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Terms in this set (1687)

-Doing processes that are directed toward a desired and intended outcome and require energy and thought to engage in and complete
-The goal-directed tasks and/or behaviors that make up occupations

Characteristics of purposeful activity
-Universally people participate in purposeful activities, although there are personal a sociocultural differences in the manner in which activities are performed (dressing)
-Fundamental to the development and acquisition of performance skills is active participation in purposeful activities
-Fundamental to performance in areas of occupation is engagement in purposeful activities -Purposeful activities are composed of identifiable parts that can be analyzed -They are holistic
-They can be manipulated and adapted to be appropriate to and/or therapeutic for the individual
-Can be graded along many dimensions to meet the needs of an individual
-Determination of the individuals differential responses to purposeful activities can provide information for the selection of appropriate activities for use in evaluation and intervention
-Verbal and nonverbal communication is facilitated through engagement
-Organization and ability to focus are enhanced because purposeful activities provide concrete structure
-Doing is emphasized
-Involvement in and with the nonhuman environment is enhanced
-Vary on a continuum from conscious to not conscious/unconscious
-Vary on a continuum from real to symbolic -Vary on a continuum from simulated in a clinical setting to real in the individuals environment
-Although OT aides are not considered OT practitioners, according to AOTA Standards of Practice, the use of OT aides has increased in response to changes in the health care system (ie. pressures to control costs have resulted in the delegation of non-skilled tasks to aides)
-OT aides can be trained by OTAs/COTAs or OTs to perform specific non-skilled tasks
-Tasks performed by OT aides must be supervised by a COTA or occupational therapist (this supervision must be documented)

Nonskilled non-client tasks aides
-include: routine maintenance and clerical activities (preparation of clinic area for intervention, organizing supplies)

Nonskilled client tasks
(contact guarding a client during transfers)
-Can only be delegated to an OT aide after the occupational therapist has determined that the following conditions have been met.
1. Anticipated result of the delegated task is known
2. The performance of the delegated task is clearly established, predictable and will not require the aide to make any interpretations, adaptations and/or judgement calls
3. the patients situation and the practice environment are stable and will not require the aide to make any interpretations, adaptations and/or judgement calls
4. the patient has previously demonstrated some capabilities in performing the task
5. The aide has been appropriately trained in the competent performance of the task and is able to demonstrate service competency in task performance
6. the aide has received specific instructions on task implementation relevant to the specific patient with whom the aide will be performing the delegated task
7. The aide knows the precautions of the designated task and patient signs and symptoms that could indicate the need to seek assistance from the OTA/COTA or occupational therapist
-Health care is a highly regulated industry with most regulations mandated by law
-Legally mandated regulations are set forth by the Center for Medicare and Medicaid Services (CMS), a division of US Department of Health and Human Services (HHS) (federal agency)
-CMS is the federal agency which develops rules and regulations pertaining to federal laws, in particular the Medicare and Medicaid programs
-Facilities that participate in Medicare and/or Medicaid programs are monitored regularly for compliance with CMS guidelines by federal and state surveyors
-Facilities that repeatedly fail to meet CMS guidelines lose their Medicare and/or Medicaid certification(s)
-Long-term settings, ie. skilled nursing facilities (SNFs), are strongly influenced by CMS regulations since Medicare and/or Medicaid pays for all or most of the expense of long-term care
-CMS is divided into three centers: 1) the Center for Beneficiary Choices which focuses on Medicare Choice and Medigap 2) the Center for Medicare Management which focuses on traditional fee-for-service Medicare 3) the Center for Medicaid and State Operations which focuses on state administered programs like Medicaid and State Children's Health Insurance Program (SCHIP)
-Standards related to safety are set forth and enforced by the Occupational Safety and Health Administration (OSHA), a division of the US Department of Labor
-Structural standards and building codes are established and enforced by OSHA to ensure the safety of structures
-The safety of employees and consumers is regulated by OSHA standards for handling infectious materials and blood products, controlling blood borne pathogens, operating machinery, and handling hazardous substances
-State accreditation to obtain licensure for a health care facility is mandatory. Individual states develop their own requirements, with state agencies enforcing these regulations
-Local or county entities also develop regulations pertaining to health care institutions (eg. physical plant safety features such as fire, elevator and boiler regulation)
-Largest source of insurance payment in US (there are broad variations among plans and plan options; they can be for profit or not for profit, organizations or networks)
-Many private insurers contract with Medicare to handle the day to day operations of Medicare. They are called intermediaries
-Insurers (eg. Blue Cross/Blue Shield, Aetna, MetLife, and Prudential), offer many insurance products including PPOs, HMOs, and managed care
-Coverage cannot be assumed based on the name of plan alone (co-insurance, deductibles and co-payments are common; most plans cover for OT in hospitals; outpatient coverage varies greatly; total number of visits and/or type and amount of services per diagnosis are limited)
-Insurers are not federally regulated. Each state determines its own requirements and regulations for insurers who operate within their borders
-Under the ACA, federal regulations were established for private insurance coverage. Key ones include the following: insurers must provide essential benefits to participants in their plans, these included mental health, substance abuse and behavioral health treatment; rehabilitative, habilitative and chronic disease management services and devices and preventative and wellness services. Insurers could no longer refuse coverage to persons with preexisting conditions
-Cost controlling payment strategies such as case management, precertification or preauthorization, mandatory second opinions, and preferred provider networks are often implemented
-Occupational therapists can join health care provider panels and/or a preferred provider network
-Largest single payer for OT services
-Administered by CMS
-Intermediaries determine if services provided are within Medicare guidelines
-Persons eligible for Medicare medical coverage for health care services:
1) persons 65 years or older
2) individuals of all ages with end-stage renal disease/permanent kidney failure that may require dialysis treatment or a kidney transplant
3) Persons with a long-term disability (ALS, MS) who have received government-funded disability benefits for 24 months may be eligible
4) Retired railroad workers

