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 user’s 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 people’s 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 student’s 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 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. An integratedapproach which utilizes a range of mechanisms to provide consumers with adequate information

11. Context ENVIRONMENTAL PERSONAL Functioning & Disability Body Functions & Structures Activities & Participation

12. QOL

13. Individual Influences on Activities & Participation C O N TEXT • Milieu • Policies and mandates • Financial/funding • Provider knowledge • Attitudes of others 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 person’s 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 user’s sense of competence, self-esteem and adaptability • QUEST for assessing the person’s 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 person’s 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. Seeingb210 Seeing functions 2. Hearingb230 Hearing functions 3. Speechb3 Voice and speech functions 4. Understanding,rememberingb144 Memory; b164 higher level cognitive functions; b1670 reception of language 5. Physical strength/staminab730, b735, b740 Muscle functions 6. Lower body useb760 Control of voluntary movement functions 7. Grasping and use of fingersb760 Control of voluntary movement functions 8. Upper body useb760 Control of voluntary movement functions 9. Mobilityb770 Gait pattern functions

30. Subjective Well-Being ATDPA Section B. Well-Being, QOL ICF Classification: Activities & Participation (d) _______________________________________________________________________ 10. Personal care, household activitiesd5 Self-care; d630, d640 Household tasks 11. Physical comfort & well-beingb280 (pain) 12. Overall healthb4, b5, b6, b8 13. Freedom to go wherever desiredd4 Mobility; d460 Moving around in different locations, d470, Using transportation; d475 Driving 14. Participation in desired activitiesd2 General tasks & demands; d9 Community, social & civic life 15. Educational attainmentd810-d839 Education 16. Employment status/potentiald840-d859 Work and employment 17. Family relationshipsd760, e310 Family relationships 18. Close, intimate relationshipsd770 Intimate relationships, e320Friends 19. Autonomy, self-determinationd177 Making decisions 20. Fitting in, belongingd7 Interpersonal interactions, d910 Community life 21. Emotional well-beingb152 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), friendsSupport 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 MatchICF: 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) Supports for use Support and relationships (e3) Will physically fit Moving around using equipment (d465), Domestic life (d6), Community life (d910), etc. Comfort – family Emotional function (b152), family attitudes (e410) Comfort – friends Emotional function (b152), friends attitudes (e420) Comfort - school/work Emotional function (b152), peer attitudes (e425) Comfort - communityEmotional function (b152), stranger attitudes (e445)

33. MPT (Specifically the ATD PA) + Good psychometric properties. Predictive of a match. + Useful when evaluating a person’s 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 WorkplaceSt 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, 7=most 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

42. SCAI – cost analysis

43. SCAI

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