai nst the “I”). Remember,, criteria statements are simply typical instances Remember of a particular rating for a given item that have been identified by the developers and other expert clinicians who have been part of the development process. No attempt has been made to make the criteria for the ratings symmetrical. The aim aim is to identify identify criteria statements that were likely to be used regularly by therapists in assigning a rating. Therapists should remember that it is not the number of criteria statements that match beside a particular rating which determines a rating, rather the impact on the person’s occupational participation. system rather than simply circling the rating next to the Therapists should remember that it is not the number 56 MOHOST v.2.0 Guidelines for Rating Scale of criteria statements that match beside a particular rating which determines a rating, rather the impact on the person’s occupational participation. If the therapist is truly undecided, the lower of the two ratings should always be circled in order to assist planning treatment goals. Posture & Mobility F = Faci Facilitates litates occupational participation Stable, upright, independent, flexible, good range of movement (possibly agile) • good rotation and flexion of the spine • maintains balance with ease, keeping the body stable without support • positions self in relation to objects so that movements are most effective • reaches safely in all directions A = Allows occupational participation Generally able to maintain posture and mobility in occupation, independently or with aids • movements are awkward at times • moves slowly or hesitantly at times • reaching objects requires effort • slight stoop or leaning, awkward gait ✓ ✓ I = Inhibits occupational participation Unsteady at times despite any aids, slow or manages with difficulty • may need some help with domestic activities of daily living • some unsteadines, shuffling or lurching • stooped or leaning posture leads to some instability • uses aids for support or furniture to prop self upright, may use wheelchair effectively effectively • uses excessive movements or has difficulty bending and reaching ✓ ✓ ✓ R = Restricts occupational participation Unstable, unable to reach or bend, unable to walk • dependent on others to help with domestic activities of daily living due to lack of posture/mobility • moving results in unacceptable delay or effort • poor trunk control, risks falling or other danger due to poor stability or positioning • unable to mobilise independently or reach objects independently When several ratings have criteria statements that describe the person It may not always be the case that the descriptive criteria cluster neatly around the rating. rating. This most commonly happens when a client’s occupational participation is inconsistent, or when their occupational participation varies according to the environment or the amount of support avail available. able. If the criteria statements statements that match match arerepresentative of ratings F, A, and I, the therapist should recall the meaning of the 4-point scale previously discussed. A rating of “F” should be given if the item facilitates occupational participation, a rating of “A” if it allows occupational participation, an “I” indicates that occupational participation is inhibited, and “R” if occupational participation is restricted. The rating given is likely to be the visual average of the criteria statements. If the criteria that match are spread across ratings of F, A, and I then a rating rati ng of “A” “A” may well be the most appropria a ppropriate te rating. However, However, in making a professional judgement, the therapist must weigh how important each of the criteria statements are in assessing the occupational participation of a particular client. MOHOST v.2.0 57 Guidelines for Rating Scale When there is not a criteria statement to describe the client, the therapist should write down the observation that they have used to justify the rating in the space reserved for ‘comments’. The criteria statements are designed to capture the more common patterns of occupational participation in occupational therapy clients. Simply assign the appropriate rating and write in the comment section why such a rating was made, always referring back to the general meanings of F, A, I or R to assist in making the rating. Similarly, if the therapist has selected one or more descriptive criteria, but feels strongly that an additional factor (not listed as one of the criteria) is considered important to making the rating, the therapist should briefly write down this additional criterion in the comments section. Important Principles to Guide Ratings • Making ratings is a professional judgement, informed by the data gained by the therapist. • The intent of the criteria statement is to act as a handy reference for selecting the appropriate rating. • Underline the criteria statements that best describe the client’s level of occupational participation. • Therapists are not expected to spend a great deal of time selecting the appropriate criteria statements. • Focus on making appropriate ratings of F, A, I, or R. Use the criteria statements to focus this process. • When there are not descriptive criteria that characterise the client (or when important aspects of the client are not captured by the criteria), therapists should write in descriptive criteria in the comments column. Finally, make ratings in terms of the cultural context in which the client lives. A final and important issue in making a rating for any item is to consider what is functional in the individual’s culture and context. The format of the MOHOST requires that the user be able to make judgements about what is adaptive within the culture and other relevant contexts to which the individual belongs. In taking culture and context into consideration, therapists should always recall that occupational participation is reflected in two factors: a) maintaining and enhancing the individual’s well-being and b) satisfying or meeting the reasonable expectations or norms of one’ one’ss occupational behaviour settings. 58 MOHOST v.2.0 The most important issue surrounding sensitivity to culture and context is to avoid imposing therapist’s individual cultural views when making ratings. This is probably best illustrated by example. Western cultures generally emphasise such values as mastery over one’s context, achievement, keeping busy, and independence. Eastern cultures place higher values on harmony with one’ss context, belonging, reflection and interdependence. one’ An older individual in the West who experiences a disability will tend to strive for maintaining activity and independence and his or her family will similarly expect and wish for this. However, However, an older individual from the East may feel dishonoured if her or his family does not readily accommodate to the disability and will feel less need to struggle for independence and physical activity. That family, family, in turn, considers it their honour-bound hon our-bound duty to take care of the elder with a disability, disability, thereby minimising his/her need to struggle against functional limitations. Both options represent different and culturally relevant ways of adjusting to a disability while maintaining an occupational life that satisfies self and others. In the case above therapists should be aware of their own cultural background and, thereby, avoid imposing criteria from one cultural perspective upon an individual from another. Sensitivity to cultural differences does not begin when the therapist is completing the rating scale. Rather, it begins with how the data is gathered. The therapist should gain an appreciation of the cultural perspectives that influence an individual’s views about their lives. Decision-Rules for Assigning a Rating on the 4-Point Scale • Always remember the scale rating meanings and use the scale accordingly (i.e., F = facilitates occupational participation, A = allows occupational participation, I = inhibits occupational participation, R = restricts occupational participation). • Criterion statements will usually give an indication of the appropriate rating, however, the therapist needs to make a judgement of what rating best describes the client. • When it is not clear which of two ratings to use choose the lower of the two possible ratings. Guidelines for Rating Scale • When the client’s lifestyle or occupational participation means criteria statements are inappropriate, use the meanings of the 4-point rating scale to assign a rating and write in the commentssection to explain the rating. • Do not impose a specific cultural value when making the ratings; make the ratings in terms of the context in which the person lives. MOHOST v.2.0 59 Chapter Chapt er Twelve: Twelve: INSTRUCTIONS AND EXPANDED CRITERIA 1. Fill in the client’ client’ss details and the details of the assessor Client: _____________________________________ Age: _______ Date of birth: _____/_____/_____ _____/_____/_____ Gender: Male o Female o Identification code: __________________________ Ethnicity: White o Black o Asian o Other: __________________________ Health condition: ___________________________ Assessor: __________________________________ Designation: _______________________________ Signature: __________________________________ Date of first contact: _____/_____/_____ Date of assessment: ______/_____/_____ Treatment Tr eatment settings: settings: __________________________ ___________________________________________ Designation This is likely to be Occupational Therapist. Therapist. Any worker who is familiar with the Model of Human Occupation could complete assessment. However, previous research has shown that a lack of knowledge of the model may affect the However, reliability the of an assessment. Treatment settings Include any relevant information including e.g., therapeutic groups, home visit, ward environment. In particular particular,, use this opportunity to clarify whether the ratings reflect the client’s client’s occupational participation across a range of settings, or whether they correspond purely to the client’s client’s engagement in occupational therapy. therapy. 2. Ensure familiarity familiarity with the the ratings key All ratings will refer back to these fundamental definitions, (see chapter twelve). Rating Scale F A I R Facilitates occupational participation Facilitates Assists occupatioinal participation Inhibits occupational participation Restricts occupational participation 3. Rate each item at a time Each item has a number of key concepts listed below it, which might help you to define the skill. Your Your task is to circle the number that most clearly corresponds with your perception of your client for each skill item. If you are unsure how to rate a client, then you can refer to the expanded set of descriptive criteria criteria in the manual. These should help to distinguish related items, as well as giving examples of the factors that may justify each rating. However, the criteria are meant to offer guidance only and cannot be expected to describe the precise behaviour of each individual. The therapist’ss responsibility is to constantly refer back to original ratings key in order to maintain an objective perspective. therapist’ perspective. We should not avoid reporting a deficit on the grounds that the person assessed is doing “very well in spite of their 60 MOHOST v. v.2.0 Expanded Criteria difficulties”. Only by acknowledging the problems that our clients face can we truly recognise their strengths in overcoming them and plan treatment strategies together. together. Item Rating Specific criteria Appraisal of ability F Accurately assesses own capacity, recognises strengths, aware of limitations Understanding of current strengths & limitations, accurate belief in skill, awareness of competence, awareness of capacity A I Reasonable tendency to under/over estimate own abilities, recognises some limitations Difficulty understanding strengths and limitations without support R Does not reflect skills, fails to realistically estimate own abilities Comments: David tends to overestimate how much he can achieve Key concepts 4. Record an item as ‘not ‘not assessed’ if unsure how to rate There may be occasions when the occupational therapist completes a MOHOST within a set time, e.g., to prepare for a review of a person’ person’ss progress with the multi-disciplinary team, but finds that it is not possible to rate one or two items. Given that the ratings do not lead to a total score, it is possible to leave these ratings as blank rather defer the assessment, e.g: Timing Initiation Completion Sequencing Concentration F A I R Sustains concentration, starts sequences and completes occupation at appropriate times Generally able to concentrate, start, sequence and complete occupations Fluctuating concentration or distractible, difficulty initiating, sequencing & completing Unable to concentrate, unable to initiate, sequence or complete occupations Comments: Not yet assessed 5. Record items as ‘improving’ if the item continues to warrant warrant a particular rating but improvement improvement has been noticed Responsibility Role competence Meeting expectations Fulfilling obligations Delivering responsibilities F A I R Reliably completes activities and meets the expectations related to role obligations Copes with most responsibilities, meets most expectations, able to fulfil most role obligations Difficulty being able to fulfil expectations and meet role obligations without support Limited ability to meet demands of activities or obligations, unable to complete role activities Comments: Some improvement in recent days MOHOST v.2.0 61 Expanded Criteria 6. Document the environment in which which the skills have have been assessed The environment will always influence a person’s performance and we often behave very differently depending on whether we are with our family, or our friends, or are work colleagues, as we will hold different roles in the different environments. So an occupational therapist needs to be clear about the context in which a person’s skills have been assessed. For example, the person may may have been assessed only in the occupational therapy therapy department or only in a day hospital or only in their own home. Or, if their presentation is consistent across a broader range of environments, the assessment may cover their occupational participation in wider contexts, such as the hospital as a whole, or the community.. However, community However, it will often be necessary to complete two or more MOHOST assessments to analyse the impact of different environments, especially when the facilities, resources, social groups and occupational demands offer different levels of support. Motivation for Occupation Pattern of Occupation Communication & Interaction Skills ENVIRONMENT Process Skills Environment: Motor Skills Primary Environment assessed: Day Hospital Day hospital 7. Complete the summary summary sheet Write a summary of your comments, highlighting the main points, e.g.: David remains moderately overconfident given his current inability to maintain a balanced routine. All his performance skills are relatively intact. He is capable of good planning and organisation skills and his communication and interaction skills are much improved. He continues to have difficulty with problem-solving and tends to be very impulsive with the result that he has few occupational demands that fit his needs and interests. Copy out the ratings. This provides a record that can be compared at a glance with previous or subsequent assessments. Motivation for Occupation ss e c c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A Pattern of Occupation s e c i o h C ts e r te In y itl i b a t p a d A e itn u o R Communication & Interaction Skills lls i k S l a b r e v n o N y ti li b si n o p s e R s e l o R n io ss e r p x E l a c o V n ito a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy li b o M & re tu s o P g n i v l o sm e l b o r P n o it a si n a rg O g n i m i T Environment: Motor skills Hospital tr ffo E & th g n e tr S n ito a in d r o o C s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y rg e n E sd n a m e D l a n o it a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 62 MOHOST v.2.0 Expanded Criteria Motivation for Occupation APPRAISAL OF ABILITY Key concepts inc. N.B.