-The primary difference between Part A and Part B is the frequency in which the individual receives services. Inpatient Part A coverage requires services for a minimum of 5 days per week services. Part B typically covers 3 days a week outpatient services
-Medicare does not cover chronic illness, long term supportive care, or all medical expenses incurred when ill
-OT hospice care is provided to persons who are certified as terminally ill (medical prognosis of fewer than 6 months to live). OT services are provided to enable a patient to maintain functional skills and ADL performance and/or control symptoms
-OT is covered as an outpatient service when provided by or under arrangements with any Medicare Certified provider (ie. hospital, SNF, home health agency, rehabilitation agency, a clinic) or when provided as part of comprehensive rehabilitation facility services (CORF)
-OT services can also be covered if provided by a Medicare certified OT in independent practice (OTIP) when services are provided by the OT in the OT's office or in the patient's home (payment is according to the fee schedule entitled the Resource Based Relative Value Scale (RBRVS)
-All of these standards can change when and if new federal legislative guidelines are passed for Medicare
-Use legible handwriting must be used for handwritten documentation (illegible notes may result in denial of reimbursement)
-Documentation for an EMR/EHR must adhere to all established documentation standards
-Be correct in grammar and spelling (errors detract from a professional presentation)
-Be concise but complete (if it is not written down it does not exist and never happened; non-important, extraneous details [ie color of clothing] should be left out)
-Be objective, with clear distinctions between facts and behavioral data and opinions and interpretations are required
-Be current, relevant and accurate (occupational therapy notes/record are legal documents)
-Follow institution and/or program guidelines, as well as reimbursers'/third party payers' guidelines ( non-compliance can result in services and/or payment being denied)
-Only use standard, well recognized abbreviations (ie. ROM) (avoid alphabet soup; write in functional terms using uniform terminology consistent with AOTA's Standards of Practice and state practice acts)
-Use person first language at all times (eg. "a mother with schizophrenia", or "the student with developmental delays", not "the schizophrenic", "the retarded")
-Client's name and ID number should be on every page
-No whiting out or blocking out of information is accepted (in handwritten notes, errors must be crossed out with one line, initialed, and dated. Black or blue ink is used at all times)
-Include the date, including month, day and year
-Identify the type of documentation (ie. initial note, progress note, discharge plan)
-Comply with confidentiality standards (ie. do not put other clients' names in a note)
-Informed consent for treatment can only be given by a competent adult (minors or adults determined to be incompetent must have written consent provided by a parent, legal guardian, person with power of attorney, or proxy)
-Sign with a full signature (first and last name with professional designations) directly following content with no space left between content and signature
-Countersignature by an occupational therapist on documentation written by an OTA or a student if required by law or the facility
-All documentation may be subject to subpoena; therefore, documentation standards must be adhered to
-To be reimbursed OT services must be properly coded and billed as required by payers
-Practitioners must represent their services in terms of diagnosis and procedure codes
-Diagnosis codes describe a persons condition or medical reason for requiring services (The Internal Classification of Diseases (ICD) is the most frequently used diagnosis-coding system in the United States- each services, procedure, supply or piece of equipment must be related to a current ICD code; in 2014, the ICD-10 clinical modification (ICD-10CM) replaced the ICD-9)

Procedure codes describe the specific services provided by health-care professionals
1. HCFA Common procedure coding system (HCPCS) is most widely used
2. HCPC includes the Physicians Current Procedural Terminology (CPT)
3. The most current HCPCs and CPT codes must be used in practice.
4. Specific codes that most closely describe the services provided should be used. Each procedures, modality and/or treatment should be coded
-Specific billing forms are used by institutional providers (hospitals and home health agencies) and by physicians practice for Medicare, Medicaid and most states workers compensation programs. Form numbers may change.

Outpatient OT services provided under Medicare Part B must report functional data on their claims in the form of G-codes.
1. G-codes identify the primary issue being addressed by therapy, modifiers are used to report the persons impairment/limitation/restriction
-All G-codes are available to be used by all therapy disciplines (OT practitioners can use the codes for mobility, memory, swallowing and cognition)
2. G-codes will be used to track patient outcomes over time
-OTAs/COTAs are generally not eligible for direct payment because they require supervision and do not perform evaluations
-The use of certain words, terms, and/or physicians errors can result in delay, denial, and/or discharge from services
-Avoid these in all documentation, unless they are tru and accurate representations of a clients status
-If a client has met their goals and/or is not longer making sufficient functional gains, this must be documented and the client may need to be discharged from services

Words to carefully consider for they do no reflect progress
1. chronic
2. status quo, no change in status
3. maintaining
4. little change
5. plateau
6. making slow progress
7. stable or stabilizing

Words to carefully consider for they do not reflect potential for improvement
1. same as
2. uncooperative, noncompliant
3. dislikes therapy
4. confused/disoriented
5. inability to follow directions
6. custodial care needed
7. treatment repeated
8. repeated instruction
9. unmotivated
10. extreme depression
11. fair to poor potential
12. chronic/long-term condition
13. general weakness

Errors in physicians orders, for they can result in denial or delay of payment for OT services
1. incomplete or nonspecific orders
2. orders with a span of frequency over the duration of intervention (two to three times/week for 4 to 6 weeks)
3. Orders that do not state a specific type of intervention (activities, splint or equipment, as needed)
4. Orders that cover only evaluation but intervention has been initiated
5. Order is specific to a certain type of treatment but the treatment plan does not include it
6. Order does not include duration of treatment
7. The plan changes mid-month, but the order is not updated to meet the new plan change
8. There is no discharge order or there is no order immediately after treatment ends
-Content must indicate that the treatment shows a level of complexity and sophistication or the condition of the person must be of a nature that requires the judgement, knowledge, and skills of a qualified therapist. This statement is as per Medicare

Skilled rehabilitation intervention is mandatory
1. Delineate the specific skilled care rendered. This is the biggest cause for retroactive denial
2. Notes must reflect skilled therapeutic intervention

-Skilled care rendered must match the diagnosis and the physicians order
-Services must be unique to OT and not sound like PT/SLP. Medicare does not pay for duplication of services

In home care, homebound status due to functional limitations must be clearly delineated
1. If the diagnosis may not render the individual homebound, explain why this particular person is homebound
2. Do not give a reviewer any doubt that this person does not meet Medicare homebound criteria (do not state client not a home when you arrive. Rather state there was not answer to a locked door)

-Document honestly, but not over-optimistically, Medicare reviewers are interested in determining the need for continued intervention
-Documentation must demonstrate that the person is making significant functional improvement in a reasonable and generally predictable period of time.
1. Improvement should bed noted with a description of functional changes
2. If a person has improved bu can benefit from further intervention, the therapist should clearly document why continued treatment is medically necessary (provide behavioral observations and evaluation results that substantiate the need for further care)
3. If improvements are not observed and/or progress is slower than expected, the reasons for lack of progress including extenuating circumstances and/or limiting factors (secondary diagnosis) should be documented

