OT process and the 4 levels of Intervention

By Stephanie Shane OTR/L

Pass the OT (www.passtheot.com)

OT Process:

 Referral: Before working with a patient, the occupational therapist needs to get a referral from a
family member, caregiver, physician, regional center, employer, etc. Occupational therapists
cannot work with any patient because they may have a therapeutic need, there needs to be a
referral. Therapists can also refer to other therapeutic practitioners.
o If a teacher detects a student in the school setting may have a delay, the student needs to
go to the physician. The therapist cannot work with the patient.
o Visual acuity issues=refer to the optometrist
o Eye disorders= refer to the ophthalmologist
o Not following dietary recommendations=refer to the dietician
o Speech delay=refer to the speech language pathologist
o Gait disorders=refer to the physical therapist

A referral can be very specific such as asking for a neoprene splint or general by asking to test for
a developmental delay.

 Screening: After the referral, the occupational therapist needs to screen the patient in order to
determine if an evaluation is needed. A screening is used to obtain preliminary information of the
patient’s situation. A screening is normally quick and easy to administer such as using the ACL
screening tool. The screening also includes chart and medical review, checklists, and observation
in the classroom, clinic, or hospital.
 Evaluation: An occupational therapist can use a standardized assessment such as the Peabody,
functional independence measure (FIM), or the sensory profile. If a standardized assessment is
used, then the therapist needs to follow the assessment word for word and step by step. An
occupational therapist can also use a non-standardized assessment.
o For example, if the therapist is trying to test a patient for visual perception, the therapist
can ask the patient to go to the fruit bowl and pick up an orange. If the patient picks up an
apple, then it is indicated that the patient does not perceive an orange as an orange.
 Intervention: In order to incorporate client centered interventions occupational therapists can go
through for 4 levels of intervention (adjunctive, enabling, purposeful, and occupation based) for
successful treatment.
o Adjunctive: This is the initial step in the intervention process in order to prepare the
patient for occupational performance. These methods are often used to prepare the client
for meaningful activity and are often seen in the acute care setting. Education, physical
agent modalities, and resources are used at this level. Examples include:
 A customized exercise pamphlet with stretches and strengthening exercise that
the client can do at home 1-2 times every day
 Providing electrotherapeutic agents to improve muscle strength, modulate pain,
and relax targeted muscles with other physical agent modalities
 Educating the client on ways to prevent pain by including exercise, diet, sleep,
and stress avoidance into their daily life
 Teaching relaxation, breathing, mediation, and coping techniques
 Providing the client with community resources, workshops, and associations so
the client can have access to a support system
  Verifying whether the client was provided with the right wheelchair for the right
purpose
o Enabling Activities: These are exercises or ways to condition the body in order to get to
the clients end goal. Together the occupational therapist and the client can work on range
of motion, muscle conditioning, schedules, pacing activities, coping strategies, time
management, and medication management. Other examples include:
 Practicing exercise techniques such as stretching and strengthening with an
elastic band or with other types of adaptive equipment, such as a reaching stick,
in order to do their morning grooming routine.
 The client can write in a daily journal to document performance, accidents,
injuries, and emotions
o Purposeful activities: These activities have a relevant goal and are meaningful to the
client. If the client’s goal is to garden at home, the patient will practice gardening in the
therapy clinic with adaptive equipment. Other examples include:
 Work tabletop practice activities, practice boards, simulators, driving simulators,
and hooks for mastering dressing along with methods that stimulate the activity.
 Equipment such as wheelchairs, communication devices, environmental control
objects, and other ambulatory aids.
 Practicing feeding, dressing, mobility, communication, art, sports, and work with
the therapist in the clinic or hospital.
 Practicing combing their hair with a universal cuff
o Occupation-Based Activity: Interventions at this level include client centered activities
and goals. The therapist’s involvement begins to decrease as the client performs ADLs,
IADLs, play, and leisure to his or her own maximum capacity. Examples include:
 Cooking eggs for their kids in their home
 Playing softball in their community with their friend
 Discharge: Planning for discontinuation of services begins at the evaluation. Goals may or may
not be reached but occupational therapy services are terminated.

Questions about the OT Process

1. A manufacturing company consults with an OT about the increased number of back injuries
among the employees. The company wants all employees in identified jobs to be trained in injury
prevention. What part of the service delivery process is the OT involved in?

2. The OT works with a person following a MI in an outpatient clinic three times weekly for
strengthening to improve work related skills. What part of the service delivery process is the OT
involved in?

3. A 30 year old woman with a brain stem CVA presents for a wheelchair assessment with her
mother. She independently uses an augmentative communication device. She has been seated in
a manual wheelchair for 5 years and is dependent on her aging mother and father for all mobility
 and activities. During the assessment, the mother informs the OT that she is not ready for her
daughter to regain independence. What part of the service delivery process is the OT involved
in?

4. An inpatient who has borderline personality disorder has been hospitalized due to an exacerbation
of suicidal and self-mutilating behavior. An initial evaluation has been completed and it indicates
that the patient is functioning at Allen Cognitive level V (exploratory actions). The patient reports
being overwhelmed by a new personal relationship, experiencing job dissatisfaction, and feeling a
lack of control in many daily situations. What part of the service delivery process is the OT
involved in?

5. An individual with chronic undifferentiated schizophrenia is referred to a day hospital. The

referring psychiatrist notes that the client’s positive symptoms have responded well to a new
medication, but the negative symptoms remain. What part of the service delivery process is the
OT involved in?

6. An OTR is evaluating a client who has an ulnar nerve injury at the wrist level of the right
dominant extremity. What part of the service delivery process is the OT involved in?

7. A therapist has just received a referral for a resting hand splint. The therapist is in the process of
determining the need for an in depth evaluation. What part of the service delivery process is the
OT involved in?

Answers:

1. Screening
2. Intervention
3. Evaluation
4. Intervention
5. Screening
6. Evaluation
7. Screening