* Accurately assesses personal strengths & limitations Accurate belief in skill & Accurate awareness of capacity Awareness of physical, intellectual and social abilities Awareness Confidence in ability ability to to utilise skills effectively is asserted asserted in CHOICES CHOICES Confidence in social situations is assessed in RELA RELATIONSHIPS TIONSHIPS Ability to take credit credit or criticism is assessed in RESPONSIBILITY RESPONSIBILITY Ability to think rationally rationally is assessed in PROBLEM-SOLVING PROBLEM-SOLVING F = Facil Facilitates itates occupational participation Accurately assessed own capacity capacity,, recognises strengths, aware of limitations • • • • • recognises impact of medical conditions on skills and abilities recognises own progress or lack of progress, accurately reflecting on past performance accepts that skills are not perfect recognises the impact and consequences of limitations accurately predicts own performance A = Allows occupational participation Reasonable tendency to over/under estimate own abilities, recognises some limitations • • • • finds self-appraisal difficult and/or painful but acknowledges strengths and limitations is beginning to discover changes in personal capacity may not fully appreciate the impact or all the consequences of limitations mostly able to predict own performance I = Inhibits occupational participation Difficulty understanding strengths and limitations without support • • • • • usually under or overestimat overestimates es own abilities overestimates limitations, limitations, possibly in order to maintain secondary gains overestimates strengths leading to inappropriate occupations that exacerbate symptoms unduly self-critical at times has difficulty defining particular strengths and limitations R = Restricts occupational participation Does not reflect on skills, fails to realistically estimate own abilities • • • • • • does not recognise limitations or failures or greatly under or overestimates own abilities dwells on negative comparisons to abilities of others or to previous abilities believes that own abilities are unique, either the best or the worst possible expects abilities to be perfect or dwells on mistakes and failures blames limitations on external causes overestimates strengths leading to risk of injury or failure *N.B., used throughout, means “note carefully” MOHOST v.2.0 63 Expanded Criteria EXPECTATION OF SUCCESS Key concepts also N.B. Self-efficacy, mastery Sense of control over the environment Optimism, hope Expectation of achieving agreed goals Strength of will Awareness of own capacity is assessed in APPRAISAL OF ABILITY Awareness Realism or accuracy is assessed in APPRAISAL OF ABILITY Realism or appropriateness of actions is assessed in CHOICES A person’s motivation for occupation may be driven by sheer strength of will, so realism is not assessed in this item F = Facil Facilitates itates occupational participation Anticipates success and seeks challenges, optimistic about overcoming obstacles • • • • • accepts occupational circumstances beyond control without discouragement feels in control of where life is heading and accepts risks looks forward to occupational challenges, shows pride in achievements maintains a positive outlook about engaging in occupations strong belief in personal effectiveness A = Allows occupational participation Has some hope for success, adequate self-belief but has some doubts, may need encouraging • • • • may be cynical or self-critical but continues to build on occupational success expects success in some aspects of occupation, may be apprehensive in new situations positive most of the time about ability to engage in occupation slight uncertainty about ability to influence future events I = Inhibits occupational participation Requires support to sustain optimism about overcoming obstacles, poor self-efficacy • • • • • doubts ability to control/face obstacles/limitations/failures obstacles/limitations/failures within their occupational life easily discouraged when faced with occupational challenges and requires support to continue to engage in occupation feels uncertain about prospects for success within their occupational life minimises the risks involved in occupations fear of failure inhibits willingness to take positive risks R = Restricts occupational participation Pessimistic, Pessimis tic, feels hopeless, gives up in the face of obstacles, lacks sense of control • • • • 64 believes that circumstances are stacked against success or that others conspire against self feels helpless and unable to control self or influence occupational outcomes despite support negative perception of own potential to engage in occupations despite feedback and support consistently avoids situations that challenge self-efficacy MOHOST v.2.0 Expanded Criteria INTEREST Key concepts also N.B. Expressed enjoyment Satisfaction Curiosity Participation Passive or active interest in available occupa occupation tion Expressed or demonstrated pleasure in occupation Curiosity and sustained interest Level of engagement in surroundings Pursuit of occupations is assessed in COMMITMENT F = Facil Facilitates itates occupational participation Keen, curious, lively, lively, tries new occupations, expresses pleasure, perseveres, appears content • • • • • • actively engages in own interests independent of structured occupations expresses enjoyment and may have clear dislikes expresses interest and curiosity in surroundings follows occupations to completion due to high level of enjoyment fully engages in occupations of interest may be enthusiastic at times while engaging in occupations A = Allows occupational participation Has adequate interests that guide choices, has some opportunities to pursue interests • • • • • • • appears reasonably but not highly satisfied when engaging in occupations compliant — may be engaging only to please those in authority — requires some encouragement holds no clear opinion about occupations despite readily participating in activities available may require encouragement at times to engage but then sustains interest reliant on social support — external rather than internal motivation beginning to identify interests independently has adequate interests but is not pursuing all of them at present I = Inhibits occupational participation Difficulty identifying interests, interest is short-lived, ambivalent ambivalent about choice of occupations • changeable, variable response according to occupation, unreliable, infrequent participation • easily gives up, requires much encouragement or support to maintain interest • expresses interest but does not engage or does not sustain interest • expresses vicarious interest in lives of others • interested in selected activities but generally lacks curiosity • may be attracted by novelty but does not pursue interests • requires support to sustain engagement in a stated interest R = Restricts occupational participation Easily bored, unable to identify interests, apathetic, lacks curiosity even with support • • • • does not engage in interests even with support may engage in passive activities e.g., watching T.V. but without enjoyment no spontaneous interest expressed, no pursuit of interests not interested in any occupation and actively resists engaging, refuses all suggestions MOHOST v.2.0 65 Expanded Criteria CHOICES Key concepts also N.B. Appropriate commitment Readiness for Change Sense of value & meaning Preferences & goals Drive, initiativ initiativee and persistence to work towards appropriate goals Ability to take appropriate action Being aware of what needs doing and being able to prioritise Spontaneity of action Reactive to the environment and able to put plans into action Level of activity is assessed in ROUTINE Action is assessed in ENERGY F = Facil Facilitates itates occupational participation Clear preferences and sense of what is important, motivated to work towards occupational goals • • consistent and logical, identifies chosen lifestyle and has clear direction has clear priorities and personal standards that match societal values • • • persists in activities and tries to problem-solve, positive risks seeks challenges, engages in complex activitiestaking and sets projects requiring effort selects activities that support socially acceptable values, pursues meaningful occupations A = Allows occupational participation Mostly able to make choices, may need encouragement to set and work towards goals • • • • appears to be holding certain values in order to please others attaches some importance to chosen occupations and lifestyle may be slightly impulsive at times or may be a little cautious at times usually makes choices that fit in with their sense of what is important I = Inhibits occupational participation Difficulties identifying what is important or setting and working towards goals, inconsistent • • • • • • able to make choices that fit that long-term goalsand if given support difficulty choosing activities have value meaning to life uncertain about purpose of life or holds conflicting values initiativee is restricted to activities of daily living or structured situations initiativ often impulsive or easily led, regretting actions later somewhat dependent, tents to ‘drift’ aimlessly without support R = Restricts occupational participation Cannot set goals, impulsive, chaotic, goals are unattainable or based on anti-social values • • • • • • 66 dependent on others, needs prompts to manage personal activities of daily living highly suggestible or placid, cannot identify valued occupations impulse-led — may take action to meed own needs regardless of needs of others lacks commitment or feels alienated by society or cannot identify with societal needs unable to make goal choices even with support other than to meet basic needs choices lead to unacceptable risks MOHOST v.2.0 Expanded Criteria Pattern of Occupation ROUTINE Key concepts Balance Organisation of habits Structure Productivity also N.B. Balance between work and leisure, social and personal, physical and creative Daily schedule Sleep pattern Amount of activity Level of Social Activity is assessed in RELA RELATIONSHIPS TIONSHIPS Energy levels are assessed in ENERGY F = Facil Facilitates itates occupational participation Able to arrange a balance organised and productive routine of daily activities • able to organise daily routine in order to keep appointments • • • follows well-organised and productive daily schedule maintains appropriate activity levels to support role responsibilities and goals routine is adaptive and facilitates meeting role responsibilities and/or goals A = Allows occupational participation Generally able to follow an organised and productive daily schedule • • • • • • beginning to improve organisation of daily activities but improvement is still only recent engages with activity best when a structure exists and there are clear appointments may arrive early for events or slightly late for appointments needs encouragement to utilise time effectively to meet goals and responsibilities time is filled but balance of activities may not always meet responsibilities and goals usual routine is temporarily affected by current environment I = Inhibits occupational participation Difficulty organising balanced, productive routines of daily activities without support • • • • • • engages solely in sedentary activities that don’t support goals or meet responsibilities has difficulty getting up in the morning looks to others to provide structure for the day participates in limited number of activities, some imbalance evident considering goals poor sleep pattern affects daytime routine requires support and reminders to make appointments, tends to be late R = Restricts occupational participation Chaotic or empty routine, unable to support responsibilities/goals, erratic routine • • • completely reliant on others to provide daily organisation does not utilise time productively despite support erratic routine that doesn’t support goals or responsibilities • may be unaware of day-to-day routines/sleep pattern may be reversed MOHOST v.2.0 67 Expanded Criteria ADAPTABILITY Key concepts also N.B. Anticipation of change Habitual response to change Tolerance of change Response to changes in routine Willingness to adapt Reaction to adversity/ adversity/obstacles obstacles Feelings related to change are assessed in EXPECTA EXPECTATION TION OF SUCCESS F = Facil Facilitates itates occupational participation Anticipates change, alters actions or routine to meet demands (flexible/accommodating) • • • • • • able to make the best of things even if expectations aren’t fulfilled accommodating, understanding, responds appro-priately to changes in routine or activity adjusts and compensates to cope with changed circumstances/the unexpected changes routine to meet changing responsibilities copes with disappointment within activity copes with suggestions and change to routine or activity A = Allows occupational participation Generally able to modify behaviour, may may need time to adjust, hesitant • • • • • copes well but is somewhat unquestioning, laissez-faire laissez-faire improving ability to modify behaviour within activity when necessary, necessary, possibly with encouragement may express disappointment, but accepts situations and can adapt appropriately unsettled by change but alters actions appropriately despite expressed emotion some impulsivity I = Inhibits occupational participation Difficulty adapting to change, reluctant, passive or habitually overreacts to change • • • • • may feelings and be prone to outbursts, anxious or irritable or impatient may bottle resort to manipulation in order to resist change passive — may not voice frustration and therefore not get needs met reluctant to change, usually responds to firm boundaries and support unpredictable response — may be governed by mood rather than logic R = Restricts occupational participation Rigid, unable to adapt routines or tolerate change • • • • • 68 desires immediate satisfaction — lacks patience despite all attempts to support change may be extremely anxious or fearful, avoidant of change poor response to boundaries or pushes boundaries causing distress to others resists suggestions, intolerant, reacts inappropriately to change volatile, explosive, aggressive, aggressive, physically violent or verbally abusive in relationship to change MOHOST v.2.0 Expanded Criteria ROLES Key concepts also i.e., N.B. Role identity Role variety Belonging Involvement Social acceptability Student,, worker, volunteer career, home maintaine Student maintainer, r, friend, family member, religiou religiouss particip participant, ant, participant in hobbies or organisations, health maintainer roles Ability to relate to others is assessed in RELA RELATIONSHIPS TIONSHIPS Role competence is assessed in RESPONSIBILITY Practical and emotional support from others is assessed in SOCIAL GROUPS F = Facil Facilitates itates occupational participation Identifies with a variety of roles, has a sense of identity/belonging that comes from roles • • • • • able to include others and support others in occupations able to maintain roles without support, fits in well able to take on a variety of roles and balance multiple role demands recognises obligations and has productive/const productive/constructive ructive roles able to maintain self-care, leisure and productive roles A = Allows occupational participation Generally identifies with one or more roles and has some sense of belonging in these roles • • • • • at risk of role overload or roles are reduced has clear roles and sense of belonging but may require encouragement to meet obligations major role is vulnerable to change in the near future OT questions strategies used to maintain roles puts considerable effort into the valid role of ‘health maintainer’, but holds no other roles I = Inhibits occupational participation Limited