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Models of Practice

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Title: Models of Practice


1
Models of Practice
  • Lecture 7

2
A successful outcome begins with choosing the
most appropriate AT for a person. How can we best
do that?
3
  • Assistive technology is designed to provide
    functional benefits and to facilitate
    participation for a person with a disability
    (World Health Organization, 2002).
  • However, research shows that there is a high
    level of device abandonment, even with what
    appears to be a well matched device (M. J.
    Scherer Craddock, 2002).
  • Studies on device abandonment, often explained by
    inefficient assessments and intervention
    processes (Judge, 2002 M. J. Scherer Craddock,
    2002), have led to the development of assistive
    technology specific outcome measures to evaluate
    the satisfaction and effectiveness of a device.
  • There is a lack of evidence- based procedures
    that are specific to assistive technology
    provision.

4
  • Although the International Classification of
    Functioning (ICF) was not specifically developed
    to guide assistive technology assessment, the
    literature shows that it lends itself as a
    descriptive model for the assistive technology
    assessment process.
  • ICF captures the complex aspects of the impact of
    assistive technology and its service delivery
    process and can assist the professional in
    decision-making (Bernd, Van Der Pijl, De Witte,
    2009).

5
  • When assistive technology is successful, it
    reduces or removes barriers, to allow the person
    to take part in activities (Jutai, Fuhrer,
    Demers, Scherer, DeRuyter, 2005).
  • The ICF checklist assists the service provider to
    elicits what capabilities and limitations the
    users experience in activities and participation
    related domains.
  • Examples of relevant domains are learning and
    applying knowledge speaking getting around
    inside and outside the home self-care
    interpersonal relationships and social life etc

6
Matching people with assistive technology is
complex because peoples expectations of and
reactions to technologies are complex. Reactions
are highly individualised. Scherer M. J.
(2005). Assistive technology in education for
students who are hard of hearing or deaf.
Handbook of special education technology research
and practice. Knowledge by Design. (2005).
Whitefish Bay, WI.
7
Sometimes the evaluation is driven by a request
for a specific piece of equipment. In these
instances, the focus is on the equipment, and the
students problem is not identified. Kurtz J.
(2003). Assistive technology in schools how do
we make it work? OT Practice. Aug 18 8 (15),
16-20.
8
ATD Selection Framework

Environmental Factors  Cultural and Financial
Priorities Legislation Policy Attitudes of Key
Others
Personal Factors
AT Decision-Making and Device Selection
  • Resources
  • Family/Friends Significant Others
  • Financial

       Follow-Up Trialling, Use and Realization
of Benefit
Assessment of Functional ATD Need  (Objective
Need)
Knowledge and Information
Consumer
Expectations
Provider
 Assessment of ATD Predisposition   (Subjective
Need)
Personal Preferences and Priorities
Scherer, M., Jutai, J., Fuhrer, M., Demers, L.
DeRuyter, F. (2007). A framework for modeling
the selection of assistive technology devices
(ATDs). Disability and Rehabilitation Assistive
Technology, 2(1), 1-8.
9
Purpose of Outcomes measurement
  • Ensure good outcomes for individuals
  • Provide evidence for successful practices
  • Augment AT knowledge base
  • Document need to funding and policy makers

10
Consumer-Centered Outcome Measurement
  • An integrated approach which utilizes a range of
    mechanisms to provide consumers with adequate
    information
  • to make informed choices
  • to monitor how well solutions meet their goals,
    preference and ongoing requirements
  • to enable them to direct the process in order to
    optimize their utilization on the solution.

11
Context
  • ENVIRONMENTAL

PERSONAL
Functioning Disability
Body Functions Structures
Activities Participation
12
QOL
13
Individual
Influences on Activities Participation  
  • Milieu
  • Policies and mandates
  • Financial/funding
  • Provider knowledge
  • Attitudes of others

C O N T E X T
Environmental Factors
  • Individual Predisposition
  • Resources and knowledge
  • Personal perspectives, priorities
  • Prior experiences
  • Expectations

Personal Factors
  • Outcomes
  • Degree of AT use
  • Perceived benefit/gain from
  • use
  • Subjjective well-being/quality of life

 
14
  • It is no longer sufficient to show we have
    improved a persons functioning. We must show we
    have enhanced
  • participation.

