WRHC LivingSkillsMan

Western Region Health Centre
Living Skills
assessment
& intervention
www.wrhc.com.au
Acknowledgements
This manual was made possible through internal grant funding at Western Region Health Centre. The following people are gratefully acknowledged for their assistance and contribution to the project: Muriel Cummins, the team leader of the SRS relocation program for project supervision. Bernadette McCartney the program manager of Outreach, Aged and Disability Services for support for the project. Collette Davis from RDNS, Ben Quinn from ACACIA, and Jane Pinnuck from MACNI for their feedback and suggestions. Staff of the SRS relocation program for piloting sections. This manual was written by Diane Fox.
Contents
Introduction 2 Information to accompany the initial assessment 6 Initial assessment 10 Comprehensive Assessment of Living Skills 15 Introduction to intervention 46
Intervention
53
Bibliography
96
Appendix
98
Introduction
What are living skills?
The term living skills encompasses a broad range of skills that people require in order to participate in the community. A number of organisations run living skills programs and these often involve the teaching of social skills, building social networks, increasing participation in leisure activities and vocational skills. This manual specifically addresses another set of living skills that are required to maintain and sustain accommodation. The skills addressed, and from hereon referred to as living skills are tenancy, community mobility, cooking, meal planning, shopping, cleaning, laundry, personal care, budgeting, banking, money handling, bill paying, medication management, communication, managing emergencies and first aid.
Why living skills assessment and training is important for clients who experience homelessness
Workers in the homelessness sector aim to help clients who experience homelessness to achieve housing stability. Housing stability involves obtaining as well as sustaining housing. In order to sustain housing a person must be able to care for themselves, conduct household duties and fulfil the obligations of being a tenant. While access to affordable housing is the primary barrier for many homeless people, maintaining housing can be a greater obstacle to some (Livingstone& Miller, 2006). Occupational therapists in OA&D assert the importance of living skills assessment to determine the most appropriate accommodation and level of support for clients, and living skills training to enable many clients to maintain housing. Limited living skills has been identified as one of the risk factors for tenancy failure (Jones et al, 2004). Breakdown in housing may occur because of many, often interconnected reasons. Often the cause of housing breakdown is not known, and the transience of clients makes records difficult to obtain as clients move between multiple services. Frequently, difficulties performing living skills go undetected by workers, especially if clients are not seen in their own homes. These difficulties impact greatly on tenancy as well as well-being and quality of life. More extreme consequences of difficulties with living skills may be illness, injuries, or fires. The reasons that clients experience difficulties with living skills are varied. Living skills are usually learned in adolescence, though observation and practice with family. Some people however, do not receive this normal learning experience. Some have never had the opportunity to learn living skills because their parents did not have these skills, or they left home at a time when they would have been learning them. For people with mental illness, the onset of illness often occurs at the time they are learning these skills and this learning is disrupted. Some clients have cognitive deficits as a result of mental illness, ABI or intellectual disability, which affect their ability to conduct their living skills. Examples of these deficits are difficulty with planning, sustaining attention, memory and judgement. Many clients become deskilled after living in environments where they do not have
Why this manual was produced

The Outreach Aged and Disability branch of WRHC has a number of teams that work with clients who experience, or are at risk of homelessness. These are Abode a Community Connections Program, Acacia an Intensive Outreach program, and the SRS relocation team. These teams support clients to obtain stable accommodation and to maintain it. Workers in these teams reported that many of their clients demonstrated some difficulties with their living skills. A survey of these workers as well as Western Region Outreach Service (WROS), a Psychiatric Disability Support Service (PDSS), indicate that the majority of staff assess and support clients with their living skills and believe they would benefit from education in this area. This manual aims to provide workers with a systematic way of assessing living skills, highlight some of the problems clients experience with their living skills so that workers may recognise them more readily, and suggests some methods to remediate these.
Living Skills assessment and intervention
Introduction
opportunities to use their living skills, such as accommodation where there are no cooking facilities or where and bills are included in the rent. Sometimes clients who have lived in these environments for some time, lose confidence in their ability to live independently. Clients with difficulties in these areas frequently compensate for them. This can take the form of living on inadequate nutrition for periods of time between payments, depending on others to assist, such as using welfare agencies to provide food or pay bills, or they may cycle from one agency to another to pay for emergency housing. They may also learn other behaviours which help them to survive such as stealing, selling drugs or sex (Aviles & Helfrich, 2006), these issues then compound their problems. The loss of living skills has been identified as a major challenge for those working with homeless people. It has been argued that when clients have poor living skills which are not addressed, they face a spiral of skill decomposition and dependence (Mosby, 1996, p. 559).
Why a personalised training program is important

While some living skills such as cooking, are taught in group programs in community settings, it has been argued that programs that provide one intervention for all participants may fail to meet the individual needs of participants (Mairs & Bradshaw, 2002) and that people with cognitive impairment and people who experience homelessness often require a personalised program to learn living skills (Helfrich & Fogg, 2007). It is suggested that such a program for people who experience homelessness should allow for repetitive practice and ongoing coaching (Helfrich & Fogg, 2007). Living skills training is a standard practice in Community Care Units and in some of the clinical services in the Victorian mental health system. Studies have shown living skills training to improve skills in clients with schizophrenia (Brown et al 2002, Wong et al 1988). The inclusion of living skills training in programs that address homelessness and mental illness results in greater success with obtaining and maintaining housing (Morse et al, 1992).
Occupational therapy and living skills training

The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation (World Federation of Occupational Therapists, 2004). Occupational therapists are trained to assess a persons level of function in activities of daily living and provide interventions to optimise this. They consider the person in the context of their physical and social environment and how these may affect the persons ability to conduct their activities. An occupational therapy approach to living skills assessment and training involves conducting task analysis to identify where a task breaks down, forming hypotheses about why this occurs, testing hypotheses and making interventions based on these. The crux of this approach is to break down any skill into smaller component skills, identify those the client has difficulty with, and to address these. If a client has difficulty in a living skill, it is often the case that they can perform many of the component skills but have difficulty with some. When a skill can not be learned, an occupational therapist will adapt how the task is performed ether by using equipment to simplify the task or by changing the environment. Intervention utilises client strengths and targets the component skills clients have difficulty with. Living skills training is often conducted by occupational therapists working in the clinical system, such as mental health and acquired brain injury services. However many people who experience homelessness are not current clients of these services and so are unable to access this training.
How to use the manual

This manual is divided into two sections assessment and intervention. Within these sections each living skill is presented on a separate page so that the manual can be divided and skills addressed separately, if the worker desires. Each living skill features in the initial assessment, comprehensive assessment and intervention. The assessment section of the manual consists of an initial assessment interview, followed by comprehensive assessment of each skill. The initial interview provides an overview of how the client is managing their living skills. It is intended to prompt workers to consider all living skills needed to manage tenancy and to highlight areas of concern. It should be noted that the interview is not comprehensive and is subject to the reliability of the clients report. The worker should consider interview results along with any known history and their own impressions of how the client is managing each area. The comprehensive assessment section is designed to expand the information gained in the initial assessment interview. Most sections are composed of assessment by observation of the home, further questions to ask the client and observation of the client performing the task. While it is preferable to complete all of these, it is acknowledged that workers often do not have the time to do so, and sometimes it may not be appropriate to. In this case, observation of the state of the clients home will offer some indication of how they are managing. Furthermore, it may not be necessary to comprehensively assess every living skill. For example, if the client is assessed as managing cleaning the kitchen, lounge room and bathroom, and if other rooms appear clean, it may not be necessary to assess them cleaning every room. Therefore the assessment provides options for how to assess the client, and workers can decide which methods are most appropriate. Refer to figure 1 How to use the assessments to determine what parts of the assessment to use.
Introduction
Figure 1. How to use assessments
Initial Assessment Interview
Is Comprehensive assessment possible?
yes
no
Comprehensive Assessment
Observation of clients home further questions observation of client performing task
Observation
of clients home (from comprehensive assessment)
Is client willing to answer further questions?
yes
no
Assessment
further questions
No further assessment at this stage
Introduction
Description of each living skill

1. Tenancy
This relates to knowledge of the basic rights and responsibilities of tenants. It also involves simple household maintenance, such as changing a light bulb, how to turn off a smoke detector or what to do if the electricity goes off.
10. Bill paying