-If improvement is not made or expected, justifiable interventions to prevent deterioration and maximize function are covered
1. Occupational therapists are reimbursed for the documented design of a maintenance program performed by others (CNA, HHAs, PCAs) and periodic evaluations of the program effectiveness
2. Occupational therapists can continue to provide OT services to persons not expected to improve if they adequately substantiate the need for skilled services
3. Medicare no longer denies payment due to lack of improvement, coverage is denied due to inadequate documentation of the need for skilled services

-All documented service must be reasonable and necessary
1. Was the service effective and completed in a timely fashion?
2. In long-term care, if the treatment does not lessen the mount of care needed by staff, what made the service worthwhile?
-If there is no medical justification for continued treatment, the person should be discharged in a timely fashion
1. Set of standards and safeguards to assure the individuals right to continuity in health-care coverage and to ensure privacy and security of health-care records
2. All persons must be informed of the setting privacy policies and a good faith effort must be made to obtain written acknowledgement from each person about their attainment of this knowledge
-If the person refuses to sign, the provider should document the efforts made; failure to obtain written acknowledgement is not a violation of the rule
-Written consent must be obtained from a person before any personal health information is used or disclosed in the provision of treatment, obtainment of payment or the carrying out of any healthcare related operations (Exemptions to the written notification/acknowledgement are allowed if the attainment of this will prevent or delay timely care [emergency care]. Written acknowledgement must be obtained as soon as possible- if language barriers preclude signed acknowledgement, treatment can occur if the physician believes consent is implied)
3. Prior to discussing a persons status with a family member/significant other or other provider, the provider must obtain the persons permission or give the person the opportunity to object
-Providers can use their clinical judgement to determine whether to discuss the persons case with others if the person cannot give permission or objects (documentation for this decision is essential [person is at risk of harming self due to lack of judgement, consultation with a specialist is essential to ensure quality of care])
-All information used or disclosed about a persons status must be limited to minimum needed for the immediate purpose
-HIPAA does not exclude treatment from occurring in group settings or open clinics (Discussion regarding treatment should be done quietly and if possible behind a screen/room divider
-HIPAA does not require a guarantee of 100% confidentiality; it does require reasonable and vigilant safeguards
-HIPAA guidelines for research are complex, but they are congruent with the established guidelines for human subject research and Institutional review boards (IRB) standards (a limited data set that does not include any identifiable patient information can be used in research without patient approval (diagnosis, age, LOS)
-The Administrative Simplification rule also provider standardization of codes and formats for medical data
-HIPAA does not override state laws that further restrict privacy and it defers to state laws governing minors
1. Prohibits employers from discriminating against persons with disabilities in any aspect of phase of employment including recruitment, hiring, working conditions, hours, promotion, training opportunities, termination, social activities and other privileges of employment
2. Allows questions about ones ability to perform a job but prohibits inquiries as to whether one has a disability
3. Prohibits employment test that tend to screen out people with disabilities
4. A qualified individual with a disability means a person with a disability who is able to perform the essential functions of a job (that is the tasks fundamental to the position) with or without reasonable accommodations
5. Reasonable accommodations must be provided by businesses with 15 or more employees to persons with disabilities to enable them to perform essential job functions unless such accommodations would impose an undue hardship on the business

Types of reasonable accommodations
-Acquisition or modifications or equipment or devices
- Modifications or adjustments to exams, training materials or publications
-Provision of ancillary aids or services
-Modified or part-time work schedules, job restructuring or reassignment to a vacant position
Improvement of existing facilities used y employees so they are usable by and accessible to persons with disabilities and/or other similar accommodations

Types of ancillary aids and services
-Taped texts, qualified readers or other methods that can effectively make visually delivered materials accessible to persons with visual impairments
-Qualified interpreters or other methods that can effectively make aurally delivered materials accessible to persons with hearing impairments
-Modifications or acquisitions of devices or equipment
-Similar actions or services that increase accessibility

6. The government, Indian Tribes and/or private tax exempt membership clubs are exempt from ADA employer guidelines
-Established a federally sponsored national employment and vocational training system
-Established a "One-Stop" delivery system for all adults aged 18 or older seeking access to employment and training services. This means traditionally separate "unemployment" offices and "vocational rehabilitation services" are now available at a "One-Stop Center"
-Availability of all employment and training services at a One-Stop Center is aimed to allow for "universal access" for people with disabilities - a core principle of WIA

Categories of One-Stop services:
1) core services, which include outreach intake and orientation; initial assessment; eligibility determination for services; assistance with job search and placement; job market information and career counseling
2) intensive services for individuals who do not attain successful employment after receipt of core services. Services can include comprehensive assessments of service needs and skill level, development of individualized plans for employment, case management, and counseling
3) training services for individuals who do not attain successful employment after receipt of core and intensive services. These services are typically provided off-site from the One-Stop Center and can include adult education and literacy training, on-the-job training, and individualized vocational training
-The One-Stop system of services is provided through a network in each state. The names of these systems can vary from state to state
-Persons determined to be eligible for WIA services receive an Individual Training Account (ITA) which is used to obtain services from any approved provider. Specific ITA procedures can vary from state to state
-Services for youth (aged 14-21) with disabilities are also provided for in the WIA to assist in a successful transition from school to work
-Emphasizes that the purpose of the IEP is to address each students unique needs as related to their disability and decide how these needs can be served so that students with disabilities have full access to the general education curriculum and can participate in the general education classroom
-Clarifies that the IEP can include consideration of assistive technology and behavioral intervention strategies and supports (an area in which OT can offer a great deal)
-States that IEP planning team is open to related personnel at the request of the parent or school, in addition to the regular education teacher, if the student is in a regular education class
-States that the education the student receives should prepare them for independent living and employment in adult life
1. Transitional planning begins at the age of 14 (of younger if indicated) to help the student plan a course of study that will lead to post school goals
2. Transition services begin at the age of 16 (or younger if indicated) to provide student with a coordinated set of services to attain post school goals (these services can include community experience, specific instruction and/or ADL and vocational assessment and intervention)
3. The student must be invited to attend IEP meeting that discuss their transition planning and services to allow for self-advocacy and self-determination
4. This transition plan must be updated annually with appropriate service revision provided
-Maintains the established definition of related services (including OT)
-Expands orientation and mobility services by broadly interpreting them to include all students with disabilities
-Students with disabilities may be punished in the same manner as other students for serious offenses (carrying illicit drugs or weapon). However, disciplinary prevention measures are stressed
1. If disciplined students are removed to an alternative placement they must still receive education and related services
-Clarifies early intervention services and systems
1. Mandates and Individual Family Service Plan (IFSP) for children brith through 2 years of age
2. OT is identified as a primary early intervention service
-Directly addresses the students functional performance along with academic performance
1. Requires that evaluation for IDEA eligibility include relevant functional and developmental information, not just academic achievement data.
2. Expands the IEP's annual goals to include academic and functional goals
3. Specifies that accommodations must be provided as needed to measure the functional performance and academic achievement of all students with disabilities
4. Enables services to be provided to students as soon as learning needs become apparent via a Response to Intervention (RtI) (RtI provides evidence-based early intervention services to children who are having difficulty learning to prevent academic failure)