15
Challenges to Evaluating Outcomes
  •   AT is often provided as part of a number of
    interventions and it is therefore difficult to
    ascertain the degree to which the AT is
    responsible for the outcome
  •   Difficult to define the expected outcomes
  •   Consumer diversity and individualization makes
    comparisons difficult

16
We know what to measure, but how? With what
tools?
  • PIADS for assessing the increase in the users
    sense of competence, self-esteem and adaptability
  • QUEST for assessing the persons satisfaction
    with the device
  • MPT for assessing person-technology fit -- how
    well the device matches the needs,
    characteristics, preferences and expectations of
    the person -- and enhances participation
  • Plus others that were designed to address AT

17
PIADS
  • 26 self-report items on a 7-point scale ranging
    from decreases (-3) to increases (3). Items are
    competence, happiness, independence, adequacy,
    confusion, efficiency, self esteem, productivity,
    security, frustration, usefulness, self
    confidence, expertise, skillfulness, well-being,
    capability, quality of life, performance, sense
    of power, sense of control, embarrassment,
    willingness to take chances, eagerness to try new
    things, ability to participate, adapt to
    activities of daily living and take advantage of
    opportunities.
  • 3 scales, competence, self-esteem and
    adaptability

Jutai J Day H. (2002). Psychosocial Impact
of Assistive Device Scale (PIADS). Technology and
Disability, 14, 107-111.
18
PIADS
  • Good psychometric properties after a slow
    start (contact lens and eyeglasses use)
  • Quality of life is assessed with only 1 item and
    a separate items exists for well-being
  • Some items lack face validity regarding impact on
    AT use
  • Consumers report difficulty in distinguishing
    power and control

19
QUEST
  • 12 self-report items on a 5-point scale ranging
    from not at all satisfied (1) to very satisfied
    (5). Items are Dimensions, weight, adjustment,
    safety, durability, ease of use, comfort,
    effectiveness, service delivery, repairs
    servicing, professional services, and follow-up
  • 2 scales Device and Service

Demers, L., Weiss-Lambrou, R., Ska, R.
(1997). Quebec User Evaluation of Satisfaction
with assistive Technology (QUEST) A new outcome
measure. In S. Sprigle (Ed.), Proceedings of the
RESNA 97 Annual Conference (pp. 94-96). Arlington
(VA) RESNA Press.
20
  • The only evidence based assistive technology
    specific model, developed to match the ICF and
    its checklist found in the literature, is the
    Matching Person and Technology (MPT) model
  • Bernd, et al., 2009
  • Karlsson, P (2006) ICF A Guide to Assistive
    Technology Decision-making University of Western
    Sydney

21
Matching Person with Technology
  • The MPT model explores assistive technology use
    and perceived quality of life/participation of
    predetermined assistive technology users and
    non-users. The foundation of the instrument is
    the user and their environments. It assists the
    assessment process as a collaborative
    decision-making tool designed to determine the
    most appropriate assistive technology solution
    for a given individual. Separate instrument for
    children and adults
  • Mapped on ICF
  • Several instruments make up the MPT assessment
    package with versions of each to be completed by
    the consumer and by the service provider.
    Depending on what is been assessed each scale can
    be used independently They include

22
MPT assessment instruments
  • The Survey of Technology Use (SOTU)
  • The Assistive Technology Device Predisposition
    Assessment (ATD PA)
  • The Workplace Technology Predisposition
    Assessment (WPPA)
  • The Health Care Technology Predisposition
    Assessment (HCT PA)
  • The Educational Technology Predisposition
    Assessment (ET PA)

23
IMPT
  • The MPT was modified and re-validated for an
    Irish audience Irish Matching Person with
    Technology
  • Impact of Assistive Technology on the quality of
    Life and participation, student self-esteem and
    autonomy of students (Craddock 2002)
  • Expanded to include subset on QOL participation
  • 45 students assessed using the IMPT, longitudinal
    study, pre and post

