Client  Centered  Framework  of  Care  for  people  with  complex  

Care  Needs    

Michelle  French,  OT    &    

Marg  Darcy,  PT  

Client  Centered  Framework  

•  Integrated  model  of  care;  •  Person  centered;  •  Theore<cally  based;  • Mo<va<ng;  •  Strength  based;  •  Cost  effec<ve  and  •  Empowering!  

Why  is  this  needed  ?  • Need   to   reexamine   the   way   in   which   we   work   with   this  popula<on;  

•  The   number   of   people   with   high   physical,   cogni<ve   and  communica<on  impairments  is  growing  and  surviving  longer;  

•  This   popula<on   has   high   front   end   costs   (i.e.   acute   medical  care),  but  there  is  not  gap  at  the  other  end;  

•  This   popula<on   is   vulnerable   and   safety   and   comfort   is  paramount.  

The  Person-­‐Environment-­‐Occupation  Model  of  Occupational  Performance  

• Interplay  determines  occupa<onal  performance  

Person Task/Occupation

Environment Source: The Person-Environment-Occupational Model: A transactive Approach to occupational performance, Law. et al 1996 Canadian Journal of Occupational Therapy 63 (1), 9 – 23.

Changes  over  Time  

Changing  needs…  •  Support  needs  change  with  <me  depending  on  the  person,  environment  and  occupa<on;  

•  Role  of  the  team  is    to  proac<vely  manage  the  natural  process  of  change;  

• Unmet  needs  !  challenging  behaviour  

                             “unmet  needs  behaviours”  

• Outcome  that  we  aim  for  is  preventa<ve  based;  

• Maintaining  the  person  as  an  individual;  

•  Provision  of  some  level  of  joy  in  the  person’s  life.  

Person  centered…..  • Establish  goals  as  a  team;    

•  Use  of  standard  tools  to  establish  goals    

•  Wessex  Head  injury  matrix    WHIM  

•  Goal  AWainment  Scales  -­‐  GAS  

•  Canadian  Occupa<onal  Performance  Model  -­‐  COPM  

•  SMART    goals    

• Develop  a  plan  –  who,  does  what,  when;  

• Review  and  adjust  as  necessary.  

Wessex  Head  Injury  Matrix  WHIM  

• What  does  it  assess?  •  Recovery  in  pa<ents  with  severe  head  injury.    • Who  is  it  suitable  for?  

•  Pa<ents  with  a  severe  head  injury,  aged  16  years+.  •  Could  be  adapted  for  younger   individuals,  but  care   is  needed  and  there  is  no  research  to  support  this.    

GAS  Scales    

COPM  •  Looks  at  three  major  life  areas  

•  Self-­‐care;  •  Produc<vity  and    •  Leisure  •  Person  self  rates  their  performance  and  sa<sfac<on  

SMART  goals  

Developing  a  plan  

• Consider:  -­‐  • Equipment  needed  

• Environment  –  inclusive  of  rou<nes  and  regimes    

• The  person’s  strengths  and  the  meaningfulness  for  the  person  with  their  life  context;  

• SAFETY  &  COMFORT  

Safety  

• Without   individuals   feeling   safe   and  having   an   environment   of   safety,   they  then   have   reluctance   of   taking   part   in  the   city   of   being   ac<ve.   They   wind   up  wan<ng   to   leave   the   city.   That's   more  detrimental.  

Dick  Powell    

Chris  &  Russel  example    

Russell  &  Chris    

Safety  &  Comfort    • People  want  to  contribute;  

• PAIN!  

• Biomechanical  model  vs  a  func<onal  model;  

• Need  to  inves<gate  and  explore  HOW  can  people  with  complex  needs  contribute;  

• Contribu<on   cannot   happen   if   the   person   is   in  pain   or   there   is   no   meaning   in   the   ac<vity   for  them.    

Safety  includes  …    • Effec<ve  posi<oning;  • Appropriate  equipment;  

• Gentle  manual  handling;  

• Well  training  primary  care  team;    

• Well  training  aWendant  care  team.  

Integrated  and  controlled  sensory  input  

SIGHT     SOUND    

MOVEMENT    

TOUCH    

Why  does  this  approach  work???  

•  Acknowledgement  that  all  people  have  something  to  offer  and  contribute  

•  Agreed   method   of   care,   which   is   based   on   an   integrated  model  of  care;  

• Overlap  between  therapists                  Transdisciplinary  approach    •  TRUST,  openness  and  coordina<on/case  management    •  Based  on  transference  of  knowledge  and  skills;  •  Frequent  feedback  and  adjustment  of  program;  

•  Cri<cal  to  the  success  of  this  approach  is:  

•  The  selec<on  and  training  of  aWendant  carers;  

•  Careful  prescrip<on  of  equipment  to  meet  the  client's  needs  

•  Therapists  training  carers,  family  and  friends;  

•  The  establishment  of  a  key  worker  role;  

•  Regular  support  of  aWendant  care  workers;  

Procedural  Learning    

• Manual  documen<ng  detailed  sequencing  of  all  personal  care  interven<ons  and  associated  sensory  prompts;  

• Video  visually  presen<ng  the  sequencing  of  interven<ons  and  the  slow  pace  required  for  interven<ons  in  real  <me  

Motivation  !  

•  Ac<vity  must  be  meaningful  for  the  client;  

•  Ac<vity  should  be  strength  based  –  looking  at  what  the  client  can  do;  

•  All  ac<vi<es  should  be  implemented  in  a  procedural  manner,  every  <me;  

•  There  must  be  some  degree  of  ‘JOY’  and  it  is  essen<al  that  the  person  feels  SAFE  and  COMFORTABLE  

Empowering    •  For  the  individual  

•  Safety  and  comfort;  

•  Choice  making;  

•  For  the  carers  and  families  

•  Valued  members  of  the  team  •  Increase  in  confidence  

Cost  effective    •  High  cost  at  the  beginning  

•  Establishment  of  the  program    

•  Provision  of  support  documenta<on  and  DVD’s      

•  Daily  care  plan    •  Health  management  plan    

• Maintenance  –  ongoing  care    

•  Peeks  and  troughs    •  Reten<on  of  carers    

Ongoing  questions  •  This  approach  has  enabled  successful  management  of   clients  with  complex  needs  over  long  periods  of  <me  while  providing  them  with  choice,  QoL,  safety  and  comfort;  

•  The   challenge   now   is   to   get   governments   and   agencies   to  commit  :  -­‐  

• The  money  • Time    

• Training    • Individualised  care  

Everyone  deserves  JOY!