-Providers for the piloting of a multiyear (not to exceed three years) IEP to allow for long-term planning and to coincide with a students natural transition (preschool to elementary school, middle school to high school) (plan is optional for parents)

-Provides for increased flexibility in IEP meetings
1. Allows IEP team members to be excused from IEP meetings if their area of concern is not being addressed or modified at the meeting or if a written report is submitted prior to the meeting (District and parental approval for a team members absence is require, parental approval must be in writing)
2. Allows IEP revision and/or amendments to be made by parents and districts after an annual IEP meeting (parents must be provided with a written copy of the revised/amended IEP
3. Allows the use of technological alternatives to face-to-face IEP meetings (videoconferences, conference calls)

-Requires the recommendations for early intervention, special education, related and supplementary services and aids be made based on peer-reviewed research to the extent that this is practical
1. This requirement raises concern that established intervention methods may be questioned due to a real or perceived lack of evidence supporting their efficacy
2. This requirement may spur research on early intervention and school-based OT to support evidence-based practice

-Clarifies that a screening done by a specialist is not equivalent to an evaluation for eligibility for IDEA services
1. OT practitioners can conduct informal classroom-based screenings and provide consultations for classroom modifications and other teaching strategies without completing a formal evaluation according to IDEA procedures
-Requires that all students with disabilities be assessed in compliance with the Elementary and Secondary Education Act (ESEA) commonly known as No Child Left Behind Act (NCLB)
1. The IEP team determines if the student should take an alternative assessment or the standard assessment with or without accommodations
-Provides for early coordinated intervening services for general education students from kindergarten through 12th grade who do not require special education services but who do need additional supports to succeed in school
-Clarifies that the purpose of the IDEA is to prepare children with disabilities for further education, employment and independent living
-Allows school personnel to individually consider each case of student with a disability who violates the schools code of conduct
1. Students with disabilities who are discipline must (be provided with services to continue to progress toward achieving their IEP goals. Receive appropriate functional behavioral assessments and interventions, and service modifications as needed to address their conduct violations)
-Allows each state to define developmental delay criteria to determine if an infant or toddler is eligible for early intervention in the state
1. Typically states define developmental delays quantitatively (percentage of delay according to a standardized developmental assessment)

Requires that an IFSP be completed to include
1. The infants or toddlers developmental level
2. Family priorities, concerns, and resources
3. The infants or toddlers natural environments
4. Measurable outcomes
5. Projected, length frequency, and duration of research-based services
6. Transition plan to preschool or other services as appropriate

-Clarifies the role of the parent and IFSP team in determining the site for service provision (requires states to maximize the provision of early intervention services in the infants or toddlers natural environments as appropriate
-Requires states to establish procedures for the referral of infants and toddlers who are victims of abuse and/or neglect to early intervention services
1. the provision was also included in the Keeping Children and Families Safe Act
-Applied to all nursing homes that receive federal money for Medicare or Medicaid patients
-Emphasizes attending to residents rights, autonomy and self-determination, providing quality of care and enhancing quality of life within nursing homes
-Mandated a comprehensive resident assessment system the Minimal Data Set (MDS), which is administered upon admission and thereafter on an annual basis, unless there is a significant change in the residents condition
1. MDS is coordinated by an RN. Occupational therapists can contribute information
-Psychosocial well-being and activity pursuits patterns must be considered along with the residents physical condition and cognitive abilities (this has broadened OT's role in nursing homes)

-Mandated that the evaluation and treatment of conditions found during the MDS follow specific guidelines called the Resident Assessment Protocols (RAP)
1. The structured approach to assessment is called the Resident Assessment Instrument (RAI)
2. Individualized care plans mist be established within specific time frames

-The enhancement of quality of life through restraint reduction and the provision of restraint-free environments are strongly emphasized
1. Nursing homes must show evidence of consultation by an occupational or physical therapist for consideration of interventions that are less restrictive than restraints
2. Occupational therapists are frequently consulted for ADL treatment, seating adaptations, positioning ideas, environmental modifications, psychosocial interventions and activity programming
-Aims to guarantee that residents have the right to choose how they want to receive care and live their lives
1. Residents should have a choice in determining their ADL and community participation activities
2. Residents should be able to function as independently as possible
-Postdischarge plans must meet specific criteria including client or caregiver education
-Admission is due to engagement in criminal activity by a person. The person can be remanded to a variety of settings depending on the nature of the crime and if a psychiatric diagnosis has been made
1. Jail: a city or county facility that is the individuals first entry into the criminal justice system and the placement for those convicted of crimes with sentences of less than a year
2. Prison: a state or federal facility for individuals found guilty of crimes with sentences greater than a year
3. Forensic psychiatric hospital or unit: a specialized hospital or unit within a hospital which providers inpatient psychiatric care for individuals convicted of a crime and found guilty but mentally ill or not guilty by reason of insanity
-LOS is determined by court-ordered directive and criminal sentence
-The availability and quality of services vary greatly from none in most jails to extensive in some forensic hospitals
-Due to serious gaps in mental health and social services the incarceration rate of persons with mental illness has increased significantly (a homeless person with schizophrenia steals food due to hunger)

-OT evaluation and intervention focus
1. determination of individuals competency to stand trial in forensic psychiatry settings
2. Areas similar to those described under rehabilitation hospitals to develop community living skills needed for successful community reintegration upon release
3. Facilitation of skills and provision of structured programs to enable the person to function at their highest level within their current environment since discharge may be delayed or not possible, depending on the nature of the crime
4. Restoration of competency to stand trial in forensic psychiatry settings
-Acceptance criteria for an early intervention evaluation are base on at risk status of the infant/child or toddler who is under the age of 3.
1. birth complications
2. suspected delays in development
3. failure to thrive
4. maternal substance abuse during pregnancy
5. birth to an adolescent teen month
6. established disability diagnosis