identification of roles, role overload or conflict, poor sense of belonging • can become over-involved in the lives of others • has clear roles but poor sense of belonging • has limited access to long-term roles but shows role behaviour in structured environments • limited role behaviour, playing e.g. the joker, or e.g. mother figure, but little else • requires support to meet expectations and obligations R = Restricts occupational participation Does not identify with any role, negligible role demands, no sense of belonging • • has withdrawn from all previous roles unable to maintain self-care, leisure or productive roles despite support MOHOST v.2.0 69 Expanded Criteria RESPONSIBILITY Key concepts also N.B. Role competence Meeting expectations Fulfilling obligations Delivering responsibilities Willingness/readiness Willingness/r eadiness to acknowledge/accep acknowledge/acceptt role obligations and assigned tasks Reasoning skills are assessed in PROBLEM SOL SOLVING VING Role variety is assessed in ROLES F = Facil Facilitates itates occupational participation Reliability completes activities and meets the expectations related to role obligations • • • • accepts reasonable responsibility for personal actions and is aware of their effect upon others readily accepts designated tasks and takes on responsibilities without being asked recognises and fulfils most occupational responsibilities without support seeks feedback in order to take on responsibilities and meets expectations A = Allows occupational participation Copes with most responsibilities, meets most expectations, able to fulfill f ulfill most role obligations • • • • • accepts feedback or appropriate advice and, with encouragement, is beginning to make changes in order to meet responsibilities may apologise unnecessarily at times, slight reluctance to take on new responsibilities may question responsibility occasionally, but soon acknowledges responsibility recent improvement/developing awareness of occupational responsibility requires feedback to be direct, not alway alwayss aware of the impact of their actions on others I = Inhibits occupational participation Difficulty being able to fulfil expectations and meet role obligations without support • • • • • may be aware of some responsibilities but not others needs support to accept occupational responsibility, responsibility, tends to blame others or general circumstances requires support to acknowledge impact of actions upon others some guilt feelings expressed about responsibility wants to take responsibility but does not show awareness of full occupational implications R = Restricts occupational participation Limited ability to meet demands of activities or obligations, unable to complete role activities • • • • • • • consistently hostile or highly defensive when required to face responsibilities denies or disputes feedback, refuses to accept feedback or takes no responsibility difficulty disassociating self from other people’ people’ss problems, despite support lacks awareness — seems unaware of how failure to handle responsibilities affects others may attribute actions solely to illness or external situations and doesn’t take responsibility not aware of impact on others even with support overwhelming overwhelm ing guilt feelings expressed about responsibility • unpredictable acceptance of responsibilities 70 MOHOST v.2.0 Expanded Criteria Communication & Interaction Skills NON-VERBAL SKILLS Key concepts also N.B. Eye contact Gestures Orientation Proximity Facial expression and gaze Proximity Responsiveness or spontaneity Liveliness is assessed in ENERGY F = Facil Facilitates itates occupational participation Appropriate (possibly spontaneous) body language given culture and circumstances • • • able to convey mood and make needs known with non-verbal behaviour non-verbal behaviour is congruent with verbal communication non-verbal behaviour is fully appropriate in cultural context • • reactive and spontaneous non-verbal behaviour uses gestures and eye contact appropriate to the occupational situation A = Allows occupational participation Generally able to display or control appropriate body language • • • animated, gestures appear somewhat exaggerated, or may be too formal for occupational situation certain mannerisms may be distracting or repetitive and don’t support completion of occupation use of physical contact and awareness of personal space are questioned I = Inhibits occupational participation Difficulty controlling/displaying appropriate body language (delayed/limited/disinhibited) (delayed/limited/disinhibited) • • • • • • benefits from encouragement and feedback to use non-verbal expression effectively fidgety,, may appear nervous or distracted within the occupational context fidgety has limited use of gestures, variable eye-contact may give inappropriate non-verbal signals, and delay completion of occupation may invade personal space or be disinhibited at times non-verbal behaviour is incongruent with verbal communication and mood R = Restricts occupational participation Unable to display appropriate body language (absent/incongruent/unsafe/aggressive) (absent/incongruent/unsafe/aggressive) • • • • blank, mask-like, or lacks eye contact and does not respond to encouragement grossly disinhibited, incongruent or fixed non-verbal behaviour non-verbal behaviour is overactive and distracting despite feedback uses inappropriate gaze or invades personal space/may cause offence to others MOHOST v.2.0 71 Expanded Criteria CONVERSATION Key concepts also N.B. Disclosure Initiating & sustaining communications Speech content Language Appropriate content of whateither is saidverbally or through signing Ability to share information Able to communicate needs and wants and to negotiate accordingly Word-finding abilities Clarity, meaning Vocabulary and grammar Intonation and articulation are assessed in VOC VOCAL AL EXPRESSION Readiness to communicate is assessed in RELA RELATIONSHIPS TIONSHIPS F = Facil Facilitates itates occupational participation Appropriately initiates, discloses and sustains conver-sation conver-sation (clear/direct/open) • • • • chooses words or signs appropriately communicates openly clearly and concisely is able to effectively convey subtle and complex meanings makes appropriate requests A = Allows occupational participation Generally able to use language/signing to effectively exchange information • • • • • hesitant or superficially initially, or copes best 1:1 may not attend to verbal cues, may give too much or too little information at times mostly clear, may have slight word-finding difficulty responds appropriately and engages in conversation when approached slight difficulties in sustaining conversation that may be attributed to sensory impairment I = Inhibits occupational participation Difficulty initiating, disclosing or sustaining conver conver-sation -sation (hesitation/abrupt/limited/irrelevant) (hesitation/abrupt/limited/irrelevant) • can be difficult to understand at times or requires support to be understood • • • • • • • • communication is not always direct can understand communication with the help of signing or symbols limited — may have difficulty expressing feelings, have limited vocabulary or use of signs may disclose information appropriately at times may use non-words repetitively, e.g. “you see,” “sort of,” “like,” “um,” “er,” “yeah” meaning is unclear, puzzling some dysphasia speech impediment or sensory impairment interferes with communication R = Restricts occupational participation Uncommunicative, Uncommunicativ e, disjointed, bizarre or inappropriate disclosure of information • • • • bizarre or incomprehensible communication, despite therapeutic interventions dysphasic or fragmented communication has not reached developmental level that supports effective verbal communication monosyllabic or mute/refuses to give information • unable to convey information using spoken language or signing 72 MOHOST v.2.0 Expanded Criteria VOCAL EXPRESSION Key concepts also N.B. Assertion Intonation Articulation Volume Pace Pitch and modulation (may be affected by ability to hear) Langua ge is assessed in CONVERSATION Language Liveliness is assessed in ENERGY F = Facil Facilitates itates occupational participation Assertive, articulate, articulate, uses appropriate tone, volume and pace • • • firm and able to confidently refuse requests, with or without language uses vocal expression effectively to communicate needs vocally expressive A = Allows occupational participation Vocal expression is generally appropriate in tone, volume and pace • • • volume of speech may cause slight difficulties possible incongruent infection mostly able to indicate needs, with or without recourse to language I = Inhibits occupational participation Difficulty with expressing self (unclear/pressured speech/monotone) • • • • accent interferes with communicating within an occupation limited range of affect, blunted expression overly talkative, talkative, or has some pressure of speech requires encouragement and feedback to utilise vocal expression effectivel effectivelyy • • vocal expression is distractingwith leading to context ineffective communication volume may be incongruous social at times R = Restricts occupational participation Unable to express self (incomprehensible, too quiet or loud, too fast) • • • • • extremely pressured, unintelligible, despite feedback mute overbearing or frequently shouts, screams speaks in monotone whispers or is barely audible MOHOST v.2.0 73 Expanded Criteria RELATIONSHIPS Key concepts also N.B. Co-operation Collaboration Rapport Respect Helpfulness Ability to relate Dyadic and group interaction Sociability Pattern of co-operation is assessed in ROLES Continuing support from others irrespective of ability to form relationships is assessed in SOCIAL GROUPS F = Facil Facilitates itates occupational participation Sociable, supportive, aware of others, sustains engagement, friendly, friendly, relates well to others • • • attentive and able to accommodate behaviour to include others in occupation demonstrates awareness of other’s other’s needs, gives constructive criticism to support completion of occupation shares and assists appropriately within occupation • willing to help and get along with others within an occupation A = Allows occupational participation Generally able to relate to others and mostly demonstrates awareness of others’ needs • • • able to ‘put on a front’ in social situations friendly,, polite and courteous and seeks interaction but does not easily form relationships friendly naturally reserved — may keep self to themselves at times but otherwise appears comfortable in social situations — self-contained I = Inhibits occupational participation Difficulty without co-operation or makes few positive relationships • • appears vulnerable to being manipulated by others communicates with certain others but not everybody involved in occupational situation • • • • complies with direct actively collaborate difficulty coping withrequests strangersbut or does large not groups of people, interacts with selected others tendency to be self-oriented or unaware of the needs of others but responds to feedback tends to place self on the edge of social groups — degree of discomfort evident R = Restricts occupational participation Unable to co-operate with others or make positive relationships • • • • • • • • 74 does not get involved, unresponsive, unresponsive, does not display concern for others extremely withdrawn or isolative, may ignore others hostile or suspicious, may sabotage interventions or otherwise be destructive inattentive, appears to be out of touch with occupational situation intolerant of others, possibly malicious or provocative obstructive, demanding, interfering within occupational situations offensive, may provoke disgust in others unaware of boundaries, extremely vulnerable despite support MOHOST v.2.0 Expanded Criteria Process Skills KNOWLEDGE Key concepts Seeking and retaining information Knowing what to do in an activity Knowing how to use objects also N.B. Uses tools appropriately Heeds instruction Oriented to time, place and person Awareness of responsibility is assessed in RESPONSIBILITY Awareness Ability to follow instruction is assessed in ORGANISA ORGANISATION TION Knowledge refers to practical knowledge of occupations, not general knowledge or IQ F = Facil Facilitates itates occupational participation Seeks and retains information, knows how to use tools appropriately • • • • diligently retains information seeks out information and probably checks out feedback shows awareness of surroundings uses tools methodically and accurately accurately,, chooses tools logically A = Allows occupational participation Generally able to seek and retain information and know how to use tools • • • • • fully oriented but occasionally forgetful or may doubt own memory may be slow to ask for clarification, occasionally requires encouragement may use common aids (e.g. diaries and lists) effectively effectively use of tools is idiosyncratic but effective, does not impact performance slight difficulty noticed in applying previous knowledge to a new task I = Inhibits occupational participation Difficulty knowing how to use tools, difficulty in asking for help or retaining information • • • • • • chooses inappropriate tools resulting in disruption of task performance clearly remembers detailed facts and figures which may be inconsequential, but does not always retain practical information dependent on aids to jog memory and the support of others does not retain information fully, fully, regularly requires reminders highly selective, may retain valued information only or manipulate information received may ask for irrelevant information or makes ineffective inquiries R = Restricts occupational participation Unable to use knowledge/tools, does not retain information, asks repeatedly for same information • • • • confused, disoriented, may confabulate, poor long or short-term memory frequently misinterprets feedback/makes no changes despite repeated feedback illogical in choice of tools, end products are dramatically affected insight may be fleeting or lacking • may use tools without regard for hygiene or safety MOHOST v.2.0 75 Expanded Criteria TIMING Key concepts also N.B. Initiation Completion Sequencing Concentration Attentiveness, ability to focus and sustain concentration Attentiveness, Ability to cope with distractions and variable stimulation Ability to prioritise and sequence activities Awareness of time Planni ng goals is assessed in COMMITMENT in the MOTIVA Planning MOTIVATION TION FOR OCCUPA OCCUPATION TION SECTION Planning in this PROCESS SKILLS section refers exclusively to planning within an occupation F = Facil Facilitates itates occupational participation Sustains concentration, starts sequences and completes occupation at appropriate times • • • • able to become absorbed in activity and cope with distractions manages all tasks from beginning to end with minimum fuss may be capable of intense concentration or be able to think quickly proactive, able to prioritise, forward-thinking A = Allows occupational participation Generally able to concentrate, start sequence and complete occupations • • • • • concentrates sufficiently for most day-to-day tasks may repeat some steps of a task without apparent disruption occasionally preoccupied but is able to refocus with minimal encouragement reactive, does not plan far ahead, but times activities adequately some variability according to task and situation but has definite ability I = Inhibits occupational participation Fluctuating concentration or distractible, difficulty initiating, sequencing and completing • • • • • can become preoccupied or distracted and lose focus after a while continues activity unnecessarily does not always prioritise effectively effectively and benefits from the support of others hesitant, requires prompts, activity is interrupted regularly overruns time limits R = Restricts occupational participation Unable to concentrate, unable to initiate, sequence or complete occupations • • • • 76 does not get going or starts tasks but does not return to