Reading and paying bills. Knowing options if unable to pay on time. Remembering to pay bills and being reliable with paying bills.
2. Community mobility
Being able to walk to places, take public transport to places, catch taxis or drive.
11. Medication
Collecting medication from the pharmacy, remembering to take medication and taking the correct dose.
3. Cooking & meals

Preparing meals, food handling and storage, as well as planning meals, eating regularly and eating a balanced diet.
12. Appointments
Making, remembering and attending appointments.
13. Communication
Using of telephones and the post.
4. Shopping
Making a shopping list, selecting and purchasing items in a shop and transporting items home.
15. Emergencies & First aid

Knowing first aid for minor ailments and when to seek professional assistance. Knowing where to go for assistance. This includes whether the client actually seeks assistance when unwell.
5. Cleaning
Being able to conduct numerous cleaning tasks, judge when they need to be done, and doing them regularly.
6. Laundry
Judging when clothes need to be washed, knowing how frequently they should be washed, doing the laundry, and putting clothes away.
Other areas addressed in the manual are 14. Support services, 16. Daily routine and 17. Fire hazards. Whilst these are not living skills it is important to consider them, as they can affect the clients ability to live independently. In the case of support services, they affect what interventions are chosen for the client.
7. Personal care
Bathing, grooming and wearing clean clothes, and the frequency of these.
8. Budgeting
Planning a budget, as well as adhering to a budget.
9. Banking & money handling

Using bank services. Recognising the value of money, counting an amount of money and calculating change. It also involves the physical aspects of handling it.
Information to accompany the
Initial Assessment
Considerations for assessment
Assessment can be intimidating for clients, especially if they perceive that it could jeopardise their accommodation. It important to make them feel comfortable so that they will not be stressed by the assessment, as stress can affect their performance. When observing the client performing tasks, try not to assist. This includes verbally assisting them. If the client asks how to do something, ask them how they think they should do it, or ask them to try to do it. If a worker assists in any way, they will not know how much the client can do by themselves. If the client starts to fail at a task, for example if their cooking starts to burn, the worker should try not to intervene and see if the client detects and rectifies the problem themselves, and note at what point they do so. However, if the situation is unsafe, the worker should intervene. Ideally assessment should be done prior to the client moving in, or as soon as possible after they move in, so that any problems can be addressed promptly. When the client has been living in the home for a few weeks make another observation of it, as any problems will become more evident after client has been there for some time. Clients skills should be monitored periodically, to ensure that they are maintaining that level of function. In particular, monitor and reassess if there is a change in their presentation - eg. if they become unwell or if there is an increase in alcohol or drug intake - as their attention to their living skills, and ability to conduct these might deteriorate significantly.
1. Tenancy
If the client has never lived alone it is particularly important to assess their skills to ensure they can manage in the unit. Similarly, if the client has had accommodation break down in the past it is important to try to find out what happened and if necessary, put strategies in place to avoid the problem recurring. If a client has lived independently in the past, it does not a guarantee that they will manage currently. Things that would raise concern are if the client has not lived independently for some time they may have become deskilled if they have not lived independently since a psychiatric admission, their abilities might have declined if there has been a deterioration in their mental state or they have increased their drug or alcohol intake, their abilities may have declined
Information to accompany the initial assessment

The following section describes the rationale for asking the questions in the initial interview.
The type of accommodation the client has been living in may alert the worker to areas they may be deskilled in eg. A rooming house may not have had cooking facilities which would indicate that cooking skills should be assessed. If possible and with clients permission, contacting previous case managers can provide valuable information. Clients sometimes do not provide an accurate account of their accommodation history; they may be reluctant to, or they may not remember it properly. When clients have a psychiatric admission, they should be assessed by an occupational therapist prior to discharge. With the clients consent, you may be able to request a copy of the OT assessment by contacting the hospital. This will tell you about the clients living skills at the time of discharge and recommendations for accommodation and supports at that time. It may explain the reasons behind a client being discharged to particular accommodation or may indicate areas of concern which you should monitor. Similarly, case managers may be able to provide information about clients past accommodation histories. If a problem emerged when the client was unwell that threatened their tenancy, eg failure to pay rent, monitor this closely if client has more episodes of illness, as clients may encounter the same problems with each episode.
Initial Assessment
2. Community Mobility
A client may be independent with transport because they are familiar with transport routes in that area, but may require training to familiarise themselves with new routes if they move to another area. Mental health issues can also affect ability to use public transport. Some clients have phobias or delusions that interfere with their ability to go out, or use public transport. Some clients rarely leave their unit due to a number of things such as the above and poor motivation or depression. Asking the client if they have any problems going out may elicit this information. Intervention for this is outside the scope of the manual however assessment needs to note what the client is able and unable to access, and the implications of this on other living skills considered. When a client is rarely going out, ensure the assessment covers areas such as how they are getting their shopping done and going to appointments. Also consider if they have contact with anyone, if they are socially isolated, and how they occupy their days.
4. Shopping
Some clients only shop at corner stores which are more expensive than the supermarket. Clients who go to the supermarket or market may have difficulty transporting shopping home, especially if carried in plastic bags. This may cause them to purchase small amounts (as opposed to shopping in bulk economically) and if they only go once a fortnight, they may supplement this shopping with shopping at the corner store.
5. Cleaning
Consider that when a client is moving to more independent accommodation they will have to do more cleaning than in the current accommodation. As with cooking, cleaning may not have been done in the past due to cultural or environmental reasons. Unless the client is going to receive council services, they will need to learn how to clean in order to live independently. If the client does not know how frequently to clean, it may indicate it has been a long time since they have done cleaning or lived independently. The client may have insight into difficulties with cleaning and if they identify problems with this, it will help you when you do training.
3. Cooking & Meals

There are varying levels of complexity of meal preparation. Some clients do not cook at all. Some prepare simple meals like sandwiches or toast. Some would like to cook but do not because they lack access to a kitchen. Others have never cooked and have no interest in learning how to. Culture and gender of the client may influence motivation to cook, eg. some men believe it is not their role to cook. Ask the client about this if this is suspected. Some clients are unsafe cooking and if a client intends to cook in their new accommodation you should observe them doing so. This is particularly the case if they have not lived independently before, if there is a history of fires in past accommodation or if the reason for breakdown is not known, if there is an increase in their drug or alcohol intake, or deterioration in mental state.
6. Laundry
An SRS may do some of the laundry for clients so it is important to establish how clients will manage their laundry when they live independently. Moving home may mean a change in the type of laundry facilities available, which may require training.
7. Personal care
Some clients do not attend to their personal hygiene for long periods of time due to a number of reasons such as amotivation, delusions and lack of access to showers. Clients may be prompted to shower by SRS staff, case managers or other workers such as nurses; consider if the client will have this support in their new home. When clients live alone it can be difficult to judge how frequently they bathe. They may not give you an accurate account of this and your observation of them over time is the most reliable method.
Meal planning
Asking clients to describe what they eat in a week provides a lot of useful information. It gives an indication of their diet; some clients have extremely poor diets and poor nutritional intake. This information reveals how many meals clients eat; some clients neglect meals and may only have one per day, or go without food for days. It also gives an indication if a lot of their money is spent on takeaway food, which has implications for their budget.
Initial Assessment
8. Budgeting
Clients often have difficulty managing their budget. Sometimes clients go without food for days between pays. Clients may spend impulsively, spend money on drugs or alcohol or gambling, or prioritise things they cannot afford. Cigarettes can consume a large amount of a clients budget if they live on a pension or benefit. Takeaway food can also quickly use up a budget. Some clients are vulnerable to exploitation by others who borrow money which is not returned. Clients who are more at risk are those who are unassertive and have difficulty saying no, and those who live in accommodation where people stand over others. Some clients also give money they cannot afford give away, to people who ask for it such as charities.
12. Appointments
If you suspect the client may have difficulty attending appointments, ensure that the comprehensive assessment relating to appointments is done.
13. Support services

If the client receives support services, this needs to be considered in further assessment, e.g. if a client receives Meals On Wheels (MOW) and does no other cooking then assessment would involve only heating their meals.
9. Banking & money handling.