-Acceptance criteria for early intervention services are based on the following criteria
1. the extent of the developmental delay (typically a 33% delay in one area of development or a 25% delay in two areas)
2. an established diagnosis/disability

-Length of service provision
1. if the infant/child qualified for services, an infant family service plan (IFSP) is completed by the service coordinator after a review of all assessments and in collaboration with the family and early intervention team
2. 6 month reviews are submitted by all professionals to determine if services should continue

OT evaluation
1. assessment of 5 developmental areas
-cognitive
-physical
-communication
-social-emotional
-adaptive
2. determination of the effects of current development on the occupational areas of play and activities of daily living
3. evaluations need to be written in a strength oriented manner
4. functional goals must be written in family friendly terms and include levels of functioning, unique needs and recommended services

OT intervention process
1. development of cognitive/process, psychosocial/communication/interaction, and sensorimotor skills
2. development of play and activities of daily living skills
3. provision of family education
4. provisions of advocacy and advocacy training
-Acceptance criteria for OT services as a related service in an educational setting
1. The child requires special education services and OT will enable the child to benefit from special education
2. OT will facilitate the child's participation in educational activities and enhance the child's functional performance
3. Referrals are received from the previous agency that provided early intervention services the child's teacher and/or school's child study team
4. The school reviews the referral and if indicated recommends an OT evaluation (If an OT evaluation has already been completed the need for OT intervention services is discussed, the frequency, length of sessions and duration of the intervention are also determined)

-Length of services is dependent on the impact of OT services on the child's abilities and prevention of loss of abilities
1. If OT services can improve the child's ability to participate in education-related activities and allow full access to the general education curriculum, services can be continued
2. A review of services and progress made toward the child's individualized education plan (IEP) is conducted on an annual basis

-OT Evaluation
1. Assess client factors, performance skills and patterns and areas of occupation that impact on the education and functional performance of the child within the school (findings are used to contribute to the IEP, in which goals and objectives are formulated to address the overall educational needs of the student)
2. Assess the child's functional and developmental level to contribute to the Functional Behavioral Analysis

OT intervention focus
1. Based on an educational model versus a medical model
2. Addresses the students functional performance along with academic performance
3. Activities are utilized to address the goals and objectives documented in the IEP using both corrective and compensatory methods
4. Assistive technology and transition services in accordance with the regulations of IDEA are provided
5. Performance skills deficits and client factors (sensorimotor, cognitive/process, and psychosocial/communication/interaction) are treated to improve the child's ability to participate in and perform education-related activities within a school setting.
6. Skills in the performance areas of ADL, school, and play are developed to improve the child's ability to participate in and perform education-related in accordance with the students transition plan
7. Skills for adult life post-school are developed in accordance with the student's transition plan

-The OT practitioner needs to know the school district's and states funding resources and regulations and interpretations of the federal laws regarding education

-The role of OT practitioners in school-based practice has expanded beyond education-related services to include programs that address students psychosocial needs and prevent school violence
1. Behavioral Intervention Plans which include Response to Intervention (RtI) and Positive Behavioral Supports (PBS) may be a component of school-based OT service provision
a. RtI is an evidence-based, structured intervention approach that uses EIS to address academic difficulties and PBS to address behavioral problems early in child's education
+ An RtI is designed to meet the needs of children who are having difficulty learning without requiring a full evaluation as require for an IEP
+The provision of classroom modifications (the use of a therapy ball as a seat instead of a standard desk chair) and the use of educational strategies (incorporating movement into the class lessons) can positively impact children's ability to learn
+If the RtI approach is not effective, the occupational therapist can recommend the completion of a comprehensive evaluation and the development and implementation of an IEP
-Acceptance is for the development of specific vocational skills
1. Person has the prerequisite abilities to work (goos task skills and work habits) but requires training for a specific job and/or ongoing structure, support and/or supervision to maintain employment
2. Person has to develop their work capacities to a level acceptable for competitive employment (strength and endurance)

-LOS is determined by agency's funding and attainment of goals
1. In rehabilitation workshops (formerly called sheltered workshops) and supportive employment programs, discharge is not always a goal (maintenance of the person in these structures work environments can be the desired objective for some individuals while other will be discharged to other programs or to work)
2. Transitional employment program (TEPs) are generally time limited (3 to 6 months) with discharge to competitive employment, supportive employment or rehabilitation workshops
3. Employee assistance programs (EAPs) provide ongoing support, intervention and referrals as needed to a company's employees to enable these individuals to maintain this employment

-OT evaluation is focused on the individuals functional skills and deficits related to work in their current and expected vocational environment
-OT intervention focus
1. Remediation of underlying performance skill deficits and compensation for client factors that affect the work performance area
2. Development of general work abilities and specific job skills
3. Consultation to and/or supervision of vocational direct care staff
4. Identification and implementation of reasonable accommodations in accordance with ADA
5. Referral to state offices of vocational and educational services (One-stop centers) for persons with disabilities for further evaluation, education and training
-Admission is for a developmental, medical or psychiatric condition that has resulted in functional deficits that impede independent living but are not severe enough to require hospitalization
1. residential programs are on a continuum from 24-hour supervised quarter way houses, halfway houses or group homes, to supportive apartments with weekly or biweekly check-in supervision
2. the degree of functional impairment determines the residential level of care needed

-LOS for transitional living programs (quarter way and halfway house programs) is determined by agency's funding
1. Long-term and permanent housing options (group homes and supportive apartments) are available and are funded through the individuals social service benefits

-OT evaluation is focused on assessment of the individual skills for living in the community and determination fo the social and environmental resources and supports needed to maintain the individual in their current and expected living environments
-OT intervention focus
1. consultation to and/or supervision of residential program staff
2. Remediation of underlying performance skill deficits and compensation for client factors that affect independent living skills
3. ADL training, activity adaptation, and environmental modifications to facilitate community living skills
4. Referral to appropriate residential services along the continuum of care as individuals functional level improves
5. Education about ADA the Fair housing act and section 8 housing
-Membership is open to adults and elders with a current mental illness or a history of mental illness
1. All members have equal access to all clubhouse functions and opportunities regardless of functional level or diagnosis
2. Individuals who pose a significant and direct threat to the safety of the clubhouse community are the only persons excluded

