Running head: OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN

Michelle Wilson
Occupational Analysis and Intervention Plan
Touro University Nevada

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Occupational Profile
Client Background
Joni is a 75-year-old female who sustained a right cerebrovascular accident (CVA) in
July, 2015. She and her husband of 50 years live twenty minutes east of Mesquite, Nevada in a
single-story home with their small dog, Foxy. Family is an essential component of their life and
they have two grown daughters, both living in Rexburg, Idaho. Their eldest daughter is retired
and currently staying with the couple to assist with daily tasks within the home and community.
Jonis husband is 86-years-old and was previously diagnosed with macular degeneration a few
years back, leaving the responsibility of driving to her. Joni and her husband are very connected
to their parish and have developed strong relationships with fellow church members.
Reason for Occupational Therapy Services and Patient Concerns
Joni is seeking skilled occupational therapy services to improve judgement in regards to
safety, increase independence in activities of daily living (ADLs) and instrumental activities of
daily living (IADLs), improve self-awareness, and to receive suggestions on adaptations and
compensatory techniques. Currently Joni is experiencing difficulty in organization and
sequencing skills which is interfering in completion of daily tasks independently and safely.
Constant verbal cueing is required to remind her to lock the brakes on her four wheel walker
(4WW) during functional ambulation and transfers. Prior to the CVA, Joni assisted her husband
with home management, meal preparation and cleanup, driving, and pet care of Foxy. Her
husband is unable to complete these tasks independently due to the diagnosis of macular
degeneration.
Success, Barriers, and Concerns in Occupations
Joni has made substantial recovery in the three weeks following a CVA. Barriers at an
individual, family, and societal level are currently preventing Joni from reengagement in past

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meaningful occupations, a major promotion of health and prevention of further disability. At an

individual level, it is important for Joni to self-identify meaningful occupations she hopes to
regain participation and independence in through therapy. At an internal level, this will increase
self-awareness of current functioning level post CVA. From a family perspective, Joni used to
hold the role of primary caregiver for her husband and now has various limitations permitting her
from returning to that prior occupation. Her husband believes that she will regain necessary
function to fulfill this role once again, but her daughter does not see this happening in the future.
Changes in fulfillment of family roles in completion of various occupations may need to occur in
order to recreate the cohesive family dynamic. Lastly, at the societal level, the community is
required to put in place various factors to ensure their population stays healthy. Environmental
adaptations need to be in place for Joni to successfully engage in community mobility while
completing functional ambulation using a 4WW. Adaptations may include providing ramps
outside of buildings in addition to stairs, repair of cracked sidewalks, and alternative
transportation services which allow plenty of room to transfer a 4WW. Living in a medically
underserved rural community poses many limitations at the societal level. Being on Medicare,
Joni will be granted on average six to eight occupational therapy sessions. When services run
out, she will need to identify what the community offers to keep her active and engaged in
occupations. Being from a rural community, these services are sparse and hard to come by.
Environment or Context Supports and Barriers
Joni feels successful in the ability to reside in her home with her husband and daughter.
Her daughter stated if needed, she would move to Beaver Dam and live with her parents
indefinitely. In regards to the physical environment, living in a single-story home provides Joni
the ability to functionally ambulate amongst her home using a 4WW. Pertaining to the social

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environment, Joni has a supportive family of whom are involved and supportive in the goal of
restoring optimal function. Her and her husband have lived in the same home for many years
and have developed close relationships with neighbors. Since sustaining a CVA, neighbors have
been delivering meals and offering to run any errands, and stop by often to socialize.
In order for Joni to restore optimal function, home modifications and adaptations need to
be put in place to address various cognitive deficits she has been experiencing. Modifications in
the bathroom will be useful. Currently, the client attempts to use the master bathroom, but her
daughter does not feel it is a safe environment. There are no grab bars in place, no shower chair,
and the sliding glass doors often become an obstacle. Being able to use the master bathroom is
important to Joni. Additionally, the inability to drive due to impaired judgement and safety is
inhibiting participation in the community. Beaver Dam is a rural town and does not offer public
transportation, which may prove to be an obstacle.
Occupational History
Joni grew up outside of Las Vegas with her family. In Jonis early thirties, she was
working full time at a governmental paper mill. A machine that she was working on
malfunctioned and her left hand was caught and crushed in the machine. It severed her second,
fourth, and fifth phalanges and unfortunately the doctor was unable to reattach them due to the
severity of the cut. This condition does not affect her ability to complete tasks. Soon after the
incident, she decided to stop working and become a stay at home mom. Her time was soon filled
with volunteering at the childrens school events and at their parish. After her husband retired,
the couple moved to Beaver Dam, Arizona and engagement in the parish strengthened.
Values and Interests