Most clients are able to access their bank account. Some clients have specific problems relating to banking; for detail see the comprehensive assessment and intervention sections.
14. Communication
Most of the clients are able to use phones and some have mobile phones, however some clients experience problems with these.
10. Bill paying

If client has been living in a rooming house their bills are included in their rent and they would have not had to budget or pay them. If this is the case, ensure the functional assessment for bill paying is done.
11. Medication
If the client has been living in an SRS their medication is supervised. There the client does not collect their medication from the pharmacy, measure their dose or remember when it is due. If the client takes medication and is moving out of an SRS it is important to consider how medication will be managed in the new accommodation and whether the client can manage each of these tasks.
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Initial Assessment
You will need a separate piece of paper for this assessment.
Rate each item (2-13) as follows: Evidence of skills deficit Skills need assessment Independent Skills Use the clients responses to the questions, as well as your knowledge of the client, to inform your rating.
1. Tenancy
1. What type of accommodation do you live in? eg. rooming house. 2. Do you live with anyone else? 3. Are you having any problems in your current accommodation? If so, describe
2. Community mobility
1. How do you get around? 2. Do you use public transport? 3. Do you have any problems getting around? If so, describe
4. How often do you get out of the house? Evidence of skills deficit Skills need assessment Independent Skills
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Initial Assessment
3. Cooking & meals

1. Do you do any cooking? If yes- i) what type of things do you cook? eg simple meals such as toast, or more complicated meals such as cooked dinners.
If no- ii) have you ever done your own cooking? If so, how long ago? 2. Do you receive delivered meals such as Meals on Wheels?
3. Do you have any difficulty with cooking? If so describe
4. On a separate sheet of paper, write down each of the meals you usually eat in a week. eg. breakfast, lunch and dinner for each day, (prompt and/or write them for the client if necessary).
Evidence of skills deficit
Skills need assessment
Independent Skills
4. Shopping
1. Do you currently do any grocery shopping? If yes i) does anyone help you? If so describe
2. Do you have any difficulty with shopping? If so describe
3. Where do you do your shopping?
4. How do get there? (eg. walk, public transport)
5. How do you get groceries home? (eg. carry in bags, delivered)
6. How often do you go shopping? Evidence of skills deficit

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Independent Skills
Initial Assessment
5. Cleaning
If living in independent accommodation
1. How often do you clean your home? (prompt for each main area)
2. Do you have any problems with cleaning? If so, describe
Independent Skills
6. Laundry
1. Do you have a washing machine/ dryer /clothes line/ use the laundromat? 2. How often do you do the laundry? 3. Does anyone help or remind you to do your laundry? If so describe
4. Do you have any problems doing laundry? If so describe
Independent Skills
7. Personal care
1. Do you have any problems with personal care such as showering, washing hair or brushing teeth? If so describe
2. How often do you do each of these? 3. Does anyone assist or remind you to do these?
Independent Skills
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Initial Assessment
8. Budgeting
1. What is your source of income? 2. Does anyone help you manage your own money? If so, describe
3. Do you have debts? If so, describe
4. Do you run out of money between pays? If so describe
5. Do you borrow money, or lend or give it to others? If so, who to and how often
Independent Skills
9. Banking & Money Handling

1. How do you access your bank account (eg. Eftpos, go into bank)? 2. Do you have any problems with using your bank account? If so describe
Independent Skills
10. Bill paying

1. Do you pay any bills currently? 2. How do you pay your bills? (eg. Bpay, Post Office, Centrepay, EasyPay, State Trustees).
3. How do you pay your rent?
4. Do you have difficulty paying bills? If so describe
Independent Skills
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Initial Assessment
11. Medication
1. Do you take medication? If no go to q.12 If yes i) is medication supervised? If so give details 2. Do you have any medical conditions requiring monitoring such as diabetes? If yes i) how is this monitored? ii) if equipment is required for monitoring, do you have this?
Independent Skills
12. Appointments
1. Do you have any regular appointments? If so, what are they? 2. How do you remember when your appointments are? Does anyone remind you?
3. Do you have problems attending appointments? If so describe
Independent Skills
13. Communication
1. Do you have a phone? 2. Do you have any problems using a phone? If so describe
Independent Skills

1. Do you have any support services? (eg. RDNS, case manager) If so, who
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Comprehensive Assessment
Combine the information from the initial interview with information from this assessment. The assessments have been divided into observation of the client or their home, questions to ask the client and observation of the client performing the task. The worker must choose which skills to assess and which methods of assessment are appropriate. Decide which areas to assess comprehensively based on the initial interview and knowledge and impressions of the client. At a minimum, a lot of information can be gathered by visiting the clients unit and making observations of it. It is recommended that if the client is to be observed performing only a few tasks then choose cooking, cleaning (kitchen) and shopping. At the end of each section are notes which accompany some of the questions. These explain why a question is asked or provide additional information about it. It is suggested that the worker familiarise themselves with these prior to the assessment. A note about vision: Prior to assessment it is useful to establish whether the client is able to read without difficulty. If the client has glasses ensure they wear them in assessments. The clients ability to read can affect much of this assessment, for example if they have poor vision they may not clean their unit thoroughly, may not see signs and prices in the supermarket, and may not be able to read bills.
Ask the client

1. Do you wear glasses? 2. Do you have trouble reading? 3. Can you read small print, e.g. the mail?
1. Tenancy
Ask the client
1. How do you change a light bulb? 2. What would you do if a tap was dripping a lot? 3. What would you do if all the lights went off? 4. What would you do if you accidentally broke a window? 5. What would you do if the oven stopped working? 6. If you could not pay the rent on time, what would you do?
This is not an exhaustive list but these are some of the basic skills or knowledge that a client needs to live independently. If a client does not know the answer to any of these ensure that they are taught maintenance that they are responsible for, and that of the landlord. Also ensure that they know the obligations of the tenant and landlord.
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Functional Assessment
Ask the client
1. How would you find out how to get to somewhere you dont know how to get to?
2. What would you do if you got lost?
3. Do you buy a ticket on public transport?
4. If not, do you have outstanding fines?
Observe the client going out

5.Are they safe around traffic? eg. do they check for cars before crossing roads and when getting on or off trams.
6.If they use public transport ask them to read the timetable and tell you when the next tram/train/bus is.
7.Do they buy a ticket? 8.Do they have any difficulty buying a ticket? 9.Do they know where to get on and off transport?
4. Some clients amass large debts through not paying fines, incurring additional charges. Some fail to pay fines they receive because they seem unmanageable or they do not know how to ask for an extension or negotiate paying it off.
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3. Cooking & meals

Ask the client to prepare a meal that they know how to cook. If they cook things that require them to use more than one pot, then ask them to cook this. This is because it is more difficult to attend to several things cooking at the same time. If the client has not cooked but is going to start, encourage them to start with something not too complex and to use a recipe. While the client is cooking take the opportunity to look around the kitchen and note if they have an adequate amount of food in the unit and what type of food they have?
Observe the client going out