24
MPT (IMPT)
  • Environment Educational Environment Subscale
  • Technology Educational Technology Subscale
  • User-Capability
  • Quality of Life
  • Self-evaluation
  • Educational Goal
  • Additional information, transport, family support
    etc

25
MPT IMPT models
  • It was developed to address the environment, the
    person and the technology, factors that need to
    be considered when evaluating a persons need for
    assistive technology
  • The MPT supports a collaborative partnership
    between the service providers and the user

26
  • The Assistive Technology Device Predisposition
    Assessment consumer form (ATD PA), a part of the
    MPT assessment battery, is compatible with ICF
    and measures the impact of technology using the
    ICF domains.
  • The ATD PA items ask the user to rate their
    predisposition to using the assistive technology
    that is being considered, to better match
    technology with the person and therefore minimize
    device abandonment. ATD PA is developed for
    adults

27
IMPT
  • Pre-test was used to capture the stage of
    technology experience, their quality of life,
    their degree of support and level of self-esteem
    before the assistive technology was introduced.
  • Post-test was used to measure these qualities
    after the client has used the technology for two
    years, in order to investigate if assistive
    technology had made a difference

28
MPT (Specifically the ATD PA)
  • It has 66 self-report items on a 5-point scale
    and yes/no questions, all mapped to the ICF
  • 4 scales Functional capabilities, Subjective
    well-being, personal factors, and person-device
    match with each item mapped to the ICF

Scherer, M.J. (1989). The Assistive
Technology Device Predisposition Assessment (ATD
PA) Consumer Form. Webster, NY The Institute
for Matching Person Technology, Inc.
29
Functional Abilities
  • ATDPA Section A Abilities ICF
    Classification Body Functions (b)
  • __________________________________________________
    ______
  • 1. Seeing b210 Seeing functions
  • 2. Hearing b230 Hearing functions
  • 3. Speech b3 Voice and speech
    functions
  • 4. Understanding,remembering b144 Memory b164
    higher level cognitive

  • functions b1670 reception of
    language
  • 5. Physical strength/stamina b730, b735,
    b740 Muscle functions
  • 6. Lower body use b760 Control of
    voluntary movement functions
  • 7. Grasping and use of fingers b760 Control
    of voluntary movement functions
  • 8. Upper body use b760 Control of
    voluntary movement functions
  • 9. Mobility b770 Gait pattern functions

30
Subjective Well-Being
  • ATDPA Section B. Well-Being, QOL ICF
    Classification Activities Participation (d)
  • __________________________________________________
    _____________________
  • 10. Personal care, household activities d5
    Self-care d630, d640 Household tasks
  • 11. Physical comfort well-being b280 (pain)
  • 12. Overall health b4, b5, b6,
    b8
  • 13. Freedom to go wherever desired d4 Mobility
    d460 Moving around in different locations,
    d470, Using transportation d475 Driving
  • 14. Participation in desired activities d2
    General tasks demands d9 Community, social

  • civic life
  • 15. Educational attainment d810-d839 Education
  • 16. Employment status/potential d840-d859 Work
    and employment
  • 17. Family relationships d760, e310 Family
    relationships
  • 18. Close, intimate relationships d770 Intimate
    relationships, e320 Friends
  • 19. Autonomy, self-determination d177 Making
    decisions
  • 20. Fitting in, belonging d7 Interpersonal
    interactions, d910 Community life
  • 21. Emotional well-being b152 Emotional
    functions d240 Handling stress and

  • other psychological
    demands

31
Person Factors
  • ATDPA Section C Psychosocial factors
    ICF Classification Contextual Factors
  • __________________________________________________
    ____________________
  • Attitudes and support from family,
    Support from family (e310, 410),
  • friends Support
    from friends (e320,420)
  • Temperament Personal, Temperament
    personality (b126)
  • Mood Emotional functions (b152)
  • Autonomy and self-determination Making
    decisions(d177), Higher cognitive
    functions (b164), Attitudes (e4)
  • Self-esteem Personal, Emotional
    functions (b152)
  • Readiness for technology use
    Incentive to act (b1301), Forming an opinion