-Services are provided by staff and members with the responsibility of operating the clubhouse shared equally by staff and members under the oversight of a director
1. Due to this role equality, it can be difficult to distinguish between members and paid staff
2.Staffs main role is to engage membership, provide needed support and structure and enable recovery

-Individual schedules will vary to meet each persons unique needs and interests
1. Clubhouses are open at least 5 days per week. Many are open 7 days per week
2. The daily schedule is organized around the work-ordered day which parallels typical working hours to engage members and staff in the running of the clubhouse
3. Evening and weekend schedules are focused on avocational interests and recreational pursuits
4. Additional services that can be provided include literacy and education programs, transitional employment placements, independent employment assistance, community support and out-reach services, housing programs and legal and financial advisement

-LOS is indefinite and members can exit and reenter a clubhouse community at will
-OT evaluation and intervention are not provided in a formalized manner
1. the role of the OT practitioner is integrated into generalists who contribute to the development and enrichment of members abilities and the promotion of their recovery
-Acceptance criteria for home health services
1. presence of a medical or psychiatric condition that is not serious enough to warrant hospitalization or for a condition that has sufficiently stabilized to enable the individual to be discharged from a hospitals but that still has remaining symptoms requiring active treatment
2. reimbursers can have strict and variable criteria for qualifying for home health care.
-Treatment is usually provided in 60 minute sessions once a day for up to 5 days a week as determined by insurance coverage
-LOS is determined by diagnosis, presenting symptoms, response to treatment, insurance coverage, or ability to pay for a fee for service
-OT evaluation is focused on the individuals client factors and functional skills and deficits in their performance skills and patterns, areas of occupation, and the occupational roles that are required in the current and expected environments

-OT intervention focus
1. active engagement of the client, family and caregivers in the treatment planning and other places of accommodation, implementation and reevaluation processes
2. functional improvement in areas of occupation and occupational role functioning within the home
3. remediation of underlying performance skill deficits and compensation for client factors that affect functional performance within the home
4. education of the family, caregivers, and/or home health aides to provide appropriate care and/or assistance as needed
5. environmental modifications and activity adaptations that maintain optimal functioning and improve quality of life
6. increasing ability to resume occupational roles outside of the home
7. Prevention of hospitalization and avoidance or delay of residential institutional placement
1. Define a focus for the program based on the needs assessment results
-problem areas, functional limitations, and unmet needs that are relevant to the majority of the target population are the priority focus
-Program level of difficulty as determined by the range of populations functional levels and the level required by the current and expected environment

2. Adopt a FOR that are most likely to successfully address and meet the needs that are the programs focus
3. establish objectives and goals of the program specifically related to primary focus
-Individuals goals that will be met by the program are set
-programming goals that establish standards for program evaluation are determined

4. Describe integration of program into existing system of care
-establish realistic timetable for program implementation
-define staff roles, responsibilities and assignments
-identify methods for professional collaboration
-determine the physical setting and space requirements
-consider potential barriers to program implementation
-develop methods to effectively deal with identified obstacles before program implementation

5. Develop a system for referral for entry into completion of and discharge from the program
-Evaluation protocols to standardized information to be obtained from each person referred to the program and to assess the type of program services needed
-criteria for acceptance into the program and for movement through program levels
-discharge criteria to determine when an individual has achieved maximum gain from the program, usually defined as the achievement of program goals

6. Described the fiscal implications of program plan
-Determine projected volume or service demand to estimate revenue
-identify resource utilization and projected expenses to estimate costs
-directly compare estimated revenue and estimated expenses to determine financial viability of program
the process of determining staffing needs, predicting turnover and vacancies, and identifying and recruiting potential replacements to maintain the staffing levels required to meet program objectives
-identify the position available and determine its job description
-attract potential qualified applicants
1. advertise in trade publications, state and national OT association newsletters, and/or online
2. Network internally within own organization and externally at local, state, and/or national OT meetings and conferences and through established OT contacts
3. Conduct open houses, job fairs, and workshops
4. Direct mail recruitment information to OT practitioners
5. Use placement agencies
6. Train and educate fieldwork students

-Screen interested applicants for an interview
1. review applications and resumes
2. check references

-Interview screened applicants to determine experience ability for position
1. obtain information about relevant experience and career goals
2. verify knowledge and skills
3. use open-ended semi-structured questions to facilitate discussion
4. ask the same questions of every candidate
5. take notes of applicants responses

6. questions to the applicant that violate civil rights legislation or ADA should not be asked
-age
-sexual orientation
-marital status or family composition
-race or national origin, religion, or political beliefs
-physical, mental or cognitive disabilities

7. share information about the positions salary, benefits, work hours, job description and advantages and limitations of the organization