1. Does the client wash hands before meal preparation?. 2. Does the client choose correct cooking implements and kitchen wear for the task, e.g. use a spatula to turn a fried egg.
3. Does the client handle hot items correctly, e.g. use tongs to pick up hot food, pick up saucepan by handle, use oven mitt if necessary?
4. Is client cautious handling hot water, hot oil and around steam?
5. Is client cautious around hotplates and gas burners, e.g. does client reach over lit burners, wipe hotplates while still hot?
6. Does client turn oven or appropriate burners on without difficulty?
7. Does client turn oven or appropriate burners off promptly after use?
8. Does client handle knives safely? 9. Does client appear to be familiar with the basic steps in food preparation such as how to cut up vegetables, how to heat things, how to boil or fry things?
10. If client is using a recipe do they follow the steps?
11. Does client use appropriate measures of food, e.g. use appropriate amount for the meal, put in amount specified in recipe.
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12. Does client consider how long it takes to cook each item, so that everything will be completed at the same time?
13. Is client able to attend to several pots cooking at the same time or do they seem to ignore one or more?
14. Does the client adjust cooking temperature as required? If the client is managing cooking well, start a conversation with them.
15. Is the client able to maintain attention to the cooking while talking to you or do they start to neglect it?
16. When client finishes cooking, does the food appear to be adequately cooked?
17. Ask client how they judge when food is cooked?
18. Does client clean up after cooking?
19. Does client store food correctly?
20. Choose some foods that client has and ask how long they can be stored in the fridge/ in the freezer/ how do they know how long things have been in the freezer?
21. Ask client how they can tell when food and drink have gone bad?
1- 8 The above present safety risks and may indicate unfamiliarity with cooking but could also indicate cognitive problems. If there are any problems with these an occupational therapist should assess. 9-10 Clients who are unfamiliar with cooking may appear clumsy cutting things up and do things such as not peel onions before chopping them or not discard ends of vegetables. Some clients may do things which are unsafe such as put metal in microwave, put an unopened or unpierced tin of beans in a saucepan of boiling water, put meals on wheels containers directly onto hotplates. This may indicate cognitive problems but could also indicate unfamiliarity with cooking. If there are any concerns about safety an occupational therapist should assess. 11. These can indicate that the client is unfamiliar with cooking or can indicate cognitive problems. If the client does not learn to do this after being shown, an occupational therapy assessment should be conducted. 13. Some clients can only attend to one pot at a time and when you observe this it looks like they do not notice, or forget, the others. Even if the other pots start to boil over or burn, they may not notice or respond to them for a while. This can indicate a cognitive problem. An occupational therapist should assess. 14. This can indicate unfamiliarity with cooking or a cognitive problem. If the client does not learn this after being shown an occupational therapy assessment should be conducted. 15. If they start to neglect it, it can indicate they have a cognitive problem. If a client is distracted from the cooking, e.g. by the TV or the phone and does not return to it, or if there is an unreasonable delay to return to it, or needs to be reminded to, then there is a risk of fires. For any of these issues, an occupational therapist should assess for safety. 16 -17. These can demonstrate unfamiliarity with cooking or cognitive problems. If the client does not learn this after being shown an occupational therapy assessment should be conducted. 21. Clients with head injury and with schizophrenia can have an impaired sense of smell (correct answer is by smell and/or observation, not by taste).
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4. Shopping
If possible, do the shopping assessment prior to the cooking assessment, that way you can make sure the client has the ingredients they need for the cooking. Ask client to make a shopping list and have a look at it. Not everyone uses shopping lists but this way you can determine if the client buys everything they intended to.
Prior to shopping Observe

1. Does client check cupboards to see what they need? 2. Does client make a list that contains a variety of groceries such as food, cleaning products, toiletries?
Ask client
3. How much money do you have for the shopping? 4. How much do you think the shopping will cost?
In the supermarket observe

5. Is the client able find their way around the supermarket and locate what they want?
6. If the client cant find items do they ask for help from shop assistants?
7. Does the client buy appropriate amounts of products, e.g. do they buy too much?
8. Does the client check prices on products? 9. Ask the client how much a product costs. Is their answer correct?
10. Does the client compare prices to find the cheapest product? When they select something ask them why they chose it.
11. Does the client consider value, i.e. both quantity and cost when choosing products? Ask them about this if necessary
12. Is the client able to determine value? Pick out 2 different sizes of the same brand of product e.g. a kilo of Homebrand rice costs $1.00 and kilo of Homebrand rice costs 80c and ask the client which is better value.
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13. Does the client check use by dates? 14. Does the client consider the quality of produce such as fruit and vegetables?
15. If applicable, is the client able to use the delicatessen? e.g. do they take a number, do they know how to ask for quantities of products?
16. Does the client purchase all the items on their shopping list?
17. Does the client purchase the items they intended to? (e.g. if laundry detergent is on their list and they select fabric softener instead).
18. Did the client shop within their budget (from q3)? 19. How does the client transport groceries home? 20. Does the client have difficulty carrying bags, or getting the groceries home?
4. Is this a realistic estimate and is it within their budget? 6. Some clients go back and forwards in a supermarket which is not a great problem unless it causes the client to become frustrated and upset. Some clients have difficulty locating what they want in the store. 7. Buying inappropriate amounts of product can indicate various cognitive problems or unfamiliarity with shopping. There could also be a reasonable explanation for it, such as the item being on sale. If the client buys a large amount of a product, ask them about this. 9. This will show you if they check prices and if they do so accurately. 10. Some clients buy things which have a sale sign on them believing them to be the cheapest option without considering the price, similarly some buy all things which are Homebrand. 12. Some clients will say that the cheaper one is better value.
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5. Cleaning
5.1 Lounge room Observe the client clean the lounge room
1. Does the client clean the room adequately? i.e. are all main tasks done such as empting ashtrays, throwing out rubbish, cleaning floors?
2. Does the client use cleaning products and equipment correctly? i.e. does client use the correct equipment or product for the task, do they know how to operate appliance, and if not can they work it out for themselves?
3.
Does the client observe safety using electrical appliances? eg. do they turn power point off before unplugging vacuum, do they trip on vacuum cords, do they vacuum over cords, do they vacuum wet areas?
4. Does the client do the tasks in a logical sequence? eg. if vacuuming several areas do they vacuum some areas repeatedly and miss others?
Ask the client

5. How often do you clean the lounge room?
If you do not observe this task ask the client

6. What is involved in cleaning the lounge room?
7. How often do you do each of these tasks?
3. If safety is a concern an occupational therapist should assess. 5. From your observation of the room, consider if the clients answer appears to be accurate 7. From your observation of the room, consider if the clients answer appears to be accurate.
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5.2 Bathroom and toilet In the bathroom and toilet observe
1. Does the bath/ shower appear clean? 2. Does it appear to have been used? (e.g. is there dust inside it).
3. Are towels reasonably clean? 4. Is the toilet clean?
Observe the client clean the bathroom and toilet.

Does client use correct products and equipment for the task, e.g. use toilet brush
5. Does client use the same cloth for toilet and basin? 6. Are all the tasks involved in bathroom cleaning completed?
7. Are they done to an adequate standard?
Ask client
8. How often do you clean the toilet, the bath, the basin, the floors, the walls?
9. How often do you wash the towels?
If you do not observe this task ask the client

10. What is involved in cleaning the room?
2. Sometimes the rest of the unit looks lived in and the bathroom is quite clean which can indicate the client is not bathing (the same applies to the towels, also check if there is soap, shampoo etc in the shower, these may indicate a problem with personal care). 8. Clients sometimes clean areas and do not seem to notice obviously dirty areas such as mould on the basin. 10. Based on how the bathroom appears, does this appear to be accurate information? 12. From your observation of the bathroom and toilet, consider if this answer appears to be accurate.
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5.3 Bedroom Observe
1. Do the sheets appear clean?
2. Are there sheets on the bed / do they cover the mattress?
3. Is there evidence of cigarette burns on the bedding or on the floor?
4. Is the room generally clean?
5. Are there piles of clothes lying around?
6. If you are able to, have a look in the wardrobes, are clothes hung up or are they on the bottom of the wardrobe.
7. Are there clothes in the drawers?
Observe client cleaning

8. Does the client clean the bedroom adequately? ie. are all main tasks done such as tidying, putting clothes away, cleaning the floor?
9. Does the client use cleaning products and equipment correctly? i.e. does client use the correct equipment or product for the task, do they know how to operate appliances?
10. Does the client observe safety using electrical appliances? e.g. do they turn power point off before unplugging vacuum, do they trip on vacuum cords, do they vacuum over cords?
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11. Does the client do the tasks in a logical sequence? e.g. vacuum after dusting.
Ask client
12. How often do you do each of these cleaning tasks?
If cleaning is not observed ask the client

13. What is involved in cleaning the bedroom?
14. How often do you do each of these cleaning tasks?
2. Some clients do not know how to make a bed and the sheets may not be covering the mattress. 3. Note the fire hazard this presents. See interventions section 7. 9. Based on your observation consider if this appears accurate. 10. If there are any risks to safety an occupational therapist should assess.
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5.4 Laundry In the laundry observe
1. Is the laundry generally clean? 2. Are there piles of dirty clothes? 3. Look inside the washing machine; are there washed or unwashed clothes inside, does it smell as though they have been left there for some time?
Observe client clean the laundry

4. Does client use cleaning products and equipment correctly?
5. Does client do the tasks in a logical sequence? e.g. mop the floor after doing other tasks?
6. Is the room cleaned adequately?
Ask the client