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Prior to the CVA, Joni was an active, healthy 75-year-old. Her free time was filled with
completing household tasks, spending time with husband, neighbors, and family, and
volunteering at the parish. Family is a valuable component in her life and she enjoys when her
daughters are able to visit. In addition to family, the client values her independence and ability
to take care of herself and manage a home with her husband. In her current physical and
cognitive stage, the client is extremely thankful and values her daughters assistance with basic
needs and tasks among the home and community. She also enjoys taking care of her dog, Foxy.
Daily Life Roles
Daily life roles of being a wife, mother, and grandmother take up much of Jonis day to
day life. Fulfilling the role of a wife now for a over 50 years has ensued commitment and
dedication to their marriage. The client is an active member of her church and volunteers much
time to the parish.
Patterns of Engagement in Occupations and Change over Time
When Joni was younger, her time was filled with being a full-time worker and mother of
two young children. Currently, her time consists of caring for her and her husbands home and
pet dog, Foxy. Managing the beautiful acre lot of which her home is located and spending time
in the garden are often where Joni can be found throughout the day. A typical day begins with
Joni waking up in the morning, completing showering and self-care activities, and spending time
outside on her deck if the weather permits. She finds herself becoming fatigued easily and often
naps at least once per day.
Client Priorities and Desired Targeted Outcomes
Ultimately, Joni is most concerned with being as independent as possible and is open to
any modifications that may achieve this goal. Living in her own home and being able to assist

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her husband with home management is a priority. As stated previously, her husband is 86-yearsold with health concerns of his own to manage, unable to care for their home by himself. Joni
has always valued equal partnership in their marriage and does not want to leave all of the
responsibilities to her husband alone. Returning to caring and managing their home together and
completing meal preparation tasks is an important and desired outcome of therapy. Continuing
these daily tasks and roles will continue to strengthen their marriage resulting in an increased
quality of life and well-being. In addition to her husband, Joni values family, including her two
daughters.
Occupational Analysis
Occupational Therapy Services Context
Occupational therapy services will take place in Jonis home, once a week, for 60
minutes. The client lives in a single story home containing two exterior stairs. If needed, a ramp
is located outside the front of the home. Inside the home there is plenty of room for Joni to
navigate using her 4WW. In regards to the master bathroom, she is able to navigate using her
4WW but lacks certain modifications crucial for safety. These modifications may include grab
bars around the toilet and shower, non-skid mats, a shower chair, and the removal of sliding glass
doors.
Observation of Clients Performance during Activity
Joni was able to recognize the occupational therapist upon arrival and greet him,
however, appeared confused when the occupational therapy student stated they had not met prior.
Immediately, the daughter brought up a concern regarding her mothers safety during transfers,
specifically in the master bathroom. When waking in the middle of the night, she has been
ambulating to the master bathroom without use of the 4WW. This is causing her daughter much
stress and anxiety at the possibility of Joni falling, worsening her condition. Joni made it clear