them does not prioritise despite support and encourage-ment to do so loses track of time or unaware of time poor sequencing ability, gets muddled MOHOST v.2.0 Expanded Criteria ORGANISATION Key concepts also N.B. Arranging space and objects Neatness Preparation Gathering objects Quality of work carried out (including activities of daily living) Ability to search for for,, locate and gather tools systematically Understanding instructions is assessed in KNOWLEDGE Organisation Organisa tion of routine routiness is assessed in ROUTINE in the PA PATTERN TTERN OF OCCUPA OCCUPATION TION section Organisation in this PROCESS SKILLS section refers exclusively to organisation within an operation F = Facil Facilitates itates occupational participation Efficiently searches for, for, gathers and restores tools/objects needed in occupation (neat) • • • • accurate and methodical, efficient organises space and objects thoroughly and systematically produces careful work, arranges objects effectively uses tools safely A = Allows occupational participation Generally able to search, gather and restore needed tools/objects • • may have a specific disability that impacts on organisation but generally manages well works safely and is mostly efficient I = Inhibits occupational participation Difficulty searching for, gathering and restoring tools/objects, appears disorganised/untidy • • • disorganised, rushed and/or messy messy,, may want immediate results does not always tidy up after self ineffective or random in search for tools • • • • may appear overly fussy vague at times or lose track of what needs doing requires assistance and may make some errors requires plenty of time, or firm encouragement R = Restricts occupational participation Unable to search for, gather and restore tools and objects • • • • haphazard, chaotic, extremely messy lacks awareness of what needs doing, requires repeated instruction each time often does not act upon instruction or makes frequent mistakes despite instruction unsafe or at risk due to poor organisational skills MOHOST v.2.0 77 Expanded Criteria PROBLEM-SOLVING Key concepts also N.B. Judgement Adaptation Decision-making Responsiveness Objectivity — ability to distance self Concrete v. abstract thinkin thinkingg Ability to generate workable solutions Ability to learn from mistakes and benefit from instructions Motivation to seek solutions is assessed in GOALS Ability to identify problems and response to feedback are assessed in RESPONSIBILITY F = Facil Facilitates itates occupational participation Shows good judgement, anticipates difficulties and generates workable solutions • • • able to make decisions quickly and objectively clear,, independent, appropriate clear notices what needs doing and responds, modifying actions to prevent problems A = Allows occupational participation Generally able to make decisions based on difficulties that arise • • • often intuitive (uses ‘gut reaction’) but unable to substantiate choices seeks reassurance or advice occasionally when in difficulty slow to respond to environmental cues I = Inhibits occupational participation Difficulty anticipating and adapting to difficulties that arise, seeks assurance • • does not notice or respond to problems that arise, resulting in unacceptable outcomes may not avoid or delay making some decisions, but responds to feedback • • may feedback inappropriately inappropriately, frequently reassurance or ‘fishing for compliments’ tendsseek to base decisions on emotion, rather thanrequesting logic R = Restricts occupational participation Unable to anticipate and adapt to difficulties that arise and makes inappropriate decisions • • • • • • 78 avoidant, does not seek information and fails to respond to feedback fails to overcome problems or to make appropriate changes frequently resorts to inappropriate or anti-social coping strategies highly dependent/reliant on others, extremely vulnerable irrational, makes random or inappropriate decisions, unamenable to reason makes unsuccessful attempts to solve problems MOHOST v.2.0 Expanded Criteria Motor Skills POSTURE & MOBILITY Key concepts also N.B. Stability Alignment Walking Reaching Positioning Balance Bending Transfers Standing and sitting balance Range of movement Gait Moving and transporting objects is assessed in STRENGTH & EFFORT F = Facil Facilitates itates occupational participation Stable, upright, independent, flexible, good range of movement (possible agile) • • good rotation and flexion of the spine maintains balance with ease, keeping the body stable without support • • • positions self ininrelation to objects so that movements are most effective reaches safely all directions walks freely, freely, manages stairs and uneven surfaces A = Allows occupational participation Generally able to maintain posture and mobility in occupation, independently or with aids • • • • movements are awkward at times moves slowly or hesitantly at times but completes tasks reaching objects requires effort slight stoop or leaning, awkward gait I = Inhibits occupational participation Unsteady at times despite any aids, slow or manages with difficulty • • • • • may need some help with domestic activities of daily living some unsteadiness, shuffling or lurching stooped or leaning posture leads to some instability uses aids for support or furniture to prop self upright, may use wheelchair effectively effectively uses excessive movements or has difficulty bending and reaching R = Restricts occupational participation Unstable, unable to reach or bend, unable to walk • • • • dependent on others to help with domestic activities of daily living due to lack of posture/mobility moving results in unacceptable delay or effort poor trunk control, risks falling or other danger due to poor stability or positioning unable to mobilise independently or reach objects independently MOHOST v.2.0 79 Expanded Criteria CO-ORDINATION Key concepts also N.B. Manipulation Ease of movement Fluidity Fine motor skills Hand-eye co-ordination — vision, perception Dexterity Sensation Range of movement is assessed in POSTURE & MOBILITY Grip is assessed in STRENGTH & EFFORT F = Facil Facilitates itates occupational participation Co-ordinates body parts with each other, uses smooth fluid movements (possibly dextrous) • • able to manipulate tools easily and quickly well-co-ordinated, uses the whole body A = Allows occupational participation Some awkwardness or stiffness causing minor interruptions to occupations • • may be slow, but manages all tasks, activity is not disrupted may have sensory impairment but manages all tasks independently I = Inhibits occupational participation Difficulty co-ordinating movements (clumsy/tremulous/a (clumsy/tremulous/awkward/stiff) wkward/stiff) • • • • difficulty manipulating objects causing activity to be delayed or interrupted increased tone or ataxia impacts on speed of performance or leads to increased effort may need help in some personal activities of daily living because of difficulty with co-ordination poor grip, difficulty stabilising objects R = Restricts occupational participation Unable to co-ordinate, manipulate and use fluid movements • • • • 80 coarse tremor or weak grip, risks breaking or dropping objects dependent on help with personal activities of daily living because of lack of co-ordination severe tremor or rigidity leads to unacceptable delay with risk of damage unable to manage tasks requiring co-ordination MOHOST v.2.0 Expanded Criteria STRENGTH & EFFORT Key concepts also N.B. Grip Handling and lifting Moving and transporting Calibration Force Ease of movement is assessed in CO-ORDINATION F = Facil Facilitates itates occupational participation Grasps, moves & transports objects securely with adequate force and speed (possibly wrong) • • • • able to carry appropriately and even pressure and to regulate speed of actions able to carry objects easily and safely able to grasp objects securely with adequate grip to open fastenings and containers able to lift objects smoothly, smoothly, with appropriate effort A = Allows occupational participation Strength and effort are generally sufficient for most tasks • • • may adjust strength and effort as task progresses possibly hesitant or slow but manages independently task performance may be slightly delayed due to weakness I = Inhibits occupational participation Has difficulty with grasping, moving, or transporting objects with adequate force & speed • • • • • difficulty carrying more than one item without help has difficulty with grasping handles, opening fasteners or containers or removing coverings lacks adequate control and may appear clumsy may use both hands to life objects that typically need only one objects are liable to slip due to poor grasp • • uses (e.g. objects sliding, pushing or pulling objects) to complete activity weakcoping or overstrategies forceful with R = Restricts occupational participation Unable to grasp, move, transport objects with appropriate force and speed • • frail, dependent on help or intervention of others to complete tasks risks breaking objects or danger to self MOHOST v.2.0 81 Expanded Criteria ENERGY Key concepts also N.B. Endurance Pace Attention Stamina Fitness Tempo Activity level is assessed in ROUTINE F = Facil Facilitates itates occupational participation Maintains appropriate energy levels, able to maintain tempo throughout occupation • • • • able to increase activity to meet deadlines and relax appropriately good stamina, able to maintain focus maintains a consistent rate of task performance possibly lively, probably engages in physical exercise A = Allows occupational participation Energy may be slightly low or high at times, able to pace self for most tasks • completes tasks slowly but steadily • poor sleep, but manages to cope during the day • sedentary, but this is normal given their lifestyle • tires quickly but soon recovers • describes changes in energy levels but manages tasks effectively • I = Inhibits occupational participation Difficulty maintaining energy levels (tires easily/evidence of fatigue/distractible/restless) fatigue/distractible/restless) • • becomes short of breath generally lacking energy — sufficiently active to achieve bare minimum • • • • • • may in physical butrelaxing, withoutmay exerting self may engage keep busy but haveactivity difficulty be fidgety performance is restricted or slow quality of performance is affected, movements may be rushed restless, moderately overactive, overactive, but able to settle with encouragement variable — may have bursts of activity followed by exhaustion R = Restricts occupational participation Unable to maintain energy energy,, lacks focus, lethargic, inactive, or highly overactive • • • • continually restless/pacing or extremely lethargic and inactive difficulty settling, overactive, overactive, may not sleep adequately needs to rest frequently, unable to complete tasks swings from one extreme to the other • works too fast, resulting in risk or danger despite encouragement to pace self 82 MOHOST v.2.0 Expanded Criteria Environment PHYSICAL SPACE Key concepts Self-care productivity and leisure facilities Privacyy and accessibility Privac Stimulation and comfort i.e., Accommodation Buildings Nearby shops and amenities Local surroundings Natural and fabricated contexts in which people behave A person’s person’s skills need to be seen within the context of the environment in which they are assessed, whether this be an occupational therapy department, a day hospital or the hospital as a whole, their home or the wider community F = Facil Facilitates itates occupational participation Space affords a range of opportunities, supports and stimulates valued occupations • • • • environment is identified as a good place to be facilities are available for work, relaxation and recreation environment is familiar no unmet needs identified A = Allows occupational participation Space is mostly adequate, allows daily occupations to be pursued • • contains apparent risks but is still the best option given the circumstances individual may express satisfaction despite apparent unmet needs I = Inhibits occupational participation Affords a limited range of opportunities and curtails performance of valued occupations • • individual is disadvantaged by some aspects of the physical environment some unmet needs identified R = Restricts occupational participation Space restricts opportunities and prevents perfor-mance of valued occupations • • • • facilities are unsuitable lacks opportunities for work, relaxation or recreation major unmet needs identified architectural architectur al barriers impose severe restrictions MOHOST v.2.0 83 Expanded Criteria PHYSICALL RESOURCES PHYSICA Key concepts i.e., Finance Equipment and tools Possessions and transport Safety and independence Clothing and furnishings Aids and adaptations Technology Natural and fabricated things with which people interact F = Facil Facilitates itates occupational participation Allows occupational goals to be achieved with ease, equipment and tools are appropriate • • physical resources meet needs for safety and for self-expression within the environment resources are meaningful and valued A = Allows occupational participation Generally allows occupational goals to be achieved, may present some obstacles • • • • individual may express satisfaction despite apparent unmet needs physical resources meet all basic needs but without any luxuries resources have been restricted recently but remain adequate aids and adaptations are acceptable I = Inhibits occupational participation Impede ability to achieve occupational goals safely, equipment and tools are adequate • • • • • individual may be handicapped due to lack of some resources lack of appropriate resources or funding leads to major inconvenience/personal discomfort resources appear to be inappropriate resources are adequate in the short-term but are not sustainable resources limit personal freedom • aids and adaptations engender ambivalent feelings R = Restricts occupational participation Have major impact on ability to achieve occupational goals, lack of tools lead to high risk • • • 84 individual is unable to make ends meet major handicap results from lack of appropriate resources, including loss of freedom or safety aids and adaptations are not accepted MOHOST v.2.0 Expanded Criteria SOCIAL GROUPS Key concepts i.e., N.B. Family dynamics Friends and social support Work climate Expectations and involvement Cultural groups Religious organisation Fellow student studentss Membership of clubs or societies Expressed emotion Emotional atmosphere Ability to relate to social groups is assessed in RELA RELATIONSHIPS TIONSHIPS Ability to take on roles in social groups is assessed in ROLES F = Facil Facilitates itates occupational participation Social groups offer practical support, values and attitudes support optimal functioning • active participation • • • • • clear opportunities exist for social interaction and collaboration functioning is enhanced by support of social groups members get along well others can be relied upon to lend a hand praise is given for skills, contributions, efforts A = Allows occupational participation Generally able to offer support but may be some under or over involvement • • • • functioning is generally supported influence of social groups on functioning is unclear opportunities exist for necessary interaction and communication skills, contributions and efforts are acknowledged I = Inhibits occupational participation Offer reduced support or detracts from participation, some groups support but not others • • • • • • belongs to few social groups emotional or practical climate detracts from functioning, make things difficult at times has some difficulties getting along with colleagues or family skills, contributions and efforts are not recognised support is unreliable/under or over involvement limits functioning expectations (high or low) may induce stress R = Restricts occupational participation Do not support participation due to lack of interest or inappropriate involvement involvement • • • emotional or practical climate contributes to maladaptive functioning has major difficulties getting along with colleagues or family interaction or collaboration is non-existent or impossibly demanding/conflicting • skills, contributions or efforts are ignored or devalued MOHOST v.2.0 85 Expanded Criteria OCCUPATIONAL OCCUPA TIONAL DEMANDS DE MANDS Key concepts i.e., Activity demands (self-care, productivity and leisure) Cultural conventions Construction of activities Occupational forms Activities associated with major roles “Things to do” within a particular occupation Recognisable, coherent and purposeful behaviours F = Facil Facilitates itates occupational participation Demands of activities match well with abilities, interests, energy and time available • • • • afford satisfaction and enjoyment challenging and stimulating provide a range of opportunities for balanced routine, including self-care, productivity and leisure offer opportunities for success A = Allows occupational participation Generally consistent with abilities, interest, energy or time available, may present challenges • • individual may express satisfaction despite apparent inconsistencies or imbalance demands are limited at present but are normally appropriate I = Inhibits occupational participation Some clear inconsistencies with abilities and interests, or energy and time available • • • • activities may match match either abilities, interests, energy or time but not all some mismatch between demands of tasks and current personal capacity opportunities for involvement in either leisure, domestic or work activities are limited social or cultural responsibilities are a source of stress R = Restricts occupational participation Mostly inconsistent with abilities, construction of activity is under or over demanding • • • 86 poorly suited result in over or under stimulation, excessive excessive stress or boredom self-care activities severely challenge personal capacity MOHOST v.2.0 MOHOST v.2.0: APPENDIX I. OCAIRS Questions — Mental health settings......... ........................ ............................ ............. 88 II. OCAIRS Questions — Forensic settings ................. ................................ ............................ ............. 90 III. OCAIRS Questions — Physical Physical settings/Older settings/Older Adult Mental Health .... 92 UK English Forms IV.. MOHOST Rating Form (UK English IV English)) ...................... ..................................... ............................ ............. 96 V. Multiple Summari Summaries es MOHOST Form (UK English English)) ............. ........................... .............. 100 VI. MOHOST Data Sheet Single Observation Observation Form Form (UK English) ... ........ ....... .. 102 VII. MOHOST Data Sheet Multiple Observation Form (UK English) ... ...... ... 103 USA English Forms VIII.MOHOST Rating Form (USA English) .................. ................................ ............................ .............. 104 IX. Multiple Summaries MOHOST Form Form (USA (USA English).............. ......................... ........... 108 X. MOHOST Data Sheet Single Observation Form (USA English) ....... ....... .. 110 XI. MOHOST Data Sheet Multiple Observation Form (USA English) ... ..... 11 111 1 MOHOST 2.0 87 Appendix I. Recommended OCAIRS Questions in Mental Health Setting • Are you able to over come these limitations and barriers? • Do you prefer to work alone or with others? How well do you work with others? PATTERN PA TTERN OF OCCUPA O CCUPATION TION N.B.: Focus questioning questioning on current status. status. Encourage client to consider all daily activities, being sure to include self-care and activities of daily living. If the client identifies having a health maintainer (patient) role, it is to be considered as a valid role. Successful performance of the role of health maintainer requires considerable effort and may be (or become) a source of pride. • Describe a typical weekday (before you began treatment/this programme/were hospitalised). • Describe a typical weekend day (before you began treatment/this programme/were hospitalised). • Does your daily schedule let you do the things you need and want to do? • Has your daily routine changed (over the last 6 months/since your accident/since your divorce etc.— pick some pivotal event if possible)? How? • Are you satisfied with your current daily routine? • What do you do? What are your major responsibilities? (Parent? (P arent? Spouse? Worker? Student? Homemaker?) • Do you belong to any groups? • (For each role mentioned) How important is ______ to you? Do you enjoy ______? • How well are you able to_______(for each role mentioned)? • What else do you do? What other roles do you fill? SKILLS: COMMUNICATION & INTERACTION SKILLS, PROCESS SKILLS, MOT MOTOR OR SKILLS Note: If unsure of self-report reliability, reliability, ask for examples of performance of each skill in questions. ENVIRONMENT • Where do you live? (location, house, apartment?) Is it easy to get around and get things done? • In the area where you live, are there things to do/ places to go that interest you? • Is there someplace you go to on a regular basis (e.g. work, school, church, the park, the doctor’s office)? Is it easy to get to from your home? • Are there any physical barriers at _______(from above) or at home that prevent you from getting things done? • In terms of activities you would like to participate in, places you would like to go, what if anything prevents you from doing so? (money,, transportation, (money safety concerns, physical barriers) • Are there resources available to help you overcome barriers to getting things done? • Do you spend a lot of time alone? Who do you spend most of your time with? • Who are the most important people in your life right now? • Does what they expect from you match what you like or would like to do? • Would you describe your (work, school, community) setting as supportive? • Do the people or situations in your life place limits on you? • If you need help/support, can you count on family/ friends/community? MOTIVATION MOTIVA TION FOR OCCUPA OCCUPATION TION • Are you able to do the things you want or need to do? (If no) What limits your ability to do things? • • Are you able to concentrate, problem-solve, and make decisions to get things done? What things in your life do you feel you do well, or are proud of? • • Do you have the physical ability to accomplish what you need and want to do? What are some things that have been difficult for you? How did you handle it? • What is the biggest challenge you are currently facing? 88 MOHOST v.2.0 Appendix • How successful do you think you will be over the next six months? • Is your major occupational role such as worker, student, volunteer, caretaker something you enjoy? • What about it interests or satisfies you? What do you like to do with your time outside of work or major occupational role? • Do you have any other interests or hobbies? • (For interests mentioned) How often do you _______? Are you satisfied with the amount of time you are able to spend ________? • What do you value most most in your life? (What is most important to you?) • What are other things or ideals that you value (are important to you)? • How important are these to you? • Are you able to live life in ways that fit with the values you think you should have or try to live up to? • Is there anything about your life that you feel goes against your values? • Do you ever set goals for yourself/make plans for the future? Have you you followed through through on any of them? • What goals do you have for the next week? The next month? • What are you doing to accomplish that? • Do you have any long-term goals (1 year, 5-10 years)? • How will you accomplish those? MOHOST v.2.0 89 Appendix II. Recommended OCAIRS Questions in Forensic Settings • How successful do you think you will be over the next six months? • How do you think you will achieve this? ROLES • Is there anything you thought you may be able to do, but have problems achieving? • • Do you have have any family responsibilities? responsibilities? Are you managing to keep up with these? How much contact do you have with your family or friends? How often do they they telephone/visit/write? telephone/visit/write? VALUES • Are you studying now or have any other responsibilities here? What do you value most in your life? (Who or what is most important to you?) • What are your needs relating to your culture or religion? Are you able to live by your values or ideals at present? If not, why not? • How well are you able to ________ (for each role mentioned)? Are there any other things that are important to you? • Why are these things important? • (For each role mentioned) How important is _______ ___ to you? Do you enjoy_______? READINESS FOR CHANGE • What else do you do? What other roles do you fill? • • • • change in your life (around the time of your index offense/change in in mental state). state). What did you you do, did things become better or worse? HABITS • What would you like your routine to be like? • How is your sleep pattern just now? • Describe a typical weekday (before you were admitted here) • Were your weekends any different? • What is your routine now? Are you able to do what you want to do? • Has your routine changed (since your index offense/ admission here)? If so, how? • Are you satisfied with your current routine? Tell me about a time when you experienced a big • How do you cope when your expected daily routine changes? (e.g. when a session/community leave is cancelled at the last minute/ moving to a secure unit). Is it difficult for for you to adjust? adjust? • How do you react when someone criticises you or challenges you about an issue (e.g. about your behaviour on the ward/in a session)? Do you get angry with them? them? What kinds of things do you you do when you are angry? Do you feel sad? What kind of things do you do when when you feel sad? Etc. INTERESTS PERSONAL CAUSA CAUSATION TION • How well do you think you understand your own abilities? • What things do you feel you do well, or are proud of? • What things have been difficult for you? Can you give me an example of something you have found difficult to cope with recently? How did you handle it? • 90 What is the most difficult thing for you at the moment? MOHOST v.2.0 • What interests interests or hobbies do you have? have? Is there anything that stops you currently participating? • (For each interest mentioned) How often do you ________? Are you satisfied satisfied with the amount of time you are able to ___________? • Are there any activities here that you would like to do in this environment? • (If applicable) Do you have an interest interest in a criminal lifestyle? (e.g., (e.g., drugs/alcohol/theft)? drugs/alcohol/theft)? What is good or bad about the criminal lifestyle? lifestyle? Would you like to live like this? Appendix • What would you like to do with your time when you leave hospital? PHYSICAL ENVIRONMENT • How do you feel about your physical environment here? How could it be improved? • Is it better or worse than where you were living before? Why? • How do you feel about being in a locked environment? What effect does this have on your being able to move around the hospital? • Are there places that you would like to go that you are currently not able to access? SKILLS • Are you able to concentrate, problem-solve, and • make decisions to get things done? Do you have any physical complaints which limit what you do during the day? • Are you able to overcome any problems you have? • Do you complete tasks to your satisfaction (e.g., too fast, too slow)? • • Do you prefer to work alone or with others? How well do you work with others? Do you feel comfortable in a group situation? Are there resources that you can use on the ward to compensate for your limited access to other parts of the building? • Do you manage to get things done that are important to you? • Are you able to keep your possessions accessible? • Does your environment afford enough privacy? • Do you feel the physical environment has an effect on your behaviour? GOALS • Do you ever set goals for yourself/make plans for the future? Have you followed through with any of them? • What goals do you have for the next week? The next month? • How are you going to achieve them? • Do you have any long-term goals (1 year, 5-10 years)? • How will you accomplish them? • Do you feel able to set goals at present? SOCIAL ENVIRONMENT • How do you find the other patients on the ward? • Do you spend a lot of time alone? Who do you spend most of your time with? Do you have any friends here/outwith at the hospital? • Who are the most important people in your life right now? • Do you hear from them/see them as often as you would like to? • • Where do you feel most vulnerable or at risk? If you need help or support, who do you turm to? Can you talk to your family/friends/staff? • Are you able to form trusting relationships? INTERPRETATION OF PAST EXPERIENCES • When you think about your life so far, do you think you have had a good deal or a bad deal? • What was happening to you around the time of your index offense? • Have you even taken drugs or alcohol? If so, how has your life been influenced by your drug taking/ alcohol problems? • Give an example of the best period of your life. • Give an example of the worst period of your life. • Thinking about your life so far, when you had to make an important choice about something (say a new job or choosing friends), were you able to do this freely, freely, or were there things that got in the way? • What effect do you think your past has had on your current situation? MOHOST v.2.0 91 Appendix II. Recommended OCAIRS Questions in Physical Ph ysical Settings/Older Adult Mental Health Settings SOCIAL ENVIRONMENT • In your local area, are there places you go to regularly (i.e. church, bingo, drs, visit family etc), do you manage to get there ok? We have looked at what social support you have at home, I would like to move on to look at your actual house and Firstly, I would like to look at how things are for you at home in regards to family or homecare support and how this helps you with your daily life. local community to find out what equipment and support you have from that. • Do you live alone? • • Do you have friends/ family/neighbours who visit you regularly? What type of house is it? How many rooms do you have? • Who owns your property? • Do you have any home helps? • How do you manage the stairs at home? (Banisters) • Are you happy with the help they (family/ home helps) provide you with at the moment? (Restricted/ more support/ more independence) • What is the layout of the house? • At your front/ back door do you have steps? (Rails) • Do you use a walking aid? • If you needed help or support do you feel you could count on your friends/ family/ home helps? • Are you able to keep in touch with family/friends? PHYSICAL ENVIRONMENT We have at your home situation I would now like to find outlooked a bit more about your daily routine. MORNING SELF-CARE ROUTINE I’d like you to talk me through your morning routine. (NB: As each activity is discussed a range of questions are asked I’d for each activity.) Activity Bed Transfer Toileting Bathing/Washing Dressing Chair Transfer For each activity ask Do you feel confident doing this activity? (PC) Do you find this activity enjoyable/satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete the activity? (PS) Do you have the full responsibility for doing the activity? (R) Does someone help you? (SE) Where do you carry out this activity? Do you have any equipment to help you? (PE) Do you have a routine when doing this activity? (H) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your morning self-care routine? (H) 92 MOHOST v.2.0 Appendix BREAKFAST I’d I’ d like you to talk me through your breakfast routine. Activity Making Breakfast For each activity ask Do you make you own breakfast? (R) What do you have for breakfast? , Do you have a routine when making your breakfast?, When do you have breakfast? (H) Do you feel confident with this activity? (PC) Do you find this activity enjoyable/ satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Does someone help you? (SE) Where do you have