7. How often do you clean the laundry? 8. If there is a dryer ask how often do you clean the lint filter?
If you do not observe the client clean the laundry, ask the client
9. What is involved in cleaning the laundry?
8. Based on your observation consider if this appears accurate. 10. Based on your observation consider if this appears accurate.
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5.5 Kitchen In the kitchen observe
With clients permission look inside the oven, microwave, fridge, and in all cupboards or try to do this as client opens them during tasks. Observe for dirty dishes or food scraps in cupboards. Observe for rancid or mouldy food. Also look to see if client has cleaning products. 1. Is the kitchen generally clean? 2. Is there an excess of dirty dishes piled on the sink? 3. Do floors appear generally clean? 4. Is the bin overflowing? 5. Are there rubbish and food scraps left around on benches? 6. Are there an unusual number of flies or pests in the kitchen?
Observe the client cleaning the kitchen

7. Does the client use appropriate products for each task? e.g. dishwashing liquid, floor cleaner. 8. Does the client use appropriate amounts of product for these? e.g. excessively foamy sink, fill sink too full so that it overflows when dishes are put in it.
9. Does the client move objects to clean areas, or do they clean around objects leaving dirty areas? e.g. do they move a light chair when mopping the floor?
10. Does the client clean the kitchen to an adequate standard? eg. are all tasks completed or are some things not attended to?
11. Does the client have difficulty with any tasks?
Ask the client

12. How often do you clean the kitchen?
If you do not observe the client cleaning the kitchen ask them
13. What is involved in cleaning the kitchen?
12. Based on your observation consider if this appears accurate. 14. Based on your observation consider if this appears accurate.
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6. Laundry
Observe the client and the unit
1. Does the client often wear dirty clothes?
2. Are there lots of dirty clothes in the unit, either in piles or in laundry baskets?
Observe the client do their laundry

3. Does the client use the machine properly i.e. turn it to appropriate setting, water level?
4. Does the client use detergent; do they use appropriate amounts of detergent?
5. Does the client use a dryer or clothes line?
6. If a laundromat is used how does the client carry clothes there?
7. Does the client complete the laundry? i.e. wash, dry then put clothes away.
8. Does the client observe safety precautions while using the washing machine or dryer?
Ask client
9. Does anyone help you do your laundry (eg council services)? If so how often do they do this and what do they do
2. Client was asked in initial interview how often they do their laundry, based on your observation of the clothes in the unit and what the client wears, consider if this appears accurate and if the frequency is adequate. 6. If it is difficult for clients to get clothes there it may deter them or they may only take a small amount of clothes. 7. If they use a clothes line you probably will not be at the unit long enough to see this task completed so check that clothes are not still on the line the next time you visit. 9. If someone assists them, in assessment ensure the client is able to do the aspects of the task they are required to, e.g. take clothes off the line and put them away.
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7. Personal care
You will not be able to observe this being performed, so you will need to assess this through the means below over a period of time.
Observe the client

1. Does the client appear dirty (discreetly look at hands, nails and forearms, and neck and face)?
2. Does their hair appear to be oily, unkempt or matted, are they unshaven, are their nails long?
3. Is the client malodorous? 4. Do their teeth appear badly decayed? 5. Do their clothes usually appear to be dirty? 6. Do they always wear the same clothes?
Observe the bathroom

7. Are there personal hygiene products in the bathroom? e.g. soap and shampoo in the shower recess, or toothpaste and toothbrush at the basin.
8. Does the client share a bathroom with others?
Ask the client

9. Do you use deodorant? 10. How often do you change your clothes? 11. When did you last visit the dentist?
2. Some of these may be the clients fashion choice so ask about them. 6. Sometimes a client will wear the same clothes repeatedly, or may not be changing them and sleeping in them. This can be due to a number of reasons; examples are, they may only have one or two sets of clothes, they may have poor motivation, or they may have delusions about this. If you notice that the client usually wears the same clothes ask them about it. 7. This can indicate client does not shower or that client showers without using soap. As you observe the client over time, do they ever appear to have had a shower? e.g. is their hair wet (though this is not always a sign they have had a shower as sometimes clients only wet their face and hair in the basin), is the shower recess wet or bathroom steamy, are towels wet? Does the shower or bath appear to get used e.g. does it remain clean while the rest of the unit gets dirty, is there dust in the bath? If you notice that the client is not showering, ask them about it. It is important to understand the clients reason for why they are not. 8. Sometimes when clients share a bathroom they are not comfortable using it, and this may be a reason some do not shower, or shower infrequently. This can also apply to the toilet, and clients may keep a bucket in their room for this purpose.
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8. Budgeting
Ask the client
1. On a separate piece of paper, write down all your income and expenses for a month, prompt if there are expenses that they do not include.
If client reported in initial interview that they run out of money between payments ask
2. When you run out of money, how do you manage until the next pay?
3. Do you run out of food in this period?
4. What would you do if you noticed that a pay had not gone into your bank account?
Observe
5. Over time observe if the client lives within their budget regularly.
1.
Does their income equal expenses?
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9.1 Banking Observe client banking
1. How do they withdraw money? 2. Do they appear to have any problems doing so? 3. Does client check their money? 4. Do they put it away promptly? 5. If they keep their PIN number written down, is it kept securely?
Ask the client

6. Do you have a credit card?
If client uses a keycard ask

7. How do you remember your PIN number?
9.2 Money handling Observe the client

When they are shopping, observe the client. 1. Does the client hand over correct money and check their change?
Also observe how the client stores their money.

2. Do they keep it in a wallet? 3. Do they carry around large sums of money? 4. Are they careful with putting money away or do they carry it in their hands or put notes loose into pockets where they could slip out easily?
Ask the client

1. If you gave $2.00 for a purchase of $1.85, would .15c change be correct? 2. If you gave $5.00 for a purchase of $1.35, would $3.55 change be correct? 3. If you had $10 and bought something that cost $4.50, how much change should you get?
2.1 When clients have a problem with mental arithmetic, they may hand not over enough money or may hand over an excess (e.g. if they buy something for $5 and have $10 and $20 in their wallet they may hand over the $20), they may not count out how much they hand over, and accept change without checking it. When clients have difficulty with this they are vulnerable to getting short-changed at shops and exploited by people who become aware of this.
2.4 Some clients are at risk of losing money because of where or how they carry it.
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10. Bill paying

Show client a bill, either one they have in their unit or one you take with you.
Ask the client

1. What it this bill for? 2. Who is it addressed to? 3. How much needs to be paid? 4. When should it be paid by? 5. How would you pay this bill?
6. What number would you call to enquire about it? What would you do if you couldnt pay a bill by the due date?
7. What would you do if you couldnt pay rent on time?
From your knowledge of the client

7. Is rent usually paid on time?
8. Are bills usually paid on time?
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11. Medication
If client takes medication
Ask the client

1. When do you take your medication and what doses do you take?
2. Where do you collect your medication from?
3. Are there times when you do not take it, if so why?
4. Do you ever forget to take medications? If so what do you do?
5. Ask the client to read the labels on the bottles and count out the correct number of pills. Do they do this accurately?
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12. Appointments
Ask the client
1. What is the day and time?
2.
Where would you go if you need a doctor?
3.
Where would you go if you need a dentist?
From your knowledge of the client

4. Does the client seek assistance when required?
5. Does the client have difficulty when required to wait in a medical centre waiting rooms or in Emergency Department for appointments?
Observe
6. Does the client remember appointments you have with them?
2. & 3. Ask the client for a location; alternatively if they say they would use a phone book to find one, ask them to do so.
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13. Communication
Observe client using the phone
1. Does client have difficulty dialling phone numbers?
Ask client
2. How would you find a phone number that you dont have?