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that returning to her old routines and habits is a priority. The occupational therapist wanted to
address safety concerns regarding use of the master bathroom, as this is Jonis desired
environment to complete ADLs.
Joni was instructed by the occupational therapist to stand from the recliner, ambulate
using the 4WW to the master bathroom, and demonstrate the process of transferring to the toilet.
As soon as Joni approached the entryway to the master bathroom, she situated her 4WW to the
side, and attempted to continue to ambulate throughout the bathroom without use of the 4WW.
Joni was then verbally instructed by the occupational therapist to turn around, take hold of the
4WW, and continue functional ambulation using the 4WW in the master bathroom. The toilet is
situated in a closed off area along with the shower. There is enough room prior to this closed off
area where the sink and bathtub are housed to ambulate using the 4WW. The occupational
therapist instructed Joni to park the 4WW off to the side of the closed off area housing the toilet
and shower, and from there use grab bars for safety while transferring onto and off of the toilet.
These grab bars will ensure safety during independent transfers.
Key Observations
Upon request from the occupational therapist, Joni stood and ambulated to the master
bedroom and bathroom, she listened and comprehended the instructions, and initiated the activity
independently. During ambulation using the 4WW, the occupational therapist observed that Joni
was experiencing left side neglect, causing her to lean more towards the right side of her body
and place more weight through her right hand. Once it was time to lock the brakes on the 4WW,
Joni required verbal cueing to remember to do so, posing a future safety risk.
After completion of navigating the master bathroom and bedroom, Joni sat down on her
bed while the occupational therapist discussed possible modifications that may increase safety

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during the completion of ADLs. As soon as she was seated, she pushed her 4WW far out of her
own reach. This concerned the therapist and daughter in regards to Jonis ability to problem
solve the further difficulties this action would pose.
OTPF Domains
Joni was referred to home health services to receive therapy in the most natural
environment, her home. She is seeking skilled occupational therapy services to address deficits
in cognitive functioning as well as physical environmental barriers affecting safety in the home
and community. Specific domains in the OTPF affecting Jonis ability to independently and
safely engage in occupations include the occupations of toileting and toilet hygiene, functional
mobility challenges due to deficits in organizational and sequencing skills, care of her pet dog,
Foxy, driving and community mobility, and home management tasks. (American Occupational
Therapy Association [AOTA], 2014). Additional challenges in the domain of client factors,
include difficulties with higher-level cognition, executive functions, and judgement in regards to
safety are underlying factors needed to be addressed to improve performance in occupations
listed above.
Problem Statements
Following completion of observation of performance, barriers to occupational
performance were apparent. The following list of problem statements were identified by the
occupational therapy student. Problem statements are in order of importance to address to ensure
optimal functioning level and safety in the home and community.
1. Client unable to complete transfers using 4WW safely 2 deficits in organization &
sequencing skills.
2. Client unable to recognize physical & mental limitations 2 impaired self-awareness.

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3. Client unable to complete household management tasks such as meal preparation &
cleanup 2 impaired judgement.
4. Client unable to complete community mobility 2 impaired judgement in regards to
safety.
5. Client unable to complete pet care 2 deficits in problem solving skills.
Justification of Problem Statement Order
After observing Joni complete various tasks amongst the home, it is apparent that safety
is the primary concern needing to be addressed. This safety concern is directly correlated to
deficits in organization and sequencing skills as evidence by requiring verbal cuing to lock the
brakes on the 4WW during transfers. If Joni were to experience a fall, it would further
exacerbate her condition and cause regression in the achievements made thus far. The task of
remembering to lock the brakes on the 4WW is crucial in all aspects of day-to-day functioning.
Reasonable expectation is that if Joni were to master this skill in regards to completion of
household tasks, it will generalize to other more complex tasks such as in the community setting.
Next, it is noticeable that Joni is experiencing impairments in regards to self-awareness.
According to Gillen and Brockmann-Rubio, one must be aware of deficits related to everyday
functioning to be motivated to participate in the intervention process (2011). By implementing
interventions to ascertain an individuals level of self-awareness, motivation to participate in the
rehabilitation process should increase. This is crucial because without motivation in therapy
sessions, little to no achievement will be made.
Prior to sustaining a CVA, Joni was the primary caregiver for her husband who has health
concerns of his own. Meal preparation and cleanup were primarily her responsibility and she is
concerned with regaining the skills needed to independently complete these occupations once
again. However, it is apparent that Joni is experiencing impaired judgement while completing