-make the job offer
1. contact selected applicant to offer position
2. upon applicants acceptance of position, confirm terms of employment, starting date, salary and licensure requirements
1. Formulation of a philosophical foundation to reflect researcher's view of, and assumptions about, learning, human behavior, and other phenomena related to health and human services
2. Identification of a broad issue, topic or problem of interest and relevance that warrants scientific investigation
3. Review and synthesis of research literature related to identified area of interest
4. Utilization of a theoretical base to frame the research problem or area of concern to ensure that the resulting research contributes to, or build upon, theory
5. Development of a specific question or focus for research (in quantitative/experimental research this is very specific, detailing the exact variables to be studied; in qualitative/naturalistic research, this is a broad question called a "query" that will develop specificity over the course of the study)
6. Selection of a research design (in quantitative/experimental research, the design is highly standardized; in qualitative/naturalistic research, the design is more fluid)
7. Formulation of methodology
8. Determination of study's length
9. Identification of study's participants/population sample
10. Collection of data using established principles for collecting research information
-information obtained must be relevant and sufficient to answer the specific research question or query
-the method of data collection selected must be realistic given the practical limitations of the researcher, the type of research design and the nature of the research problem
-use of a combination of data collection methods can be useful and more fully answer a research question or query
11. Methods of data collection (observation; interview; written questionnaire; survey instruments; artifact and record review; hardware instrumentation; tests and assessments)
12. Analysis and interpretation of data using descriptive statistics (measures of central tendency; measures of variability)
13. Analysis and interpretation of data using inferential statistics (standard error of measurement; tests of significance; parametric statistics; nonparametric statistics; correlational statistics)
14. Report and dissemination of research findings (results section, conclusion section, summary)
-Appropriate positioning to allow for neutral pelvic alignment and trunk stability, either in caregiver's lap or chair (infant seat or wheelchair); avoid head extension to prevent asphyxiation as a result of closing the airway
-Hand Positioning of the Caregiver: place the index finger longitudinally under the child's lip, middle finger under the jaw, and place the thumb on the lateral end of the mandible
-Facilitate lip closure by applying slight upward pressure of the index finger under the child's lip
-Facilitate jaw closure by firm upper pressure of the middle finger under the jaw
-Hand positioning of the index and middle fingers to assist in inhibiting tongue trust (press bowl of spoon downward and hold onto tongue)
-Facilitate swallow by lip closure and by placement and slight downward pressure of the spoon on the middle aspect of the tongue
-Facilitate chewing by placement of foods, such as long soft-cooked vegetables between the gum and teeth
-Consider and utilize the appropriate texture of foods as related to the child's feeding problems. Thick foods are easier to swallow and manage, especially if a tongue thrust is present
-Integrate preventive measures to work out of abnormal patterns:
1. provide firm downward pressure, using a spoon, on the middle aspect of the tongue in presence of a tonic bite reflex
2. prevent tongue retraction avoid choking
3. facilitate lip closure for a tongue thrust that can result in loss of liquid and food, drooling and failure to thrive
4. decrease tactile sensitivity prior to feeding as well as at other times, by providing firm pressure; encourage sucking/chewing on a cloth; rub gums, palate and tongue; promote oral exploration of toys; use a NUK toothbrush and vary texture of foods, gradually introducing mashed potatoes mixed with other vegetables and soft meets
-A major role of the therapist is to assist the caregiver in considering and promoting a pleasant social atmosphere for feeding by utilizing positioning and handling techniques to promote eye contact and bonding in a relaxed environment
-Ability to perceive, represent and organize sensory information to think and problem-solve
1. Utilization of inborn behavioral patterns for environmental interaction (0-1 month)
2. Interrelation of visual, manual, auditory, and oral responses (1-4 months)
3. Early exploration of the environment and interest in outcomes of actions: remember action responses, believes that own actions cause responses and has an awareness of the relation of these actions and events (4-9 months)
4. Utilization of deliberate actions to achieve a goal: object permanence begins, anticipation of familiar events, imitation, interest in sizes/shapes, and perception of other objects as partially causal (9-12 months)
5. Utilization of a trial and error approach to problem-solving : tool use, begins to realize that alternate routes can be used, remembers that order of a simple sequence and realizes that others can cause events to happen (12-18 months)
6. Formulation of mental pictures: pretends, early cause and effect, manipulates objects in space, has a clearer understanding that others can manipulate the environment (18 months-2 years)
7. Representation of objects in terms of felt experiences: understands that there are consequences to actions, that others cannot read your ming and recognizes that events have causes (2-5 years)
8. Representation of objects by name: begins to understand that other people may have different opinions (6-7 years)
9. Comprehensions that different labels can be used for the same object, use of formal logic and speculation (11-13 years)
-Atrophy of nerve cells in cerebral cortex:overall loss of cerebral mass/brain weight 6-11% between ages of 20 and 90, accelerating loss after age 70
-Changes in brain morphology
1. Gyral atrophy: narrowing and flattening of gyri without widening of sulci
2. ventricular dilation
3. Generalized cell loss in cerebral cortex: especially from frontal and temporal lobes, association areas (prefrontal cortex, visual)
4. Presence of lipofucins, senile or neuritic plaques and neurofibrillary tangles (NFT): significant accumulations associated with pathology (Alzheimers disease)
5. More selective cell loss in basal ganglia (substantia nigra and putamen), cerebellum, hippocampus, locus coeruleus, brain stem minimally affected

-Decreased cerebral blood flow and energy metabolism
-Changes in synaptic transmission
1. decreased synthesis and metobolism of major neurotransmitters (acetocholine, dopamine)
2. slowing of many neural processes, especially in polysynaptic pathways
-changes in spinal core/peripheral nerves
1. neuronal loss and atrophy
2. Loss of motoneurons resulting in increase in size of remaining motor units (development of macro motor units)
3. Slowed nerve conduction velocity: sensory greater than motor
4. loss of sympathetic fibers: may account for diminished autonomic stability, increasing incidence of postural hypotension in older adults

-Age related tremors (Essential tremor [ET])
1. occurs as an isolated symptom, particularly in hands, head and voice
2. Characterized as postural or kinetic, rarely resting
3. Benign, slowly progressive, in late stages may limit function
4. exaggerated by movement and emotion
1. Address for visual deficits: visual acuity, visual fields, contrast sensitivity, light and dark adaptation, depth perception, diplopia, eye fatigue and eye pain
2. maximize visual function: assess for use of magnification as indicated or the need for environmental adaptations
3. Sensory thresholds are increased: allow extra time for visual discrimination and response
4. When considering compensatory strategies, consider other client factors that may impact function such as tremors or decreased range of motion, strength, sensation, cognition, hearing or ambulation
5. Work in adequate light, increase intensity, reduce glare, avoid abrupt changes in light (light to dark)
6. Use large, high contrast print for written materials
7. Provide magnifying glasses (either portable or attached to a stand/work table) to view objects and complete tasks. (magnification levels must be prescribed by a doctor)
8. Provide an eye patch for diplopia
-some state OT licensure practice acts do not allow OT practitioners to give clients eye patches. In these states the OT should refer the person to an ophthalmologist
9. decreased peripheral vision may limit social interactions, therefore stand directly in front of the person at eye level when communication with them
10. assist in color discrimination: use warm colors for identification and color coding
11. Provide other sensory cures when vision is limited (verbal descriptions to new environments, sighted guide techniques, touching to communicate you are listening and talking clocks and watches
12. provide safety education; reduce fall risk
-Etiology:
1) trauma
2) osteoporosis
3) pathological fractures (ie. cancer)

-Types: 1) femoral neck fracture
2) intertrochanteric fracture
3) subtrochanteric fracture

-Medical management:
1) closed reduction for minimally displaced fractures
2) open reduction internal fixation (ORIF)
3) joint replacement

-Occupational therapy evaluation:
1) review precautions and weight bearing status before initiating evaluation
2) occupational role requirements and expectations
3) ADL focus on dressing, bathing and transfers
4) ROM and strength of upper extremities
5) conduct other assessments as needed, (eg. cognitive)

-Occupational therapy intervention:
1) bed mobility and bedside ADL
2) upper extremity strengthening
3) functional ambulation and transfers with appropriate weight bearing status and appropriate ambulation device (ie. walker, crutches) (the type of ambulation device is determined by the person's weight bearing status)
4) instruct in and practice use of assistive devices for use in the home (eg. shower chair, elevated commode seat)
5) practice role activities (eg. small meal preparation) using proper weight bearing status and ambulatory device