No further assessment for support services.
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1. What would you do if you got a cold? 2. How bad would that need to be for you to go to a doctor?
3. What would you do if you burned your hand with boiling water?
4. How bad would that need to be for you to go to a doctor?
5. What would you do if you suddenly started getting severe chest pains?
6. What number do you ring for ambulance, police or fire brigade?
16. Daily routine

Ask client
1. Briefly describe a typical days activities, eg. time you get up, what you do in the day and when you go to bed.
This reveals much about the clients daily routine, social contacts and activities
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17. Fire hazards

Observe
1. Is there an operating smoke detector in the unit? 2. Does the client smoke inside?
3. Are there cigarette burns on furniture or the carpet?
4. Is there a risk client could fall asleep while smoking, eg. watching TV or in bed?
5. What type of oven is in the unit? If it is gas is there is a risk client may leave gas on?
6. What type of heating does the unit have?
7. Are there clothes or other items on the heater?
8. Does client turn heater off when they go out?
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Intervention
Introduction to Intervention
Intervention refers to a task or activity which is designed to meet an identified need. The assessment section of this manual is intended to help identify areas that a client experiences difficulty with so that intervention can be targeted at these. The following section provides suggestions for intervention which are informed by an occupational therapy approach. The intervention section of the manual, like the assessment section, is arranged according to living skills. At the beginning of each living skill is a list of the problems more commonly encountered in this client group. These are accompanied by suggestions for interventions to manage these problems and examples of how these may be implemented. There is no one intervention that will work for every client because the reasons for difficulties with living skills are often a combination of issues and unique to each client. Also, the manual cannot cover every possible problem or intervention in detail. Therefore it aims to familiarise workers with some methods that are used to deliver intervention. These are described below. The worker is required to decide which intervention and which method is best for the client and this may involve trying a number of different methods. By reading the entire manual the worker will develop an understanding of these methods. A further aim of the manual is to raise the workers awareness of the amount and type of assistance they provide to the client during intervention; as the goal is to decrease worker assistance and increase clients independence in tasks. This requires the worker to have an ability to be aware of, and monitor their input when the client is performing a task. At times workers may perceive that they provide very little assistance to a client and assume the client can do the task independently. When they withdraw support they then may not realise why the client does not perform it at the level they did previously. The manual aims to help workers identify all the levels of assistance they provide. It also offers suggestions for how to replace or reduce worker assistance with aids or strategies, in order to increase clients independence.
Skills Training
The training presented in this manual draws upon skills training approaches (Nemec et al, 1992). Skills training is based upon learning principles and uses behavioural techniques; these are outlined below. The purpose of living skills training is to restore or establish skills. When this can not be achieved, the manual suggests interventions to enable the person to live independently.
Learning principles
Skills training involves teaching, therefore some understanding of the principles of teaching and adult learning is useful. Those most relevant to the client group are presented here, for a more comprehensive discussion see Berkeland and Flinn (2005). In order for the client to learn a new skill they must perceive that there is a need to learn it. Part of the teaching process should involve ensuring that the skill to be developed has meaning and relevance to the client. Some of the work with the client may involve helping the client identify what the gaps in their skills are, and how learning the skill will benefit them. Without relevance to the client, there will be no motivation for them to learn it. The client also requires a readiness to learn. Often a significant event is the catalyst for an adult to undertake learning. They may perceive that learning something new will help them to adjust to or manage the new situation. In the case of the clients of this service, motivation often comes from having obtained accommodation and a desire to keep it. Past learning can also affect skills training. The client may already be able to perform some aspects of a task and these can be built upon. Alternatively, the client may have entrenched ways of doing a task, which may be difficult to change if this is necessary. The assessment sections of this manual aim to help the worker identify what aspects of a task the individual is able to do already and those which they need training with. In this way the training can be targeted at only those areas the client requires. This helps to increase the clients participation and motivation because training focuses on parts of skills they need to learn and avoids reteaching those they already know (Nemec et al, 1992). The preferred learning style of the learner can also affect training. Some people learn best through visual methods, such as watching someone else do the task, others through auditory methods such as listening to
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instructions of how to do the task, and some learn best through practice of the task. It may be difficult to know which type of training best suits each client and when this is not known it is best to incorporate all modes to ensure that clients learning style is accommodated. The environment that skills are taught in will also influence the learning. Skills are retained more effectively if they are taught in the environment in which they are going to be used (Godden & Baddeley, 1975). If a client learns a skill in one environment it does not necessarily mean that they will be able to conduct it in another environment. For example they may learn to shop in one supermarket and then be unable to in another because it is arranged differently. For this reason, teaching living skills in the unit the client will live is advisable. Similarly, when a client moves their living skills may need to be reassessed. The supports the client receives affect what the client needs to learn. If the client is not going to perform a task there is no need to teach it, for example if they are going to receive Meals on Wheels they may not need to learn to cook. The social environment can also influence what a client wants to learn, eg. in some cultures men are not expected to cook. If the client states that they will not perform a skill in their accommodation and you are satisfied that this is reliable information and that it will be managed, e.g. client gets meals on wheels, then assess and train only what the client is required to perform e.g. heating the meal. Other services can also impact on client learning and where possible should be informed about the training. Clients sometimes have involvement with several services at the same time and lack of communication between them may result in inconsistent approaches which may affect training. For example when one service is trying to teach a client to live within their budget and another provides material or financial assistance to the client. The ability to learn can also be affected by physical and mental state so if a client is too uncomfortable or unable to concentrate then it is best to defer the training. The cognitive abilities of the client may also affect learning, and information may need to be presented in a way which is manageable for the client. For example some clients can only remember a small amount of information at a time and giving the client too many instructions at once may overwhelm them.
Interventions
Types of intervention
The types of interventions described in this manual are skills training, compensatory strategies and environmental modification. When a client is unable to learn tasks or aspects of tasks, compensatory strategies may be used. This might involve changing how the task is done or using a device. Examples of these include teaching a client to cook in a microwave, or to use a dosette. Environmental modification may also be used when skills are unable to be learned. This involves changing the physical or social environment. An example of this is removing a stove to reduce risk of fires.
Methods of skills training
Supervision
Supervision involves monitoring the clients ability to perform a task. It is often done to ensure there are no risks to them in a task, or to ensure they are able to do a task. An example would be supervising cooking. If someone is described as requiring supervision in a task it usually means they are able to do the task without assistance but at times may require some intervention, eg. someone with memory problems may require supervision when cooking to ensure the stove is turned off. In supervising, you do not provide any assistance; this includes not providing verbal prompting or demonstration.
Verbal prompting
This involves telling the client what to do or describing how to do it. It may involve you telling the client the steps as they do them, or telling them several steps of a task at once and then allowing them to do these. What they are capable of can depend on many factors including how much information they can retain and how familiar they are with the task. It is important not to overwhelm the client with too much information. If they are learning a new skill, this itself can be challenging enough. Verbal prompting may also be appropriate when a client knows most of the steps of a task and just needs a reminder or a small amount of advice to accomplish it. Verbal prompting such as a phone call, may be appropriate when a client has difficulty remembering things they need to do, eg. appointments. In verbal prompting you do not do things for the client or show them how to do something. The advantages of verbal prompting are that the client performs the task with the workers guidance. Through performing the task they learn the procedure for it. This prompting also allows the worker to highlight any errors as they occur and the client to correct them.
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Written prompting
A task is broken down into steps and written down and the client uses this to refer to and accomplish the task without anyone elses assistance. Examples of written prompting include recipes and instructions of how to get somewhere. Other examples of written prompts include diaries, weekly schedules and reminder notes. How much detail is required depends on the client. Write down instructions for how to do something, let the client trial it with you observing; it should then become apparent if the client requires more or less detail, amend the instructions accordingly and trial them again. The advantages of written prompting are that it can be used in the absence of the worker and is especially useful for people with memory problems.
Feedback
Feedback involves telling the client how they performed in the task. It should be constructive and include what the client has done well as well as what was not done well and how it could be improved. It also needs to be clear and direct. When appropriate, ask the client how they think they performed the task and what they would like to do better. This encourages them to judge and correct their own performance (Nemec et al, 1992).
Education
Training also may involve providing knowledge or information to clients to enhance their performance in a skill. For example, it may not be enough to teach the client how to clean their kitchen; they may also need education about why it should be done and how often it should be done. Clients may also benefit from education when there are gaps in their knowledge; for example they may know what the responsibilities of a tenant are, but not those of landlords.
Demonstration
If verbal assistance is not enough to enable a client to do a task, then use demonstration. This involves showing the client how to do something. Either do the same task side by side with the client, to allow them to watch what you are doing and to practise it at the same time, or show them how to do the task, beginning it yourself and have them complete it to practice what they have observed. Explain what you are doing as you do it. Demonstration is useful when it is easier to show how a task is done than to describe it. This is frequently the case in more complex tasks like cooking and cleaning.
When to refer to an occupational therapist