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these tasks. This impairment is important to address because it may correlate to a decrease in
functional ability to properly complete meal preparation and cleanup if not addressed. For
example, Joni may forget to turn off water taps after washing dishes, causing the sink to
overflow onto the kitchen floor, creating a safety hazard and further increasing Jonis risk of
falling in the kitchen.
Community mobility is a skill needed to be addressed in future treatment sessions.
Impaired judgement decreases Jonis ability to be safe when managing environments outside of
her home, where occupational therapy treatment primarily takes place. She may be faced with
different textured surfaces to maneuver, be required to ignore distractions and focus attention on
the task being completed, and be able to make safe decisions if faced with a novel barrier. Going
out into the community forces Joni to generalize skills learned in the home to other contexts.
Lastly, pet care is of high importance to Joni making it an important occupation to
address in therapy and by doing so, it will increase motivation to participate in treatment. While
completing the occupation of pet care, the therapist will address impairments in problem solving
skills. Deficits in problem solving skills in addition to impairments in self-awareness will
increase safety risk during day-to-day tasks. After using the 4WW to functionally ambulate to
desired location, Joni would sit down, and push the 4WW as far away from her as possible. She
is unable to identify potential barriers this action will cause, for example, what will she do when
she is ready to stand up and the 4WW is out of reach? By addressing problem solving during the
meaningful occupation of pet care, it is reasonably expected that increases in problem solving
skills will generalize to other tasks, specifically keeping the 4WW close to her during functional
transfers.
Intervention Plan and Outcomes
Goals and Interventions

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LTG #1: Within 8 weeks, client will lock brakes on 4WW (I) prior to initiating movement to new
surface or location.
STG #1a: Within 3 weeks, client will require no more than 2 VC to lock brakes on 4WW prior to
initiating movement to new surface or location.
Intervention #1a: Following the initial evaluation, it was noted that Joni would need proper
education on the importance of locking the brakes on the 4WW to ensure safety. This skill
should be addressed initially because it is a foundational skill required in completion of all
occupations to ensure safety and avoid further injury.
In a study done by Kim et al., clients who had previously sustained a CVA utilized the
occupation-based virtual reality activity of safely crossing the street (2007). The study
concluded that significant improvements were made in regards to reaction time, need for visual
and auditory cueing, and success in street crossing. All of these skills are crucial for safety
during completion of occupations in the home and community. Additionally, a study done by
Maeir et al., utilized the Canadian Occupation Performance Measure (COPM) with children
diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) to self-identify goals in order
to increase safety in the home and community (2014). Symptoms associated with ADHD
include impaired executive functioning and decreased quality of life leading to impediment in
participation in daily occupations. One goal identified included safe street crossing. The study
found statistically significant findings utilizing cognitive intervention to improve executive
functioning skills. Although the first study was done in a virtual reality based setting and the
second was done with children diagnosed with ADHD, findings from both studies can be of
benefit when creating an intervention plan for Joni.

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During occupational therapy treatment sessions, Joni will utilize her 4WW to walk across
the street with the occupational therapist to retrieve her mail. The occupational therapist will
provide Joni with needed verbal cueing to lock the brakes on the 4WW. If verbal cueing is not
sufficient, gesturing will be used as well to get the message across. Prior to crossing the street,
Joni will need to stop, look both ways to ensure safety before crossing, and then proceed to the
mailbox. Once at the mailbox Joni will need to lock the brakes on the 4WW prior to retrieving
mail out of the mailbox, place the mail in the basket on the 4WW, unlock the brakes, look both
ways, and cross the street back to her home. This intervention will be focusing on the
importance of organizational and sequencing skills necessary for safe ambulation during daily
occupations outside the home which may generalize to occupations completed inside the home.
According to Gillen and Brockmann-Rubio, treatment approaches to cognitive
impairments are generally classified in one or two categories including the functional or adaptive
approach or the remediation or restoration approach (2011). Due to the evidence provided
above, it is reasonably expected that Joni will restore organizational and sequencing skills
necessary to ensure safety in the completion of occupations in the home and community. The
outcome for the intervention of retrieving the mail will be role competence. Prior to sustaining a
CVA, Joni fulfilled the role of home maker which included fulfilling various household tasks of
which she hopes to return.
STG #1b: Within 5 weeks, client will lock brakes on 4WW with Mod (I) using visual cues prior
to initiating movement to new surface or location.
Intervention #1b: Fading verbal cueing to a less intrusive prompt is essential to success because
it will lead to independence and the ability to complete tasks more independently. Compensatory