  • (b1645)

32
Characteristics of the AT Device
  • ATDPA Section D. Device Match ICF
    Products Technology Matching (e115-e145)

  • __________________________________________________
    _______________________________
  • Help achieve goals General tasks and
    demands (d2)
  • Improve QOL All Activities
    Participation (d), Energy (b130), Sleep (b134),

  • Emotional functions (b152)
  • Knows how to use Learning and applying
    knowledge (d1), Support (training) from

  • health professionals (e355)
  • Secure with use Psychomotor function
    (b147), Emotional functions (b152)
  • Fits with routine Carrying out daily
    routine (d230)
  • Capabilities for use Specific mental
    functions (b140-bb180), Neuromusculoskeletal

  • movement related functions
    (b7)

33
MPT (Specifically the ATD PA)
Good psychometric properties. Predictive of a
match. Useful when evaluating a persons
device expectations and realization of benefit
with a specific device. Computerized scoring
and interpretations available Requires a
commitment of at least 45 minutes to complete
(longer if other forms are also used such as
History of Support use) and to involving the
consumer in the process Many professionals
are uncomfortable with asking consumers personal
questions.
34
More information on consumer AT experiences and
the other measures
 
  • de Jonge, D., Scherer, M Rodger, S. (2006)
  • Assistive Technology in the Workplace St
    Louis, Mosby.

 
Scherer, M. J. (2005). Living in the State of
Stuck How Assistive Technology Impacts the
Lives of People with Disabilities, Fourth
Edition. Cambridge, MA Brookline Books.
35
COPM
  • Canadian Occupational Performance Measure is an
    individualized evaluation tool
  • uses a semi-structured interview to assist
    consumers to identify specific problems in
    occupational performance areas such as self-care,
    productivity and leisure
  • The importance of each problem is then rated on a
    scale of 1 (not important) to 10 (very
    important). Then, the client rates current level
    of performance and satisfaction with their
    performance on scales of 1(unable to perform, not
    satisfied) to 10 (able to perform, extremely
    satisfied).

36
COPM
  • Allows the client to reassess their
    performance on the identified tasks at various
    intervals
  • Very individualized
  • Requires considerable time
  • Not focused on AT

37
IPPA
  • Individualized Prioritised Problem Assessment
    (IPPA) is an interview similar to format of COPM.
  • clients identify problems and rate the importance
    and degree of difficulty experienced in carrying
    out an activity on a 7-point scale (1 no
    importance at all, not at all difficult, 7most
    important, too difficult to perform activity).
  • Provides a list of daily activities similar to
    activities listed in the ICF. Asks the AT user to
    rate how the AT has addressed each problem on a
    5-point scale with 2 being much less than
    expected and 2 being much more than expected.

38
IPPA
  • Enables issues to be prioritised and the
    baseline performance to then be compared with
    performance following acquisition of the device
  • Assesses activities and not participation
  • Requires consumers to be able to identify
    their problems
  • Has not been used extensively in outcome
    studies.

39
SCAI (SIVA Cost Analysis Instrument)
  • Designed to help clinicans estimate the economic
    aspects of AT provision
  • Using SCAI involved 3 steps describing the
    objectives of the AT programme
  • Establishing the sequence and timing of
    interventions
  • Compiling cost for each AT solution

40
SCAI
  • The social cost is the main indicator of the
    economic significance of the AT solution
  • Alternative solutions must compared in terms of
    their social cost
  • Not a decision making tool, informative which
    adds to clinical assessment to make clinicans and
    users aware of economic consequences