The strategies described in this manual are used with people with cognitive problems, however the degree of cognitive impairment and presence of other issues can make learning more difficult. Refer to an occupational therapist in the following instances when training does not improve the clients skills when the client does not seem to learn new ways of doing things when compensatory strategies do not assist the client when there is a risk to the clients safety if you are unsure of how to address the problems they have with their skills An occupational therapist can assess the clients abilities in their living skills, train the client in living skills, provide secondary consultation about how to train the client and make recommendations about the type and level of support required.
Grading
Grading involves gradually building the clients skills to achieve a task. With grading, a task is made easier for a client, either by providing assistance or modifying it, then gradually increasing the demands of the task. It involves breaking a task down into steps, identifying those the client has difficulty with, teaching the client those steps while providing as much assistance as the client requires to complete them, then reducing the amount of assistance as they master the steps. An example of grading is when you learn to drive; a driving instructor will first teach you on quiet streets and at slower speeds and increase the speed and traffic conditions as you become more experienced.
Engaging the client in training

Ensuring the client identifies the areas that they would like to work on is important to engage them in intervention and enhance their motivation. As mentioned above, the client needs to recognise a need to participate in the training and for the goals to be their own. In order to assist this, a visual aid to help clients identify areas they need to address may be used; see Figure 2 Areas to work on. This could be done either before or after assessment. The worker may ask the client to mark the areas that they would like to work on. This can be used as the basis of a discussion about areas for training.
Examples of grading in skills training are:

the amount of assistance provided by the worker, eg full assistance to minimal assistance to supervision. the type of assistance provided eg. demonstrate a task, then use verbal prompting then supervision. using strategies to make the task easier, and then withdrawing these as the clients skills increase, eg. using a simplified cookbook and progressing to a standard cookbook. The advantage of grading is that if performing an entire task is too difficult for a client, it allows them to increase their skills and confidence gradually.
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Figure 2 Areas to work on
Tenancy Cleaning
House cleaning Laundry Home maintenance & rights and responsibilities House cleaning Laundry
Money Management
Budgeting Banking Bills & rent
Personal Care
Personal hygiene Medication
Health Care
Minor first aid Appointments Emergencies
REF
Food
Planning meals Shopping Cooking
Community
Community mobility Communication
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Intervention
1. Tenancy
Common problems encountered with tenancy and strategies to address these
Difficulty with problem solving which causes clients to have difficulty managing problems that arise. As a result they may leave things unattended or become distressed by them. For these clients it may help to have a list of possible scenarios and solutions to them, see the written prompting example below. It is also important that they have someone they can contact in emergency situations, when they do not know what to do, e.g. a case manager or a friend. Lack of experience dealing with tenancy issues and lack of knowledge of their rights and responsibilities. Provide with written information and explain it to the client. Not knowing how to perform simple maintenance tasks. Demonstrate these and practice them with the client. Not keeping track of when rent is due. Try a calendar, diary, reminders. Not knowing that they can ask for an extension to pay rent, or how to do so. Educate the client about this. If necessary demonstrate it and allow the client to rehearse this. Following this, supervise their conversation with the landlord. Losing keys. Place on a chain which can clip onto clients belt buckle. Alternatively a key safe can be mounted outside the clients home (see appendix 1 for product list). They will need to remember a numerical pass code to unlock the key safe.
Written prompting
For a client who has difficulty with solving problems, it may be necessary to have a list of possible scenarios and what to do if they occur. This could be laminated and kept somewhere easy to find. An example of part of such a list is If the tap is dripping report it to the landlord. If the washing machine stops working, turn the machine off, level out the load, then turn the machine on again. If this fails, report it to the landlord. If the toilet will not stop flushing, push the button quickly. Try this a few times. If this fails report it to the landlord. etc.
Demonstration
Clients may require demonstration to learn household tasks that are the responsibility of tenants. This may include education about how to detect the cause of a problem e.g. if a trip switch has turned the power off. Demonstrate to the client how to tell if the trip switch is turned off and then set it at on and off and ask the client whether it is on or off. This may be made easier by labelling on and off in large print. Demonstrate turning it on and then turn it off, show the client that the lights are all off, then ask the client to turn the switch back on.
Grading
If the client has no experience dealing with landlords and is not comfortable to call them, grading could be used. First demonstrate to the client a phone call to the landlord, with the phone on speaker so the client can hear the conversation. The next time the landlord needs to be called, prompt the client on what to say and rehearse the call with them, then allow the client to make the call with the worker supervising and prompting if necessary. The following time prompt the client about what to say prior to the call, but do not supervise it, and discuss it with the client afterward.
Methods of implementing strategies

Verbal prompting
If the client has difficulty remembering to pay the rent, verbal prompting might involve reminding them before it is due and/or on the day. Verbal prompting might also be used to teach a client how to do simple maintenance tasks, for example talking the client through the steps of changing a light bulb as they change it.
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Education
Some clients will require education about tenancy and what is their responsibility and what is the landlords. This may be accompanied by written information to reinforce the education and for the client to refer to in future.
Intervention
Common problems encountered in community mobility and strategies to address these
Difficulty remembering to buy a ticket or how to buy a ticket. Pre-purchased tickets can simplify the task. Difficulty remembering the route number, departure time, or stop number. Write directions down and take them on the trip to refer to. If the client cannot learn where to get off they can tell the driver the stop number they want to get off at. If the client is unable to reliably take transport independently they may need to be provided with transport to appointments. Travelling without a ticket. Ask client the reason for this. Educate about possible consequences. If this is a goal of intervention then the clients budget may be addressed and a pass purchased as part of this. Ignoring fines. See bill paying on page 82.
Written prompting
Write down instructions for the client for to take on the transport with as much detail as the client requires. This may be where to get on the bus, the bus number, what type of ticket to ask for and how to identify where to get off the bus, either the stop number or through landmarks. You may supervise the client on the trip to ensure that the instructions are adequate and amend them if the client needs more detail.
Demonstration
Show the client how to perform each step of the trip. Show them how to get to the stop, where the stop is, how to read a timetable, how to purchase a ticket, how to hail a bus or tram, how to signal to get off, and where to get off. Have the client try to do these by themselves the next time.
Grading
Initially provide whatever assistance the client needs on transport, and then reduce the amount of assistance provided as the client acquires skills. At any stage the client could use written directions, instead of getting assistance. For example Trip 1: Demonstrate to the client how to take the trip. Trip 2: Accompany the client on the trip showing them where to catch the bus from, have them hail it and buy their own ticket, show them where to get off. Trip 3: Accompany the client on the trip. Have them find the bus stop, hail the bus, buy their ticket. You show them where to get off. Trip 4: Supervise the client on the trip. You sit at a separate seat to them. Trip 5: Have the client take the trip alone and report back to you how they went.

Verbal prompting
If travel training the client, verbal prompting may involve telling the client how to get to their destination and having them do it by themselves and reporting back to you how they managed. The verbal prompting may include telling them where to get the transport from and where to get off, the times the transport will depart, the tram or bus number, or name of the train line, how to purchase a ticket and how much it will cost, and asking the client to check that they have change for the ticket. Alternatively you might supervise the client throughout the trip and provide verbal prompting only if required. If you supervise the client, ensure that they go ahead of you in all the steps. Tell them that you want them to show you how to take the trip, alternatively tell them to pretend that you are not there. Be aware that if you walk ahead of them to the bus stop you will be giving them prompts about how to find the bus stop, sometimes even walking alongside the client may give prompts about where to go and what to do. On the bus, get on the bus after the client and sit separate to them. Allow them to ring the bell to get off. If they look to you to indicate if they should ring it, let them know they need to decide.
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Intervention
3. Cooking & meals

3.1 Cooking
Common problems with cooking and strategies to address these
Forgetting to wash hands before cooking. Put up a note in the kitchen reminding client to wash hands before cooking, prompt client. Lack of familiarity with cooking techniques. Educate and demonstrate. If client is using a cook book ensure they understand all terminology e.g. saut, dice, simmer, etc. Difficulty following or understanding standard cookbooks. Use simplified cook books (see appendix 1 products list). Difficulty planning how long things take to cook, so parts of meal (eg pasta sauce and pasta) may be ready at different times. Educate, prompt and practise. Could use simplified cook book. Using incorrect implements or items for a task e.g. sauce pan in microwave. Educate about correct use, ensure client has all necessary cooking equipment and implements. Difficulty attending to two or more pots at a time. Teach meals that can be cooked in one pot. Alternatively, use a microwave or rice cooker to cook vegetables or rice. Difficulty judging when food is cooked (undercooking or overcooking food). Educate and demonstrate. Forgetting how long food has been in the fridge for. Teach to check dates on products. Teach how to check if food has gone off. Label items in the fridge and freezer with dates purchased, and keep a chart of how long foods can be stored in freezer/ refrigerator. Forgetting to turn off appliances. Put a note near the door reminding the client to turn off appliances before leaving the kitchen. Forgetting to turn off stove. There are a number of strategies and devices that can be used depending on the level of risk and the clients ability to respond to strategies - Use timers on the stove to remind how long to cook items and/ or to remind to turn stove off. - A gas detector (alarm) could be installed. - a device can be fitted to the oven that will automatically turn it off after a period of time. - Replace a gas oven with an electric oven if client smokes, to reduce the risk of fires. - Cease cooking on the stove and teach microwave cooking. - Have meals on wheels delivered and teach simple meals that do not involve cooking for other meals. For any risks to safety or health an OT assessment should be made.