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techniques including a visual reminder to lock the brakes on the 4WW during completion of
occupations will be implemented after verbal cueing has been achieved.
Several research articles have found that deficits in cognitive functioning post CVA may
severely impact an individuals level of independence, further increasing dependence on
caregivers and reducing the ability to regain independence (Wolf, Chuh, Floyd, McInnis, &
Williams, 2014). Compensatory techniques are strategies that may be implemented to address
the risk of decreased independence. A study done by Gitlin et al. evaluated the effectiveness of
implementing a home-based intervention shown to decrease functional difficulties amongst older
adults (2009). The Advancing Better Living for Elders (ABLE) intervention was utilized. ABLE
is a home based intervention in which occupational and physical therapy practitioners educate
clients on compensatory strategies, home modifications, and home safety. The study concluded
that education on compensatory techniques reduced functional difficulties which contributed to
mortality rate and thereby extended survivorship (Gitlin et al., 2009).
Although this study was implemented with older adults who had not previously suffered
a CVA, components of this study very well correlate to difficulties homebound patients
diagnosed with CVA experience. Precautions of older adults coincide with those experienced by
individuals post CVA which may include risk of depression, social isolation, fall risk and
dependence on caregivers. Functional difficulties were found to decrease after implementation
of compensatory strategies in the home.
During the completion of various activities among the home, Joni will refer to a picture
of brakes being locked on a 4WW. Visuals will be placed in areas throughout the home in which
Joni often transfers from her 4WW to other locations or surfaces. Placement of this visual
reminder may include the wall near her bed, the mirror in the master bathroom, near the toilet in
the master bathroom, and in the living room near her favorite chair. This will aid as a

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compensatory strategy to remind Joni to lock the brakes on her 4WW using modified
independence to ensure safety. This technique is an adaptive strategy to address deficits in
organizational and sequencing skills. The outcome for the intervention of locking brakes on the
4WW using a visual schedule will be improvement in occupational performance.
LTG #2: Within 8 weeks client will identify 2 physical & 2 mental limitations ( I ) 0 VC.
STG #2a: Within 5 weeks, client will identify 3 goals to achieve during therapy Mod (I)
requiring no more than 3 VC.
Intervention #2a: Deficits in self-awareness, specifically limitations imposed by a CVA, may
severely impact ones motivation and participation in the rehabilitation process (Gillen &
Brockmann-Rubio, 2011). In Jonis case, it is imperative to highlight both her strengths and
limitations in regards to occupational performance to assist in a better understanding of her
current condition. This will increase her self-awareness and increase personal motivation to
improve functional skill performance.
The Cognitive Orientation to Daily Occupational Performance (CO-OP) is a clientcentered occupational therapy frame of reference aimed at enabling individuals to improve
everyday activities through self-guided detection. This approach utilizes three important
objectives which include skill acquisition, development of cognitive strategies, and generalize
learning (Imms & Nott, 2012). In a study completed by Imms and Nott, the CO-OP approach
guided the intervention of delivering the COPM assessment to self-identify three goals for
therapy in patients post CVA (2012). Researchers utilized the COPM scores, Stroke Impact
Scale, and Performance Quality Rating Scale (PQRS) as outcome measures. PQRS is an
observational measure of performance quality of client-selected, personally meaningful