41
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42
SCAI cost analysis
43
SCAI
44
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45
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47
AT paradox Andrich, Renzo Cost analysis of AT,
Portale Siva
48
Other Measures
  • COMPASS is a software program to measures
    computer performance (input, navigation and
    output). Provides quantitative data regarding
    reaction time, typing speed, number of errors.
  • The Siva Cost Analysis Instrument (SCAI)
    detail/compares costs of technology
    interventions.
  • Assessment of Life Habits (LIFE-H) questionnaire
    available in two forms a 69- item screening tool
    to identify areas of life where participation in
    limited and a 240-item in-depth assessment across
    12 domains nutrition, residence,
    responsibility, fitness, personal care,
    communication, interpersonal relations, mobility,
    community, education, employment and recreation.
  • Other measures of participation have been
    developed for wheelchair users, community
    activities (AM-PAC/PM-PAC is not an AT outcome
    measure),

49
FEW Functioning Everyday in a Wheelchair
  • Functional Evaluation in a Wheelchair (FEW)
  • ICF coded
  • Designed as a tool to measure basic wheelchair
    use including such items as ability to reach form
    the wheelchair
  • Includes a mix of body function, activity and
    participation and environmental elements
  • Difficult measure to classify because all items
    are multi-barreled, eg respondents asked to rate
    their agreement with following statement The
    size, fit, postural support and functional
    features of my wheelchair response is on a 7
    point scale

50
Wheelchair outcomes Measurment (WHoM)
  • Based on the ICF
  • Uses items nominated and weighted by the client
  • Rater solicits information that is participation
    focused
  • Captures the satisfaction with performance of
    activities or participation when using a
    wheelchair

51
At the end of the day.
  • A variety of processes and measures are used to
    address AT outcomes. Thus, it is imperative that
    you know your consumers and what will work best
    for them!
  • As important as choice in quality measures is
    their appropriate use
  • Know what you want to measure, and not want to
    measure (competence, functioning, satisfaction
    participation)
  • Determine how much time you want to devote to
    outcomes assessment
  • Know how specific or general you want to be
  • IPPA vs. QUEST

52
Evidence Based Practice
  • Evidence based practice is how
    Clinicians/researchers objectively provide
    evidence through scientific means on the outcome
    (positive and/or negative) of their
    intervention/s with their client group/s

53
Health Service Executive
  • Why we need evidence based Practice.
  • To eliminate poor/unnecessary practice and
    promote good practice.
  • To promote evidence based medicine.
  • To increase the accountability of services in
    line with the key principles of the Health
    Strategy, "Quality and Fairness (2001)
  • To develop means to evaluate services.
  • To empower consumers and involve them in service
    evaluation and planning.
  • To evaluate new services.
  • To inform priority setting and resource
    allocation.
  • To help set, monitor and improve standards of
    care.
  • To develop and share research

54
HIQA HRB
  • The HSE through the Health Information and
    Quality Authority (HIQA) is responsible for
    making sure that the resources in our health
    services are used in a way that ensures the best
    outcome for the patient or service user.
  • They intend to do this by assessing the clinical
    and cost effectiveness of the medicines, devices,
    diagnostics, and health promotion used across the
    health system.
  • The Health Research Board (HRB) is the lead
    agency in Ireland supporting and funding health
    research. They provide funding, maintain health
    information systems and conduct research linked
    to national health priorities.

55
HSE
  • The outcomes of these assessments will allow the
    HIQA to support the Minister for Health
    Children to make informed decisions on the
    desirability and effectiveness of investing in
    new therapies, drugs, equipment or health
    promotion activities.
  • HIQA will also advise on the rationale for
    continuing with existing practices to ensure that
    people are not being treated with outdated
    therapies, drugs or procedures.

56
Evidence Based Practice (EBP)
  • Where has this come from?
  • This movement emerged first in the health
    sciences in response to the demand for more
    accountability in professional practice
  • The goal of EBP is to bridge the knowledge gap
    between research and practice by providing
    guidelines based on the best available evidence
    from research
  • In the fields of EBP, methods have been
    developed, called systematic reviews, that
    insure that searches are thorough and reliable.
    Archives of systematic reviews have been
    developed that can be used as key resources for
    EBP.

