Part 1

Part 2

Assessment and evaluation

Assessment of the older person must include all the components of the ICF framework to allow the practitioner to consider the long-term impact of the acute presentation and be able to plan for their journey from an acute setting to their preferred destination which may be home or another community-based setting.

Following assessment the practitioner must consider how they will evaluate what they are doing.

Selecting an appropriate outcome measure will depend on what you are aiming to influence with your treatment programme. This may seem obvious, but often people choose an outcome measure that will not be sensitive to change and is not measuring what they want it to measure. For example global measures of functional change such as the functional independence measure (Stineman et al 1996) or the Rivermead motor assessment scale (Collen et al 1991, Lincoln and Leadbitter 1979, Sackley and Lincoln 1990) may not pick up changes in specific ranges of movement, whereas if you are working on outdoor mobility then the Community Mobility Index would be appropriate. Choose the right outcome measure to evaluate each individual’s specific programme.

A helpful tip when looking at the outcome measures is to ask yourself which component of the ICF classification system is the measure focusing on, e.g. a visual analogue scale (VAS) (McCormack et al (1988)) could focus on any of the components, a pain VAS would be targeting the impairment, whereas a VAS on how easy it is to walk to the shops would be targeting the activity and participation component. Evaluation of interventions should not only consider objective measurement.

Today’s practitioners should consider how to evaluate the patient experience and the use of patient-related outcome measures should be encouraged. Consider both the quantitative and qualitative evaluation of rehabilitation.

Patient-centred care

It has been identified that practitioners sometimes fail to identify the patients’ problems in a way that is meaningful to the patient. It is important that the clinician listens carefully to what the patient has to say during the assessment. It may take more than one session to collect all the information required. If the individual has difficulty communicating it may be necessary to collect information from other sources such as; carers, the patient’s GP, relatives and friends, social services, previous medical records, reports from other disciplines are all sources of information which help build a picture of the individual. Failure to assess the environmental and personal aspects of the individual will make it difficult to identify what is important to the individual. Often the focus of the assessment is limited to the impairments of the body structure and function and how this impacts on the activity limitations. How these limitations impact on the individual’s participation is vital. For example, if we take an older person who has been admitted from a nursing home with a chest infection and has previously been receiving full care and an older person who has been living with their family and enjoying full independent living. Both patients have the same impairment of admission with a chest infection, but the impact on their activities and participation is very different. Literature suggests that practitioners impose their views and opinions on the individual and do not work in partnership with their patients, to formulate a treatment plan that is patient-centred (Farin 2009). Recent publications suggest that there is a mismatch of views and poor listening skills amongst clinicians (Bloom et al 2006). Good patient-centred care relies on good communication skills, in particular listening (Reynolds 2004).

Goal setting

Set goals from the patient’s viewpoint. Goals need to be; specific, measurable, achievable, realistic and timed (SMART) (Bovend’Eerdt et al 2009). Goal setting can be a powerful motivator for patients, equally if the goal is too difficult it can have the opposite effect. Success is important to motivate patients.

Goal setting requires imagination and sensitivity, if the goal appears to be too difficult it is important to work with the individual to reset the targets to enable the goal to be achieved later. An example of setting appropriate goals may involve a patient that wishes to go home from hospital, what they need to do to achieve this is identified. This may involve the patient being able to roll to sit on the edge of the bed. This initial goal is then built upon by further goals working towards the ultimate goal of going home. The process is termed short- or long-term goal setting. The goals may be started in hospital, progressed into a rehabilitation setting either as an inpatient, outpatient, or indeed in the patient’s own home. It is important to remember that anywhere along the pathway the practitioner needs to be able to help the person identify where they are going and how they will get there by re-evaluating the goals.

Goals can be anything your patient wants them to be, it is the therapist working with the patient that ensures that they are SMART.

Therapists sometimes find it difficult to set goals, due to the patient not being able to communicate their wishes, as a result of their impairments. In these cases the aim of the rehabilitation may be to manage the patient to get the optimal comfort, care and education goals can be set rather than functional goals.

The concept of active goals and passive goals has been used in the management of spasticity, these may be helpful in other areas (Richardson 1998). An active goal suggests that the patient will be performing some part of that goal themselves, e.g. to open and close the hand around a cup. An example of a passive goal is where the patient’s carer opens the hand to cut and clean the nails. Both are achievable and patient-centred, but one involves active involvement and the other involves a carer achieving a care task. Active and passive goals can be patient-centred and SMART.

Team work

It is important to remember that there is no ‘I’ in ‘team’, and that the patient is also part of the team. The ICF classification of function can assist a single assessor to identify other team members that might be of assistance. Team work requires good clear communication between the members and an understanding of each other’s roles. Being able to identify where other team members’ skills and knowledge could benefit an individual is a key part of the rehabilitation process (Nijius et al 2007, Shaw et al 2008). There are many specialist health services available for the care of patients that work together to effectively manage their problems. Consider a list of impairments for one individual and then think about the impact of these on activities and participation. Identify any contextual issues in the environment and the personal factors and then decide who would be the most effective team member to assist in meeting the needs of that individual. If we consider a frail older person who has fallen and is frightened of falling again, who also has a poor memory and does not go out very much, the impairments list might include, altered balance mechanisms, weakness in the legs, poor short-term memory, fear of falling, low mood. The activity limitations might be, unable to remember her tablets, frightened to go outside, social isolation. The team members that might be able to help could include the physiotherapist, the GP, the pharmacist, the voluntary visiting service, friends and family or neighbours.