-Precautions:
1) weight bearing status and the amount of ROM allowed at the hip will be determined by the surgeon
2) time frames for beginning OT intervention are also determined by the surgeon

-Complications:
1) avascular necrosis
2) non-union
3) degenerative joint disease
4) the result of complications can be the need for a total hip replacement
1. Bony structure
-Skill (cranium): rigid bony chamber that contains the brain and facial skeleton, with an opening (foreman magnum) at its base

2. Meninges: three membranes that envelop the brain
-Dura mater: outer tough, fibrous membrane attached to inner surface of cranium, forms falx and tentorium
-Arachnoid: delicate, vascular membrane
-Subarachnoid space: formed by arachnoid and pia mater, contains cerebrospinal fluid and cisterns, major arteries
-Pai mater: thin, vascular membrane that covers the brain surface, forms tela choroidea of ventricles

3. Ventricles: four cavities or ventricles that are filled with cerebrospinal fluid and communicate with each other and with the spinal cord canal
-Lateral ventricles: large, irregularly shaped with anterior (frontal), posterior (occiplical) and inferior (temporal) horns; communicates with third ventricle through foramen of Monro
-Third ventricle: located posterior and deep between the two thalami; cerebral aqueduct communicates third with fourth ventricle
-Fourth ventricle: pyramid-shaped vacity located in pons and medulla, foramina (openings) of Luschka and Magendie communicate fourth ventricle with subarachnoid space

4. Cerebrospinal fluid: provides mechanical support (cushion brain), control brain excitability by regulating iconic composition, aids in exchange of nutrients and waste products
-Produced in choroid plexuses in ventricles
-Normal pressure 70-180 mm/H20
-Total volume: 125-150 cc

5. Blood-brain barrier: the selective restriction of blood borne substances from entering the central nervous system (CNS); associated with capillary endothelial cells

6. Blood supply: brain is 2% of body weight with a circulation of 18% of total blood volume
-Carotid system: internal carotid arteries arise off of common carotids and branch to form anterior and middle cerebral arteries, supplies a large are of brain and many deep structures
- Vertebrobasilar System: vertebral arteries arise off of subclavian arteries and unite to form the basilar artery; this vessel bifurcates into two posterior cerebral arteries; supplies the brain stem, cerebellum, occipital lobe and parts of thalamus
-Circle of Willis: formed by anterior communicating artery connecting the two anterior cerebral arteries and the posterior communicating artery connecting each posterior and middle cerebral artery
-Venous drainage: includes cerebral veins, dural venous sinuses
-During the neonatal period precautions are taken to protect the sac from rupturing and from infection which may result in meningitis
1. all or part of the sac may be removed 24-48 hours after birth
-Ventriculoperitoneal or other types of shunt is indicated should the complication of hydrocephalus occur, in which the cerebral spinal fluid is not absorbed resulting in an increase in size of the ventricles and the infants head
1. brain damage as a result of increased intracranial pressure can cause an intellectual disability
2. increased pressure may also result in Arnold Chiari syndrome in which a portion of the cerebellum and medulla oblongata slip down through the foramen magnum to the cervical spinal cord

3. shunts can become blocked, resulting in increased intracranial pressure
-signs and symptoms during the 1st year of life include extreme head growth and often a soft spot on the forehead
-Signs and symptoms by the 2nd year of life include severe headache, vomiting and irritability
-Signs and symptoms in adolescents include increasing head size, change in the function of UE, regression in milestones or decline in academic performance, neck pain, severe headache and loss of balance
-Signs and symptoms in adults can include vomiting, severe headache, vision or memory problems, irritability, personality change, loss of coordination, numbness in the upper extremities, head and neck pain, and difficulty swallowing
-intracranial pressure can possibly lead to paralysis of the 6th cranial nerve resulting in visual impairments
-intracranial pressure may contribute to seizure disorders and deterioration of physical and cognitive functioning
-blocked shunts are revised by removing the blocked section and replacing it with a catheter

4. shunts can become infected
5. urological management and if indicated intermittent catheterization
6. orthopedic management for motor deficits
7. surgical intervention may be indicated for tethered cord syndrome
-History: determine chief complaints, description of onset, and mechanism of injury
-Determine localization: chronic pain is poorly localized, not well defined
-Identify nature of pain: constant, intermittent
-Determine irritating stimuli/activities
-Determine subjective assessment using pain intensity rating scale:
1) simple descriptive scales - verbal report (eg. select the words that best describe your pain)
2) semantic differentiation scales (eg. McGill Pain Questionnaire)
3) numerical rating scales (rate pain on a scale of 1 to 10, eg. 8/10)
4) visual analog scale (eg. bisect line where your pain falls, from mild to severe pain)
5) spatial distribution of pain - using drawings to plot location, type of pain
-Physical examination: identification of underlying pathology (cause of pain); objective physical findings are usually not readily identified:
1) assess all systems - musculoskeletal, neurologic, and cardiopulmonary. Check for muscle guarding.
2) check for postural stress syndrome (PSS) - chronic muscle lengthening and/or shortening that causes postural malalignment and stress to soft tissues
3) check for movement adaptation syndrome (MAS) - habituated movement dysfunction
4) check for autonomic changes (sympathetic activity) - typically present with acute pain but not with chronic pain
5) assess for abnormal movements
-Assess degree of suffering:
1) verbal complaints are out of proportion to degree of underlying pathology; include emotional content
2) the person exhibits a stooped posture, antalgic gait
3) the person exhibits facial grimacing
-Assess for functional changes:
1) check for self-imposed limited activity; disrupted lifestyle; disuse syndrome
2) check for avoidance of work, home management, leisure, social, and/or sexual activity
-Assessment for consequences of pain, behavioral impact, and secondary gains:
1) monetary benefits (malingering, insurance claims)
2) sympathy and attention
3) avoidance of undesirable tasks
-Assess for depression, anxiety
-Assess for prescription drug misuse
-Assess for dependence on health care system; multiple health care providers, clinical services; "shopping around" behaviors
-Determine responsiveness of pain to physiological interventions/treatments: chronic pain is often unresponsive
-Determine motivational/affective components:
1) previous experience with pain
2) learned responses to pain
3) perception of control over pain
4) ethnic/cultural aspect of pain
5) familial response to pain behavior