your breakfast? (PE) Do you use any equipment to help you make your breakfast? (PE) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your breakfast routine? (H) MORNING How do you typically spend your mornings? Activity Do you go out? Attend any clubs/day centres? Meet friends? Do you go out to work? Do you have responsibilities? For each activity ask Do you feel confident doing this activity (PC) Do you find this activity enjoyable/satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Do you have the full responsibility for doing activity? (R) Does someone help you? (SE) Where do you carryout this activity? Do you have any equipment to help you? (PE) Do you have a routine when doing this activity? (H) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your morning routine? (H) LUNCH I’d I’ d like you to talk me through your lunch routine. Activity Making lunch For each activity ask Do you make you own Lunch? (R) What do you have for lunch? , Do you have a routine when making your lunch? , When do you have lunch? (H) Do you feel confident with this activity? (PC) Do you find this activity enjoyable/ satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Does someone help you? (SE) Where do you have your lunch? (PE) Do you use any equipment to help you make your lunch? (PE) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your lunch routine? (H) MOHOST v.2.0 93 Appendix AFTERNOON How do you spend your afternoons? Activity Do you go out? Attend any clubs/day centres? Meet friends? Do you go out to work? Do you have responsibilities? For each activity ask Do you feel confident doing this activity (PC) Do you find this activity enjoyable/satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Do you have the full responsibility for doing activity? (R) Does someone help you? (SE) Where do you carry out this activity? Do you have any equipment to help you? (PE) Do you have a routine when doing this activity? (H) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your afternoon routine? EVENING MEAL I’d I’ d like you to talk me through your evening meal routine. Activity Evening meal For each activity ask Do you make you own evening meal? (R) What do you have for evening meal? , Do you have a routine when making your evening meal? , When do you have evening meal? (H) Do you feel confident with this activity? (PC) Do you find this activity enjoyable/ satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Does someone help you? (SE) Where do you have your evening meal? (PE) Do you use any equipment to help you make you evening meal? (PE) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your evening meal routine (H) EVENINGS How do you typically spend your evenings? Activity Do you go out? Attend any clubs/day centres? Meet friends? Do you go out to work? Do you have responsibilities? For each activity ask Do you feel confident doing this activity (PC) Do you find this activity enjoyable/satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Do you have the full responsibility for doing activity? (R) Does someone help you? (SE) Where do you carry out this activity? Do you have any equipment to help you? (PE) Do you have a routine when doing this activity? (H) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your evening routine? 94 MOHOST v.2.0 Appendix NIGHT Activity Undressing/self care Undressing/self Bed transfers Do you have to get up to the toilet overnight? Do you have responsibility for supporting a partner to get up during the night? For each activity ask Do you feel confident doing this activity (PC) Do you find this activity enjoyable/satisfying? (I) How important is this activity for you? (V) Can you physically do the activity? (MS) Do you have enough concentration to complete activity? (PS) Do you have the full responsibility for doing activity? (R) Does someone help you? (SE) Where do you carry out this activity? Do you have any equipment to help you? (PE) Do you have a routine when doing this activity? (H) Have you had difficult past experiences doing this activity? (PstE) Are you satisfied with your over-night routine? GOALS • What things do you want to be able to do that you are currently unable? • What things are important for you to be able to get back to do at home? • Do you ever set realistic plans for the future? Do you feel you have managed to achieve any of these plans? • Do you have any plans for the next week? • How do you feel you will manage to accomplish that? • • • You said you have had a better/ worse/normal worse/nor mal life; can you identify a good time in your life? And a bad? • How did these ups and downs affect you? Often how we have managed in the past helps us manage in the future, at the moment you have XXXX and that is why you you are in hospital. This may mean things may be different for you when you are discharged from hospital. READINESS FOR CHANGE • You described XXX as a good/bad time that must have been a big event, how did you adjust to this change? Do you have any longer term plans for the foreseeable future? • Our daily routines change overtime do you feel you cope with changes to your routines? What do you think you will do to achieve these goals? • If someone gives you advice or feedback about your life, how does it make you feel, how do you react to We often set goals and sometimes looking back over past experiences helps us figure out how we will achieve future goals. INTERPRETATION OF PAST EXPERIENCES • Overall in your life do you feel you have had the typical ups and downs? • Do you feel your life has been better or worse than normal? this? We have looked at many things within you life and all this information helps us together to plan your occupational therapy treatment while you are in hospital you said you are worried/ concerned/ not managing XXX. Are these things you would like to look at while you are in hospital to help you when you are discharged??? MOHOST v.2.0 95 Appendix Model of Human Occupation Screening Tool (MOHOST) Rating Form (UK English) Client: _____________________________________ Assessor: _________________________________ Age: _______ Date of birth: _____/_____/_____ Designation: ______________________________ Gender: Male o Signature: _________________________________ Female o Identification code: __________________________ White o Ethnicity: Black o Asian o Date of first contact: _____/_____/_____ Date of assessment: _____/_____/_____ Other: _________________________ Treatment settings: _________________________ Health condition: ____________________________ __________________________________________ F A I R Rating Scale Facilitates occupational participation Allows occupational participation Inhibits occupational participation Restricts occupational participation Analysis of Strengths & Limitations _______________________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Summary of Ratings Motivation for Occupation ss e c c u S f o n ito ta c e p x E tiy li b A f o l a is a r p p A Pattern of Occupation s e c i o h C ts e r te In y itl i b a t p a d A e itn u o R Communication & Interaction Skills lls i k S l a b r e v n o N y itl i b si n o p s e R s e l o R n io ss e r p x E l a c o V n ito a sr e v n o C Process Skills s ip h s n ito la e R e g d le w o n K tiy il b o M & e r tu s o P g n i v l o sm e l b o r P n o it a si n a g r O g n i m i T Environment: ____________ Motor skills tr o ff E & h t g n e tr S n ito a in d r o o C s e c r u o s e R l a c si y h P e c a p S l a ic s y h P y g r e n E s d n a m e D l a n o it a p u c c O s p u o r G l ia c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 96 MOHOST v.2.0 Appendix MOTIVATION FOR OCCUPATION Appraisal of Ability Understanding of current strengths & limitations Accurate belief in skill, accurate view of competence Awareness of capacity Expectation of Success Optimism & hope Self-efficacy, sense of control & self-identity F A I R Accurately assesses own capacity, recognises strengths, aware of limitations Reasonable tendency to over/under estimate own abilities, recognises some limitations Difficulty understanding strengths and limitations without support Does not reflect on skills, fails to realistically estimate own abilities Comments: F A I R Anticipates success and seeks challenges, optimistic about overcoming obstacles Has some hope for success, adequate self-belief but has some doubts, may need encouraging Requires support to sustain optimism about overcoming obstacles, poor self-efficacy Pessimistic, feels hopeless, gives up in the face of obstacles, lacks sense of control Comments: Interest Expressed enjoyment Satisfaction Curiosity Participation Choices Appropriate commitment Readiness for change Sense of value and meaning Preferences and goals F A I R Keen, curious, lively, tries new occupations, expresses pleasure, perseveres, appears content Has adequate interests that guide choices, has some opportunities to pursue interests Difficulty identifying interests, short-lived, ambivalent about choice of occupations Easily bored, unable to identify interests, apathetic, lacks curiosity even with support Comments: F A I R Clear preferences & sense of what is important, motivated to work towards occupational goals Mostly able to make choices, may need encouragement to set and work towards goals Difficulties identifying identifying what is important or setting and working towards goals, inconsistent Cannot set goals, impulsive, chaotic, goals are unattainable or based on anti-social values Comments: PATTERN OF OCCUPATION Routine Balance Organisation Organisati on of habits Structure Productivity Adaptability Anticipation of change Habitual response to change Tolerance of change F A I R Able to arrange a balanced, organised and productive routine of daily activities Generally able to maintain or follow an organised and productive daily schedule Difficulty organising balanced, productive routines of daily activities without support Chaotic or empty routine, unable to support responsibilities and goals, erratic routine Comments: F A I R Anticipates change, alters actions or routine to meet demand, (flexible/ac (flexible/accommodating) commodating) Generally able to modify behaviour, may need time to adjust, hesitant Difficulty adapting to change, reluctant, passive or habitually overreacts to change Rigid, unable to adapt routines or tolerate change Comments: Roles Role identity Role variety Belonging Involvement Responsibility Role competence Meeting expectations Fulfilling obligations Delivering responsibilities F A I R Identifies with a variety of roles, has a sense of identity/bel identity/belonging onging that comes from roles Generally identifies identifies with one or more roles and has some sense of belonging from these roles Limited identification identification of roles, role overload or conflict, poor sense of belonging Does not identify with any role, negligible role demands, no sense of belonging Comments: F A I R Reliably completes activities and meets the expectations related to role obligations Copes with most responsibilities, meets most expectations, able to fulfil most role obligations Difficulty being able to fulfil expectatio expectations ns and meet role obligations without support Limited ability to meet demands of activities or obligations, unable to complete role activities Comments: MOHOST v.2.0 Appendix COMMUNICATION COMMUNICA TION AND INTERACTION SKILLS Non-verbal skills Eye contact Gestures Orientation Proximity Conversation Disclosing Initiating & sustaining Speech content Language Vocal expression Intonation Articulation Volume Pace Relationships Co-operation Collaboration Rapport Respect F A I R Appropriate (possibly spontaneous) body language given culture and circumstances Generally able to display or control appropriate body language Difficulty controlling/displaying appropriate body language (delayed/limited/disinhibited) Unable to display appropriate body language (absent/incongruent/unsafe/aggressive) F A I R Comments: Appropriately initiates, discloses and sustains conversation (clear/direct/open) Generally able to use language or signing to effectively exchange information Difficulty initiating, disclosing or sustaining conversation (hesitant/ab (hesitant/abrupt/limite rupt/limited/irrelevant) d/irrelevant) Uncommunicative, Uncommunicati ve, disjointed, bizarre or inappropriate disclosure of information Comments: F A I R Assertive, articulate, uses appropriate tone, volume and pace Vocal expression is generally appropriate in tone, volume and pace Difficulty with expressing self (mumbling/ (mumbling/pressured pressured speech/monotone) Unable to express self (unclear/too quiet or loud/too loud/too fast or too passive) Comments: F A I R Sociable, supportive, aware of others, sustains engagement, friendly, relates well to others Generally able to relate to others and mostly demonstrates awareness of others’ needs Difficulty with co-operation or makes few positive relationships Unable to co-operate with others or make positive relationships relationships Comments: PROCESS SKILLS Knowledge Seeking & retaining information Knowing what to do in an activity Knowing how to use objects F A I R Seeks and retains relevant information, know how to use tools appropriately Generally able to seek and retain information and know how to use tools Difficulty knowing how to use tools, difficulty in asking for or retaining information Unable to use knowledge/ knowledge/tools, tools, does not retain information, asks repeatedly repeatedly for same info Comments: Timing F Sustains concentration, concentration, starts, sequences and completes occupation at appropriate times Initiation Completion Sequencing Concentration AI R Generally to concentrate, start, sequence and initiating complete, sequencing occupations& completing Fluctuatingable concentrati concentration on or distractibl distractible, e, difficulty initiating, Unable to concentrate, unable to initiate, sequence or complete occupations Organisation F A I R Arranging space and objects Neatness Preparation Gathering objects Problem-solving Judgement Adaptation Decision-making Responsiveness Comments: Efficiently searches for, gathers & restores tools/objects needed in occupation (neat) Generally able to search, gather and restore needed tools/objects Difficulty searching for, gathering and restoring tools/objects, appears disorganised/untidy Unable to search for, gather and restore tools and objects (chaotic, messy) Comments: F A I R Shows good judgement, anticipates difficulties and generates workable solutions (rational) Generally able to make decisions based on difficulties that arise Difficulty anticipating and adapting to difficulties that arise, seeks reassurance Unable to anticipate and adapt to difficulties that arise and makes inappropriate decisions Comments: 97 98 MOHOST v.2.0 Appendix MOTOR SKILLS Posture & Mobility Stability Alignment Positioning Walking Reaching Bending Balance Co-ordination Transfers Manipulation Ease of movement Fluidity Fine motor skills Strength & Effort Grip Handling Moving Lifting Transporting Calibrating F A I R Stable, upright, independent, flexible, good range of movement (possibly agile) Generally able to maintain posture and mobility in occupation, independently independently or with aids Unsteady at times despite any aids, slow or manages with difficulty Extremely unstable, unstable, unable to reach and bend or unable to walk F A I R Comments: Co-ordinates body parts with each other, uses smooth fluid movements (possibly dextrous) Some awkwardness or stiffness causing minor interruptions to occupations Difficulty co-ordinating movements (clumsy/tremulous/awkward/stiff) Unable to co-ordinate, manipulate and use fluid moveme movements nts Comments: F A I R Grasps, moves & transports objects securely with adequate force/speed (possibly strong) Strength and effort are generally sufficient for most tasks Has difficulty with grasping, moving, transporting objects with adequate force and speed Unable to grasp, move, transport objects with appropriate force and speed (weak/frail) Comments: Energy Endurance Pace Attention Stamina F A I R Comments: ENVIRONMENT Physical space Self-care, productivity and