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activities. Researchers found that functional performance scores on the PQRS improved for all
self-identified goals.
Joni will collaborate with the occupational therapist to complete the COPM assessment.
The COPM assessment will be utilized to identifying strengths, limitations, and goals for
therapy. Three goals will be self-identified to achieve during occupational therapy sessions. It is
reasonably expected that by having Joni self-identify goals, self-awareness and motivation in the
rehabilitation process will increase. Joni will be remediating cognitive impairments in regards to
impaired self-awareness. The intervention outcome of self-identifying strengths, limitations, and
goals for therapy will be improvement in occupational performance.
STG #2b: Within 3 weeks, client will identify 3 alternative transportation services Mod A
requiring no more than 5 VC 2 executive functioning skills.
Intervention #2b: Jonis inability to self-identify limitations is impacting her ability to be safe in
the home and community. Prior to sustaining the CVA, Joni was the primary driver for her and
her husband. As stated previously, Jonis husband is diagnosed with macular degeneration,
unable to carry out the responsibility of driving. Both Joni and her husband feel that she will
eventually gain skills needed to resume this responsibility, however, the occupational therapist
and daughter foresee this occurring in the future.
It is imperative for all parties included in the therapist, client, and family relationship to
have an equal partnership based upon mutual respect and collaboration. An effective partnership
depends upon a shared view and understanding of the illness and how it should be treated
(Perkinson, Hilton, Morgan, & Perlmutter, 2011). This can be done utilizing the explanatory
model to increase understanding of all parties beliefs and knowledge regarding Jonis health
concern. The explanatory model is the first step towards achieving a healthy partnership

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amongst family members, the therapist, and client. Jonis daughter has expressed concern
regarding her parents belief in the ability of returning to the occupation of driving in the future.
The occupational therapist will act as a mediator between the parents and daughter to establish a
common understanding of each and everyones view and understanding of limitations post CVA.
A study done by Logan et al. focused occupational therapy intervention on exposing
participants to alternative community transportation resources (2004). Researchers found that
participants significantly increased trips outside of the home after knowledge of these sources
increased. Joni will be exposed to various paper resources and organizations provided by the
occupational therapist regarding alternative transportation sources. It is important to identify
neighbors and close friends from church who are able to assist with transportation when needed
if their daughter is unavailable to assist. Joni and her husband live in a rural environment with
limited public organizations making it crucial for the couple to collaborate with the occupational
therapist to identify these alternative sources to community transportation. Joni is unable to
return to the occupation of driving and will be utilizing the intervention approach of adaption,
thus ensuring continued participation in the community. The intervention of identifying
alternative transportation services is using the outcome of participation to continue engagement
in occupations outside of the home.
Precautions and Contraindications
In regards to the intervention process, there are various precautions and contraindications
to be aware of as a clinician when providing services to an individual post CVA. First and
foremost, safety is of utmost concern. Prior to beginning the intervention, it is important to
assess for safety considerations where treatment will be taking place, in Jonis case this will be in
her home and community. In regards to Joni, impairments in organization and sequencing, self-

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awareness, judgement, and problem solving abilities severely impact her ability to be safe during
the completion of daily tasks. It is crucial to address the fall risk associated with impaired selfawareness and judgement. If Joni were to sustain a fall, it would worsen her condition and
regress progress made in therapy thus far.
Additionally, feelings of depression are common following a CVA which may impede a
clients recovery (Reed, 2014). As the OT treating a client post CVA, it is crucial to educate the
client and caregivers on the signs and symptoms associated with depression for early detection
and treatment. Shoulder dislocation or subluxation is yet another precaution to be aware of in
which the shoulder muscles holding the glenohumeral joint in place weaken (Gillen, 2013).
Proper handling techniques are required to avoid further damage to the shoulder during transfers.
Frequency and Duration of Intervention Plan
By providing skilled OT treatment in the home, Joni will have the opportunity to engage
in meaningful occupations in the most natural environment. Additionally, she has the
opportunity to apply skills being learned in the setting skills will actually be applied. In the
home health setting, patients are seen weekly and services may be provided anywhere from
weeks to months, depending on the clients condition (Schultz-Krohn & Pendleton, 2013).
Joni was provided with OT services immediately following sustainment of a CVA.
Clinicians generally agree that the first three to six months following a CVA is the most crucial
time where the greatest improvement takes place (Gillen, 2013). In the three weeks following
the CVA, Joni has shown vast improvement in functioning. She will continue to receive OT
services weekly for 60 minute sessions. Eight therapy sessions are anticipated to be provided
initially in the home health setting.
Grading Up and Down of Intervention