57
Evidence Based Practice (EBP)
  • The Cochrane Library (health sciences) and the
    Campbell Collaborative (social sciences) are
    organizations devoted to supporting the
    development of EBP. Each maintains an archive of
    systematic reviews and has specific guidelines
    for conducting a review for their archive.
  • The National Center for Dissemination of
    Rehabilitation Research has published several
    concise articles describing the concept of
    systematic reviews and started an archive of
    systematic reviews in rehabilitation science

58
The Cochrane Collaboration
  • The Health Research Board have paid national
    subscription to make the Cochrane Database
    available to all clinicians/researchers in
    Ireland
  • 5000 scientific papers published daily
  • Clearing house for international evidence based
    practice
  • Information on evidence based practice
  • Improving healthcare decision-making globally,
    through systematic reviews of the effects of
    healthcare interventions

59
Measuring Outcomes
  • Quality of life indicators are now generally
    considered reliable measures to evaluate
    services, rather than merely questioning users as
    to their degree of satisfaction.
  • Traditionally the services received were
    considered as the standard for establishing
    social validity eg client surveys, waiting lists
    as opposed to establishing the success of
    intervention for the clients needs etc

60
Assistive Technology Outcomes
  • Clinical Result
  • Functional Status
  • Quality of Life
  • Consumer Satisfaction
  • Cost Factors
  • DeRuyter 1998

61
Perspectives of Different Stakeholders
Importance of Various Outcome Dimensions DeRuyter
98
62
Outcomes based research
  • When choosing an instrument, careful
    consideration must be given to validity and
    reliability.
  • If the instrument is considered to be invalid or
    unreliable, the research is worthless
  • Validity refers to the degree to which a study
    accurately reflects or assesses the specific
    concept that the researcher is attempting to
    measure.
  • reliability is concerned with the accuracy of the
    actual measuring instrument or procedure,
    validity is concerned with the study's success at
    measuring
  • In validating an instrument, certain criteria
    must assessed through repeated testing

63
Validity Reliability
  • Validity is key to effective research,
  • In qualitative data validity might be addressed
    through the honesty, dept, richness and scope of
    the data achieved, the participants approached,
    the researchers objectiveness
  • Quantitative data validity is addressed through
    careful sampling, appropriate instrumentation and
    appropriate statistical analysis

64
Measurement Tools
  • There are many standardised instruments available
    to clinicians
  • Assistive technology outcome measurement is
    commonly associated with a number of conceptual
    domains, including device usability, user
    satisfaction, quality of life, social role
    participation, functional level and cost.
  • Most instruments focus on one or more of the
    above domains to measure a specific type of
    outcome of the application of assistive
    technology. The challenge for clinicians is in
    identifying the most appropriate tools for their
    clients and service.

65
Outcomes based measurement
  • A analysis of existing measurement tools should
    cover conceptual, reliability, validity and
    practical considerations
  • Comprehensive reviews have been undertaken using
    the ICF
  • Older instruments which focus on the construct of
    handicap may not fully capture the full scope of
    the concept of participation

66
Appraisal of Instruments
  • Conceptual comparisons can be classified
    according to the ICF, Cieza et al have proposed a
    process
  • Each measure can be classified in terms of
    whether it measures activity or participation or
    both eg items such as mobility, self care and
    domestic life could be deemed as activity. Items
    that assess interpersonal interactions,
    community, social life etc are deemed as
    participation

67
Outcomes based research
  • As the prescription process becomes more
    complicated and Health departments begin to
    demand evidence to support the need for
    equipment, outcome measurement is becoming
    necessary
  • Attempting to decide on an appropriate measure,
    researchers and clinicians must choose from an
    increasing array of potential instruments

68
Outcomes measurement
  • Provision of the right system is essential to
    reduce not only monetary cost but also person
    related cost
  • Garber et al found that 31 of their sample
    discontinued using their wheelchairs because the
    devices no longer met their needs
  • Kittel et al found that failure to consider
    important lifestyle issues was identified as
    primary factor leading to wheelchair abandonment
  • Many studies have documented abandonment due to
    mismatch of device

69
AT System for Education NZ
  • http//www.minedu.govt.nz/NZEducation/EducationPol
    icies/SpecialEducation/ServicesAndSupport/Assistiv
    eTechnology.aspx

70
NDA Research on AT in 6 Countries and comparing
it to Ireland
71
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