leisure facilities Privacy & accessibility Stimulation Stimulati on & comfort Physical resources Finance Equipment & tools Possessions & transport Safety & independence Social groups Family dynamics Friends & social support Work climate Expectations & involvement Occupational demands Activity demands (self-care, productivityy and leisure) productivit Cultural conventions Construction of activities Maintains appropriate energy levels, able to maintain tempo throughout occupation Energy may be slightly low or high at times, able to pace self for most tasks Difficulty maintaining energy (tires easily/evidence of fatigue/distractible/restless) Unable to maintain energy, lacks focus, lethargic, inactive or highly overactive Environment in which skills have been assessed: __________________________________ F A I R Space affords a range of opportunities, supports & stimulates valued occupations occupations Space is mostly adequate, allows daily occupations to be pursued Affords a limited range of opportunities and curtails performance of valued occupations Space restricts opportunities and prevents performance of valued occupations Comments: F A I R Enable occupational goals to be achieved with ease, equipment and tools are appropriate Generally allow occupational goals to be achieved, may present some obstacles Impede ability to achieve occupational goals safely, equipment and tools are inadequate Have major impact on ability to achieve occupational goals, lack of tools lead to high risks Comments: F A I R Social groups offer practical support, values and attitudes support optimal functioning Generally able to offer support but may be some under or over involvement Offer reduced support, or detracts from participation, participation, some groups support but not others Do not support participation due to lack of interest or inappropriate involvement involvement Comments: F A I R Demands of activities match well with abilities, interests, energy and time available Generally consistent with abilities, interest, energy or time available, may present challenges Some clear inconsistencies with abilities and interest, or energy and time available Mostly inconsistent with abilities, construction of activity is under or over-demanding Comments: MOHOST v.2.0 99 Appendix Multiple Summaries Model of Human Occupation Screnning Tool Tool (MOHOST) (UK English) Client: _______________________________ Assessor: ____________ _______________________ _________________ ______ Date of birth: ________/________/________ Designation: _________________________ ID: __________________________________ Signature: ____________________________ Date of Assessmen Assessment: t: _______/____ _______/_______/_______ ___/_______ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt il i b A f o asl ari p p A se ic o h C set re t n I e n ti u o R Communication & Interaction Skills lls ik S la b re -v n o N yt il i b si n o sp e R s le o R Facilitates occupation participation Allows occupation participation Inhibits occupation participatio participation n Restricts occupation participati participation on Environment: ___________ ________________________ _________________________ ______________ __ Pattern of Occupation yt lii ab t p a d A F A I R Process Skills n o ssi er p xE acl o V n o i ast re v n o C s p i sh n o i atl e R eg d le w o n K Motor skills n o tia is n ag r O g in m iT tiy li b o M & er tu s o P g in lv o -s m le b o r P Environment rt o ff E & h gt n er tS n o i at n i rd o o C se cr u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n o tia p u cc O s p u o r G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R Date of Assessmen Assessment: t: ________/___ ________/________/_______ _____/_________ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt il i b A f o l sai ar p p A Pattern of Occupation se ic o h C set re t n I yt lii ab t p a d A e n it u o R Environment:: ____________ Environment _________________________ __________________________ _____________ Communication & Interaction Skills lls ik S la b re -v n o N yt lii b si n o p se R s le o R Process Skills n o ssi re p xE acl o V n o i ast re v n o C s p i sh n o i atl e R eg d le w o n K Motor skills n o tia is n ag r O g in m iT tiy li b o M & er tu s o P g in lv o -s m le b ro P Environment rt o ffE & h gt n er tS n o i at n i rd o o C se cr u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n o tia p u cc O s p u o r G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R Date of Assessmen Assessment: t: ________/___ ________/________/_______ _____/_________ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt lii b A f o asl i ra p p A Pattern of Occupation se ic o h C set re t n I yt il i ab t p a d A e n ti u o R Environment:: ____________ Environment _________________________ __________________________ _____________ Communication & Interaction Skills s lli kS la b re -v n o N yt lii b si n o p se R s le o R Process Skills n o ssi er p xE acl o V n o i ast re v n o C s p i sh n o i atl e R eg d le w o n K Motor skills n ito a is n ag r O g in m iT y itl i b o M & re tu s o P g in lv o -s m le b o r P Environment rt o ff E & h gt n er tS n o i at n i rd o o C se rc u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n ito a p u cc O s p u ro G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R I R 100 MOHOST v.2.0 Appendix Multiple Summaries Model of Human Occupation Screening Tool (MOHOST) (UK English) Client: ____________________________________ Assessor: __________________________________ Date of birth: ________/________/________ ID: _______________________________________ Designation: _______________________________ Signature: _________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ MOHO MO HOST ST v.2 .2..0 10 101 1 Appendix ) h ils g n E K U ( ) n ito a v r e s b O le g in S t(e e h S ta a D l o o T g in n e e r c S n ito a p u c c O n a m u H f o l e d o M ts n e m m o C o o sti p rae h T al n o i at p u cO t: n e m n o irv n e t n e m ss ses A : d es se ss a g in e b n o tia p u cc O :t n e m ss es sa f o et a D r: so se ss a f o e m a N n o i at p cii rat p al n o i at p u cc o se att il cai F t: n ile C : h tr i b f o tea D f aft s rt o p p u S T O : n o i at n gi se D n o i at p cii rat p al n o i at p u cc o s w o ll A n o i at p cii rat p al n o i at p u cc o st ci rt se R n o tia ip c tir a p la n o tia p u cc o tis b i h In t:s i p ar e h T la n ito a p u cc O f o er tu a n iSg n ee s t o N S F A I R / N :e d o c ID g n it a R : le a c S g itn a R te a lu a v E to a e r A R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N se g n el al ch sk ee s/ e d ri p s w o h S set re t n i se art st n o m e d d n a yt si o ri u c s w o h S )L D A ( s it b a h e itn u o r s in ta in a M eg n a h /c n ito p u r is d h ti w se p o /c d lte te s s in a m e R p u o r /kg s ta th i w d e lv o v in lye itv ca se m o ce B n o ssi er p xe al reb vn o n et ai r p o r p p a se s U n o i ast re v n o c et ai r p o r p p a s n ait s u s d n a se ati ti n I lye ta ir p o r p p a t n e m ip u q e se s /u se s o o h C ec n e u q e /ks s ta t u o h g u o r h t s u c fo s in ta in a M rt o f m o c d n a s u l u m i st sr ef f o ec a p S ec n e d n e p e d n i d n a yt ef as w o l al se cr u o se R rt o p p u s se d vi o r p n o i cat re t n i ali c o S tss er te i/n s ite lii b a h tca m y itv it ca f o s d n a m e D s n o i att i m il & s h gt n er st f o sse n er a w a s w o h S noi t avi t o M d te n ier o lao g i/s se c n er fee r p se fi it n e d I noi t a pucc O f o nr ett aP n o ssi se e h t n i se it lii b si n o p se r sl lfi u F n o ssi er p xe acl o v et ai r p o r p p a se s U sr e h t o h it w s tea re p -o o c d n a to s tea le R slli kS noi t car et nI &. mmo C n o i sah f yl re rd o n a n i sk r o W slli kS ss ec or P s m el b o r p e m o cr ev o o t s n o i cat se ifi d o M y tl n e d n e p e d in se ils i b o M liy sa e lsa ir tea m d n a ls o to s tea l u ip n a M tr o ffe d n a h tg n e trs tea ir p o r p p a se s U slli kS r ot o M ec a p tea ir p o r p p a d n a yg re n e s in ta in a M t ne mnori v nE rm o F T S O H O M e h t h ti w n o i ct n u j n o c n i esd u e b yl n o d l u o sh d n a rm o F T S O H O M ev i at m m u s e h rt o f t n e m ss es sa ev i at rm o f a si si h T 102 MOHOST v.2.0 Appendix ) h s li g n E K U ( ) n ito a v r e s b O le itp l u (M t e e h S ta a D l o o T g in n e e r c S n ito a p u c c n o i at p i ci rt a p l a n o it a p cu c o s et at il cai F n ito a ip itc r a p l a n io tp a u cc o s w llo A n o ti a ip itc ra p la n ito n o tia ip itc ra p la n ito a p u cc o tis b i h In a p u c c o ts icr ts e R n ee s t o N S R / N F A I o o sp ti ar e h T al n o i at p u c c O r: o ss es s A f o e m a N f aft s rt o p p u S T O : T O f o er tu a n ig S : n o it a n gi s e D : n t e m ss e ss a f o e t a D O n a m u H f o l e d o M :t n eliC : h rti b f o e atD :e d o D Ic : tn e m n o ir v n e t n e m ss e ss A : d e ss e ss a g in e b n ito a p u c c O R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N s eg n lle a h c s ke e /se d ir p s w o h S ts re te in s te a trs n o m e d d n a tiy s io r u c s w o h S ) L D (A s it b a h e itn u o r s in ta in a M gen a h /c n ito p u r is d h ti w s e p o /c d lte te s s in a m e R p u o r /g ks ta th i w d e lv o v in ly e itv c a se m o c e B n io ss er p xe la b re -v n o n te iar p o r p p a se s U n ito as re v n o c te iar p ro p p a s in tas u s d n a s tea it i In lye ta ir p o r p p a t n e m ip u q e se s /u se s o o h C e c n e u q e /s ks ta t u o h g u o r th s u c fo s in ta in a M tr fo m o c d n a s lu u itm s sr ffe o e ca p S ec n e d n e p e d in d n a tye f as w llo a se cr u o s e R rt o p p u s se d vi o r p n o it ca r et n i l ai c o S tss er te i/n s ite lii b a h tca m tiy itv ca f o s d n a m e D s n ito tia ilm & s h tg n e trs f o ss e n er a w a s w o h S noi t avi t o M d te n ier o la o g i/s s ec n er fee r p se ifi t n e d I noi t a pucc O f o nr ett aP n io ss es e h t in s ite il i b is n o p se r ls fi l u F n io ss er p xe la c o v te iar p o r p p a se s U sr e h t o h it w s tea r e p -o o c d n a to s te la e R slli kS noi t ca -r et nI &. mmo C s m le b o r p e n m o o i c h sa re v f o lyr o t e s d n r o tio n a ca in se fi i ksr o d o W M slli kS ss ec or P y tl n e d n e p e d in se ils i b o M liy s ae lsa ir te a m d n a ls o to s te la u ip n a M tr o ffe d n a h t g n e trs te iar p o r p p a se s U slli kS r ot o M e ca p te iar p o r p p a d n a y gr e n e s in ta in a M t ne mnori v nE m r o F T S O H O M e h t h ti w n o ti c n u j n o c n i d e s u e b y l n o d l u o sh d n a m r o F T S O H O M e v it a m m u s e th r o ft n e sm s e ss a e v it a m r o f a si si h T MOHO MO HOST ST v.2 .2..0 10 103 3 Appendix Model of Human Occupation Occupat ion Screening Tool Tool (MOHOST) Rating Ra ting Form (USA English) Client: _____________________________________ Assessor: _________________________________ Age: _______ Date of birth: _____/_____/_____ Designation: ______________________________ Gender: Male o Signature: _________________________________ Female o Identification code: __________________________ Date of first contact: _____/_____/_____ Ethnicity: Caucasian o African American o Date of assessment: _____/_____/_____ Asian o Hispainc/Latino o Other: ___________ Treatment settings: _________________________ Health condition: ____________________________ __________________________________________ F A I R Rating Scale Facilitates occupational participation Allows occupational participation Inhibits occupational participation Restricts occupational participation Analysis of Strengths & Limitations _______________________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Summary of Ratings Motivation for Occupation ss ec c u S f o n o i att ce p xE tiy li b A f o la is ar p p A Pattern of Occupation se ic o h C ts er te In tiy il b ta p a d A e n it u o R Communication & Interaction Skills lls ik S la b re -v n o N tiy il b is n o p se R se l o R n o ssi er p xE acl o V n o tia sr ev n o C Process Skills s p i sh n o i atl e R eg ed l w o n K tiy li b o M & er tu s o P g in lv o -s m le b o r P n o i azt i n a gr O g n i m iT Environment: ____________ Motor skills rt o ff E & h gt n er tS n o ti a n i rd o o C se cr u o se R acl si y h P ec a p S acl si y h P y gr e n E s d n a m e D la n ito a p u c c O s p u o r G ali c o S F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 104 MOHOST v.2.0 Appendix MOTIVATION FOR OCCUPATION Appraisal of Ability Understanding of current strengths & limitations Accurate belief in skill, accurate view of competence Awareness of capacity Expectation of Success Optimism & hope Self-efficacy, sense of control & self-identity F A I R Accurately assesses own capacity, recognizes strengths, aware of limitations Reasonable tendency to over/under estimate own abilities, recognizes some limitations Difficulty understanding strengths and limitations without support Does not reflect on skills, fails to realistically estimate own abilities Comments: F A I R Anticipates success and seeks challenges, optimistic about overcoming obstacles Has some hope for success, adequate self-belief but has some doubts, may need encouraging Requires support to sustain optimism about overcoming obstacles, poor self-efficacy Pessimistic, feels hopeless, gives up in the face of obstacles, lacks sense of control Comments: Interest Expressed enjoyment Satisfaction Curiosity Participation Choices Appropriate commitment Readiness for change Sense of value and meaning Preferences and goals F A I R Keen, curious, lively, tries new occupations, expresses pleasure, perseveres, appears content Has adequate interests that guide choices, has some opportunities to pursue interests Difficulty identifying interests, short-lived, ambivalent about choice of occupations Easily bored, unable to identify interests, apathetic, lacks curiosity even with support Comments: F A I R Clear preferences & sense of what is important, motivated to work towards occupational goals Mostly able to make choices, may need encouragement to set and work towards goals Difficulties identifying identifying what is important or setting and working towards goals, inconsistent Cannot set goals, impulsive, chaotic, goals are unattainable or based on anti-social values Comments: PATTERN OF OCCUPATION Routine Balance Organization Organizati on of habits Structure Productivity F A I R Able to arrange a balanced, organized and productive routine of daily activities Generally able to maintain or follow and organized and productive daily schedule Difficulty organizing balanced, productive routines of daily activities without support Chaotic or empty routine, unable to support responsibilities and goals, erratic routine Comments: Adaptability F Anticipates change, alters actions or routine to meet demand, (flexible/ac (flexible/accommodating) commodating) Anticipation of change Habitual response to change Tolerance of change AI R Generally able to modify behavior, may passive need time to adjust, hesitant Difficulty adapting to change, reluctant, or habitually overreacts to change Rigid, unable to adapt routines or tolerate change Comments: Roles Role identity Role variety Belonging Involvement Responsibility Role competence Meeting expectations Fulfilling obligations Delivering responsibilities F A I R Identifies with a variety of roles, has a sense of identity/bel identity/belonging onging that comes from roles Generally identifies identifies with one or more roles and has some sense of belonging from these roles Limited identification identification of roles, role overload or conflict, poor sense of belonging Does not identify with any role, negligible role demands, no sense of belonging Comments: F A I R Reliably completes activities and meets the expectations related to role obligations Copes with most responsibilities, meets most expectations, able to fulfil most role obligations Difficulty being able to fulfil expectatio expectations ns and meet role obligations without support Limited ability to meet demands of activities or obligations, unable to complete role activities Comments: MOHOST v.2.0 105 Appendix