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Pertaining to the intervention of Joni crossing the street to retrieve mail, it is possible that
beginning the intervention with the occupational therapist providing verbal cues may not fit the
just right challenge needed. One way to grade up the activity would be to have Joni utilize
modified assistance, specifically the visual reminder of locks on a 4WW, placed on the mailbox.
Implementing compensatory strategies would decrease Jonis dependence on the occupational
therapist to provide her with a verbal reminder of locking the brakes when needed. Additionally,
one way to grade down the activity if needed would be to increase the intensity of the cues
provided by the occupational therapist. Rather than only offering verbal cues, the occupational
therapist will provide hand over hand assistance to facilitate locking the brakes on the 4WW
when needed.
Primary Framework
The primary model guiding this intervention will be the Model of Human Occupation
(MOHO). This model recognizes that there are many factors beyond motor, cognitive, and
sensory deficits that may impact an individuals day to day functioning. A major goal of the
occupational therapy intervention to increase Jonis self-awareness and her strengths and
limitations she will be faced with following sustainment of a CVA. An increase in selfawareness will assist to strengthen motivation throughout the rehabilitation process. Three key
components form the theoretical base of the MOHO model and these include volition,
habituation, and performance capacity. Volition is defined as the process by which individuals
are motivated to engage in meaningful occupations (Schultz-Krohn & Pendleton, 2013).
Additionally, by having Joni self-identify goals, strengths, and limitations using the COPM, the
occupational therapist will have a better understanding of Jonis interests and what is going to
motivate her to participate in the intervention process.

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Client and Caregiver Education

It is imperative that the occupational therapist educate not only Joni, but her daughter and
husband as well in regards to the intervention process and expectations. First and foremost, Joni
is experiencing cognitive deficits impacting her ability to function safely. Caregivers need to be
educated on management of cognitive impairments (Reed, 2014). Education on proper use and
maintenance of DME and A/E will also need to occur (Reed, 2014). Joni requires these devices
to ensure independence and if one malfunctions, it is important that the daughter and husband
understand how and where to get the item fixed. Currently, Joni is experiencing slight unilateral
neglect with the left upper extremity. If muscles continue to weaken surrounding the
glenohumeral joint, subluxation of the shoulder may occur. If so, the client and caregivers need
to be educated on proper transfer techniques to avoid improper handling causing further damage
(Reed, 2014). Lastly, caregivers need to be educated on the signs and symptoms of depression.
Depression is often experienced post CVA and if noticed early on, can be handled with ease.
Ways to Monitor Progress of Goals
In addition to standardized assessments, the patients progress will be monitored through
skilled observation by the occupational therapist. Observation provides the therapist with
detailed information as to where progress is being made and if it is not, exactly what component
of a task is permitting progression. Standardized assessment tools will then offer specific
measurements to compare throughout the rehabilitation process.
Standardized assessments that will be used to monitor progress towards goals include the
COPM, the Arnadottir Occupational Therapy Neurobehavioral Evaluation (A-ONE), and the
Stroke Impact Scale. The COPM will be readministered periodically throughout the
rehabilitation process to identify if previously self-identified goals have been achieved and

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whether or not progress has been made in therapy. The A-ONE objectively documents ways in
which dysfunction of client factors affect self-care and functional mobility (Gillen &
Brockmann-Rubio, 2011). Dysfunction may encompass impaired executive functioning. Lastly,
the Stroke Impact Scale is a self-report measurement identifying aspects of CVA recovery in
various occupations (Imms & Nott, 2012). This measurement will be used to assess ways in
which Jonis self-awareness in regards to completion of ADLs, IADLs, functional mobility, and
participation are changing over time.

References
American Occupational Therapy Association. (2014). Occupational therapy practice framework:
Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1),
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