COMMUNICATION COMMUNICA TION AND INTERACTION SKILLS Non-verbal skills Eye contact Gestures Orientation Proximity Conversation Disclosing Initiating & sustaining Speech content Language Vocal expression Intonation Articulation Volume Pace Relationships Cooperation Collaboration Rapport Respect F A I R Appropriate (possibly spontaneous) body language given culture and circumstances Generally able to display or control appropriate body language Difficulty controlling/displaying appropriate body language (delayed/limited/disinhibited) Unable to display appropriate body language (absent/incongruent/unsafe/aggressive) Comments: F A I R Appropriately initiates, discloses and sustains conversation (clear/direct/open) Generally able to use language or signing to effectively exchange information Difficulty initiating, disclosing or sustaining conversation (hesitant/ab (hesitant/abrupt/limite rupt/limited/irrelevant) d/irrelevant) Uncommunicative, Uncommunicati ve, disjointed, bizarre or inappropriate disclosure of information Comments: F A I R Assertive, articulate, uses appropriate tone, volume and pace Vocal expression is generally appropriate in tone, volume and pace Difficulty with expressing self (mumbling/ (mumbling/pressured pressured speech/monotone) Unable to express self (unclear/too quiet or loud/too loud/too fast or too passive) Comments: F A I R Sociable, supportive, aware of others, sustains engagement, friendly, relates well to others Generally able to relate to others and mostly demonstrates awareness of others’ needs Difficulty with cooperation or makes few positive relationships Unable to cooperate with others or make positive relationships relationships Comments: PROCESS SKILLS Knowledge Seeking & retaining information Knowing what to do in an activity Knowing how to use objects F A I R Seeks and retains relevant information, know how to use tools appropriately Generally able to seek and retain information and know how to use tools Difficulty knowing how to use tools, difficulty in asking for or retaining information Unable to use knowledge/ knowledge/tools, tools, does not retain information, asks repeatedly repeatedly for same info Comments: Timing F Sustains concentration, concentration, starts, sequences and completes occupation at appropriate times Initiation Completion Sequencing Concentration A I R Generally able to concentrate, start, sequence and complete occupations Fluctuating concentration concentration or distractibl distractible, e, difficulty initiating initiating,, sequencing & completing Unable to concentrate, unable to initiate, sequence or complete occupations Organization F A I R Arranging space and objects Neatness Preparation Gathering objects Problem-solving Judgement Adaptation Decision-making Responsiveness Comments: Efficiently searches for, gathers & restores tools/objects needed in occupation (neat) Generally able to search, gather and restore needed tools/objects Difficulty searching for, gathering and restoring tools/objects, appears disorganized/untidy Unable to search for, gather and restore tools and objects (chaotic, messy) Comments: F A I R Shows good judgement, anticipates difficulties and generates workable solutions (rational) Generally able to make decisions based on difficulties that arise Difficulty anticipating and adapting to difficulties that arise, seeks reassurance Unable to anticipate and adapt to difficulties that arise and makes inappropriate decisions Comments: 106 MOHOST v.2.0 Appendix MOTOR SKILLS Posture & Mobility Stability Alignment Positioning Walking Reaching Bending Balance Coordination Transfers Manipulation Ease of movement Fluidity Fine motor skills Strength & Effort Grip Handling Moving Lifting Transporting Calibrating F A I R Stable, upright, independent, flexible, good range of movement (possibly agile) Generally able to maintain posture and mobility in occupation, independently independently or with aids Unsteady at times despite any aids, slow or manages with difficulty Extremely unstable, unstable, unable to reach and bend or unable to walk Comments: F A I R Coordinates body parts with each other, uses smooth fluid movements (possibly dextrous) Some awkwardness or stiffness causing minor interruptions to occupations Difficulty coordinating movements (clumsy/tremulous/awkward/stiff) Unable to coordinate, manipulate and use fluid moveme movements nts Comments: F A I R Grasps, moves & transports objects securely with adequate force/speed (possibly strong) Strength and effort are generally sufficient for most tasks Has difficulty with grasping, moving, transporting objects with adequate force and speed Unable to grasp, move, transport objects with appropriate force and speed (weak/frail) Comments: Energy Endurance Pace Attention Stamina F A I R Comments: ENVIRONMENT Physical space Self-care, productivity and leisure facilities Privacy & accessibility Stimulation Stimulati on & comfort Physical resources Finance Equipment & tools Possessions & transport Safety & independence Social groups Family dynamics Friends & social support Work climate Expectations & involvement Occupational demands Activity demands (self-care, productivityy and leisure) productivit Cultural conventions Construction of activities Maintains appropriate energy levels, able to maintain tempo throughout occupation Energy may be slightly low or high at times, able to pace self for most tasks Difficulty maintaining energy (tires easily/evidence of fatigue/distractable/restless) Unable to maintain energy, lacks focus, lethargic, inactive or highly overactive Environment in which skills have been assessed: __________________________________ F A I R Space affords a range of opportunities, supports & stimulates valued occupations occupations Space is mostly adequate, allows daily occupations to be pursued Affords a limited range of opportunities and curtails performance of valued occupations Space restricts opportunities and prevents performance of valued occupations Comments: F A I R Enable occupational goals to be achieved with ease, equipment and tools are appropriate Generally allow occupational goals to be achieved, may present some obstacles Impede ability to achieve occupational goals safely, equipment and tools are inadequate Have major impact on ability to achieve occupational goals, lack of tools lead to high risks Comments: F A I R Social groups offer practical support, values and attitudes support optimal functioning Generally able to offer support but may be some under or over involvement Offer reduced support, or detracts from participation, participation, some groups support but not others Do not support participation due to lack of interest or inappropriate involvement involvement Comments: F A I R Demands of activities match well with abilities, interests, energy and time available Generally consistent with abilities, interest, energy or time available, may present challenges Some clear inconsistencies with abilities and interest, or energy and time available Mostly inconsistent with abilities, construction of activity is under or over-demanding Comments: MOHO MO HOST ST v.2 .2..0 10 107 7 Appendix Multiple Summaries Model of Human Occupation Screnning Tool Tool (MOHOST) (USA English) Client: _______________________________ Assessor: ____________ _______________________ _________________ ______ Date of birth: ________/________/________ Designation: _________________________ ID: __________________________________ Signature: ____________________________ Date of Assessmen Assessment: t: _______/____ _______/_______/_______ ___/_______ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt il i b A f o asl ari p p A se ic o h C set re t n I e n it u o R Communication & Interaction Skills lls ik S la b re -v n o N yt lii b si n o p se R s le o R Facilitates occupation participation Allows occupation participation Inhibits occupation participatio participation n Restricts occupation participati participation on Environment: ___________ ________________________ _________________________ ______________ __ Pattern of Occupation yt il i ab t p a d A F A I R Process Skills n o i sse r p xE acl o V n o i ast re v n o C s p i sh n o i atl e R eg d le w o n K Motor skills n ito a iz n ag r O g in m iT y itl i b o M & re tu s o P g in lv o -s m le b o r P Environment rt o ff E & h gt n er tS n o i at n i rd o o C se cr u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n ito a p u cc O s p u ro G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R Date of Assessmen Assessment: t: ________/___ ________/________/_______ _____/_________ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt lii b A f o asl i ra p p A Pattern of Occupation se ic o h C set re t n I yt il i ab t p a d A e n ti u o R Environment:: ____________ Environment _________________________ __________________________ _____________ Communication & Interaction Skills s lli kS la b re -v n o N yt il i b si n o p se R s le o R Process Skills n o ssi er p xE acl o V n o ti sar ev n o C s p i sh n o i atl e R eg d le w o n K Motor skills n o tia iz n ag r O g in m iT tiy il b o M & er tu s o P g in lv o -s m le b o r P Environment rt o ff E & h gt n er tS n o i at n i rd o o C se rc u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n ito a p u cc O s p u o r G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R Date of Assessmen Assessment: t: ________/___ ________/________/_______ _____/_________ Motivation for Occupation ss ec c u S f o n o i att ce p xE yt il i b A f o asl ari p p A Pattern of Occupation se ic o h C set re t n I yt lii ab t p a d A e n it u o R Environment:: ____________ Environment _________________________ __________________________ _____________ Communication & Interaction Skills lls ik S la b re -v n o N yt il i b si n o p se R s le o R Process Skills n o ssi re p xE acl o V n o i ast re v n o C s p i sh n o i atl e R eg d le w o n K Motor skills n o tia iz n ag r O g in m iT tiy li b o M & er tu s o P g in lv o -s m le b o r P Environment rt o ffE & h gt n er tS n o i at n i rd o o C se cr u o se R la ics y h P ec a Sp la ics y h P yg re n E s d n a m e D la n o tia p u cc O s p u o r G la ic So F F F F F F F F F F F F F F F F F F F F F F F F A A A A A A A A A A A A A A A A A A A A A A A A I I I I I I I I I I I I I I I I I I I I I I I I R R R R R R R R R R R R R R R R R R R R R R R R 108 MOHOST v.2.0 Appendix Multiple Summaries Model of Human Occupation Screening Tool (MOHOST) (USA English) Client: ____________________________________ Assessor: __________________________________ Date of birth: ________/________/________ Designation: _______________________________ ID: _______________________________________ Signature: _________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ANALYSIS OF STRENGTHS & LIMITATIONS Date of Assessment: _____/_____/_____ _____/_____/_____ Environment: _____________________________ _____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ MOHO MO HOST ST v.2 .2..0 10 109 9 Appendix ) h ils g n E A S U ( ) n ito a v r e s b O le g in t(S e e h S ta a D l o o T g in n e e r c S n ito a p u c c ts n e m m o C o o sti p ar e h T al n o i at p u c O t: n e m n o irv n e t n e m ss es s A : d es se ss a g in e b n ito a p u cc O :t n e m ss es sa f o et a D :r o ss es sa f o e m a N n o i at p cii rat p al n o i at p u cc o se att li cai F O n a m u H f o l e d o M t: n ile C : h tr i b f o tea D f aft s rt o p p u S T O : n o i at n gi se D n o i at p cii rat p al n o i at p u cc o s w o ll A n o i at p cii rat p al n o i at p u cc o st ci rt se R n ito a ip itc ra p la n ito a p u cc o tis b i h In t:s i p ar e h T la n o tia p u cc O f o re tu a n iSg n ee s t o N S F A I R / N :e d o c ID g n it a R : le a c S m r o F T S O H O M e h t th i w n o cn ti u j n o c n i esd u e b yl n o ld u o sh d n a g itn a R te a lu a v E to a e r A R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N se g n el al ch sk ee s/ e d ri p s w o h S set re t n i se t rat s n o m e d d n a yt si o ri u c s w o h S )L D (A tis b a h e n ti u o r s in ta in a M eg n a h /c n ito p u r is d h ti w se p o /c d lte te s s in a m e R p u o r /kg s ta h ti w d e lv o v in lye itv ca se m o ce B n o ssi er p xe al reb vn o n et ai r p o r p p a se s U n o i ast re v n o c et ai r p o r p p a s n ait s u s d n a se ati it n I lye ta ir p ro p p a t n e m ip u q e se s /u se s o o h C ec n e u q e /ks s ta t u o h g u ro h t s u c fo s in ta in a M rt o f m o c d n a s u l u m i st sr ef f o ec a p S ec n e d n e p e d n i d n a yt ef as w o l al se cr u o se R rt o p p u s se d vi ro p n o i cat re t n i ali c o S tss er te i/n s ite il i b a h tca m tiy v tic a f o s d n a m e D s n o i att i m il & s h gt n er st f o ss e n er a w a s w o h S noi t avi t o M d te n ier o lao g i/s se c n er fee r p se fi it n e Id noi t a pucc O f o nr ett aP n o ssi es e h t n i se it il i b si n o p se r sl fi l u F n o ssi er p xe acl o v et ai r p o r p p a se s U rse th o h it w s tea re p o o c d n a to s tea le R slli kS noi t car et nI &. mmo C n o i sah f yl re rd o n a n i sk r o W slli kS ss ec or P s m el b o r p e m o cr ev o o t s n o i cat se fi i d o M lty n e d n e p e d in se ilz i b o M y ils ae lsa ir tea m d n a ls o to s tea l u ip n a M tr ffo e d n a th g n e trs tea ir p o r p p a se s U slli kS r ot o M ec a p tea ir p ro p p a d n a yg re n e s in ta in a M t ne mnori v nE m r o F T S O H O M ev i at m m u s e h ro t f t n e m ss es sa ev i at m r o f a si si h T 110 MOHOST v.2.0 Appendix ) h ils g n E A S U ( ) n ito a v r e s b O le itp l u (M t e e h S ta a D l o o T g in n e e r c S n ito a p u c c O n a m u H f o l e d o M n o i at p i ci rt a p l a n o it a p u cc o s et at il cai F n o tia ip itc r a p l a n o tiap u cc o s w o ll A n ito a ip itc ra p la n ito n ito a ip itc ra p la n io tp a u cc o s it ib h In au p c c o ts icr ts e R n ee s t o N S R / N F A I o o sp ti ar e h T al n o i at p u c c O :r o ss es s A f o e m a N f aft s rt o p p u S T O : T O f o er tu a n ig S : n o it a n gi s e D : n t e m ss e ss a f o e t a D :t n eliC : h rti b f o e atD :e d o c ID : tn e m n o ir v n e t n e m ss e ss A : d e ss e ss a g in e b n ito a p u c c O R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N R R R R R R R R R R R R R R R R R R R R R R R R I I I I I I I I I I I I I I I I I I I I I I I I A A A A A A A A A A A A A A A A A A A A A A A A F F F F F F F F F F F F F F F F F F F F F F F F S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N S / N s eg n lle a h c s ke e /se id r p s w o h S ts er te in s te a trs n o m e d d n a y its io r u c s w o h S ) L D A ( tis b a h e itn u o r s in ta in a M ge n a h /c n ito p u r is d h it w s e p o /c d lte te s s in a m e R p u o r /g ks ta h it w d e lv o v in ly ev tic a se m o c e B n io ss er p xe la b re -v n o n te iar p ro p p a se s U n ito as re v n o c te iar p o r p p a s in tas u s d n a s tea tii In lye ta ir p ro p p a t n e m ip u q e se s /u se s o o h C e c n e u q e /s ks ta t u o h g u o r h t s u c fo s in ta in a M tr fo m o c d n a s lu u itm s sr ffe o e ca p S ec n e d n e p e d in d n a tye f as w llo a se cr u o s e R rt o p p u s se d vi o r p n o it ca r et n i l ai c o S tss re te i/n s ite il i b a h tca m tiy v ti ca f o s d n a m e D s n ito tia ilm & s h tg n e trs f o ss e n er a w a s w o h S noi t avi t o M d te n ier o la o g i/s s ec n er fee r p se fi it n e d I noi t a pucc O f o nr ett aP n io ss es e h t in s ite lii b is n o p se r ls fi l u F n io ss re p xe la c o v te iar p ro p p a se s U sr e h t o h ti w s te ar e p o o c d n a to s te la e R slli kS noi t ca -r et nI &. mmo C s m le b o r p e n m io o c h sa re v f o lyr o t e s d n r o ito n a ca in se ifi ksr o d o W M slli kS ss ec or P lty n e d n e p e d in se ilz i b o M liy s ae lsa ir te a m d n a ls o to s tea l u ip n a M tr ffo e d n a th g n e trs te iar p ro p p a se s U slli kS r ot o M e ca p te iar p o r p p a d n a y gr e n e s in ta in a M t ne mnori v nE m r o F T S O H O M e h t th i w n o it c n u j n o c n i d se u e b y l n o d l u o sh d n a m r o F T S O H O M e v it a m m u s e h t r o f t n e m ss e ss a e v it a rm o f a si si h T