Verbal prompting
If teaching cooking the client could prepare a meal with you telling them what to do as they prepare it. Determine the amount of detail they require depending on what they already know how to do. For example you may be able to give them the instruction cut an onion and the client will know how to do this, alternatively you may have to describe to the client the steps involved in cutting an onion.
Written prompting
The client uses a recipe to prepare the meal. There are some books that have very basic and simple recipes, which may be useful for clients who do not have much experience with cooking. There are also simplified cook books designed for people who have cognitive difficulties. They have limited text, clear large print instructions and photographs of each of the steps involved (see appendix 1, products list).
Demonstration
Show the client how to prepare the meal. Explain what you are doing as you do each step. At each step encourage them to try the task, eg. you start cutting the onion, showing them how to do it, then ask them to finish it. Alternatively they could cut an onion while you cut another onion, to allow them to watch you and practise it themselves at the same time.
Grading
Provide as much assistance as the client requires to complete the cooking task, and over subsequent sessions you gradually withdraw assistance. For example, cooking vegetable pasta using a recipe Session 1: Ask the client to read the recipe out loud. At each step prompt them to check the recipe to know what to do next. Instruct the client how to put the pasta on to boil. Demonstrate to the client how to cut up each vegetable, only doing half of each, and have the client complete them. Demonstrate how to fry the vegetables and then get the client to take over the task. Tell the client how to judge when they are cooked. Tell the client when to add pasta sauce and how to judge when the sauce and the pasta is cooked. Tell the client to turn off the hotplates. Demonstrate how to drain the pasta, and instruct the client on how to serve it and the pasta sauce.
Session 2: Prompt the client to follow the recipe. Give verbal prompting of how to cut up each of the vegetables, demonstrate again if they do not remember. Supervise the client cooking and give verbal prompting as required, this may be for the timing of each item and when to add ingredients, when they need to be stirred, when they are cooked, if there is a risk of burns. Verbally prompt how to drain pasta and serve it. Check hotplates are turned off and prompt client to do so if necessary.
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Intervention
Session 3: Prompt the client to follow the recipe and tell them you want them to do as much as possible by themselves. Supervise each of the steps and direct the client to check the recipe if they are having difficulty. If the client asks for advice, ask them what they think they should do. If they ask for assistance, ask them to try by themselves first. Give verbal prompting if required. Session 4: At the beginning of the session encourage the client to use the recipe. Aim to provide supervision only.
Education
Educate the client about the need to have a balanced diet and use their weekly meal plan to consider whether they include all the food groups and recommended proportions of these.
Verbal prompting
If the client wants to work on meal planning, make a table with 3 rows for breakfast, lunch and dinner and 7 columns, one for each day of the week. Prompt the client to fill in what they would like to eat at each meal for the next week. Prompt the client to keep it within budget and aim for a balanced diet. Use strategies such as cooking in bulk and freezing meals to save money and the effort of daily cooking. Use the meal plan to make the shopping list. Encourage the client to incorporate meal planning into their weekly routine. They can copy from previous meal plans to simplify this task.
3.2 Meal planning and diet

Other aspects related to meal preparation are meal planning and adequate diet. Adequate diet involves the types and amounts of food eaten. Consider the information from the initial interview Q3.4 or Q3.6, meals usually eaten in a week. Based upon what you have observed of the food in the clients home and the cooking they do, does the information appear correct and does the client have an adequate diet? Use the information about the clients meals as a basis for a discussion about the importance of eating regularly and a variety of foods. If there is an obvious problem in the clients diet eg. if they eat only one meal a day, ask them about why that is.
Written prompting
To improve diet the client could keep a list of healthy meals or snacks they can prepare to refer to when making their meal plan and shopping list. They could keep a copy of the food groups chart to refer to when making their meal plan.
Common problems encountered in meal planning and diet and strategies to address these
Lack of knowledge about what constitutes a healthy diet. The client may need education about food groups and having a healthy and balanced diet. Not knowing how to cook and eating takeaway food instead of cooking. Work with the client to teach them cooking. Not liking cooking and preferring takeaway food. One way to work with this is by exploring what types of takeaway the client likes to eat and teaching them how to cook this. Educate about how much money this saves and how much healthier it is. Difficulty planning the shopping and therefore not having the food needed to cook. Work with the client on planning meals, making a shopping list and doing enough shopping to last until the next pay. Difficulty with budgeting resulting in not having enough money for food. Work with the client on budgeting. The client may prioritise other items above food. If diet is inadequate they may need vitamin supplements while addressing this and working on living skills. Poor dental health will affect what clients are able to eat. Consider balance in diet and work on personal hygiene and attending dental appointments (see sections 7 & 12). The client may believe it is cheaper to buy takeaway than to purchase ingredients for meals. Work with the client around budgeting and compare the costs of making meals and buying takeaway. The client may not want to cook every day. They could be taught how to cook in bulk and freeze meals.
Grading
To teach meal planning Step 1: Initially you might supervise the client making their meal plan and prompt with suggestions for meals, and supervise and assist them to use this to make a shopping list. Step 2: Over time you would reduce the assistance provided to checking the meal plan and shopping list once they have made them. Step 3: Once they are managing this, check the meal plan only.
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Intervention
4. Shopping
There are many different skills involved in shopping and if the client needs to learn a number then it may be best to focus on just one skill or a few at a time. When teaching take into consideration that shops can be busy, noisy environments which can be distracting for clients and make learning more difficult. Some skills can be taught at home where there are fewer distractions, then practised in the store, for example teaching how to calculate value for money or how to read labels. Prior to shopping, encourage the client to make and use a shopping list so that they remember all items. If the client does not check what they already have at home when making the list, encourage them to do so.
Difficulty choosing between a number of similar products, they may need education about the differences between products. Alternatively, it may help to choose a particular brand for each product and buy this each time. Difficulty problem solving if the shopping does not go to plan, eg being able to substitute if an item is not available. Teach client to ask for staff assistance. Purchasing items on impulse, buying non-essential items when there is only enough money for essential items. It may help to discuss prioritising things on the shopping list, and buying essential items first. Becoming frustrated when having difficulty with any of the above. Worker may need to grade the task and provide some assistance. The client may also need to have rest breaks during the shopping. Not checking use by dates. Educate client about how to check dates and prompt them to do so. Where clients do their shopping can be an issue it is not economic if they buy all their food at a convenience store and they should be encouraged to shop at markets and supermarkets. The client may have reasons they do not shop at these places such as the travelling distance, so talk to the client about this and look for solutions. Not planning the shopping within budget, resulting in not having enough money for the shopping. Prior to shopping, assist client to make shopping list and estimate cost of each item and write this on the list, add up total cost and ensure the list is within budget. In shop, prompt client to purchase items at price estimated.
Common problems encountered in shopping and strategies to address these

Difficulty selecting products which are value for money. Educate, demonstrate how to calculate value. If this does not work, keep a list of what brand to choose for each product and buy the same each time. Difficulty locating items in a store. Teach by repeatedly showing where the items are or keeping a list of where to find the items. Be aware that problems can arise again when the store layout changes and the client may need to relearn this. Difficulty transporting groceries home. Explore what is causing the problem. The client may benefit from buying a trolley or backpack to carry the groceries or have them delivered. If client cannot learn to shop and if they are able to access an internet, they can buy groceries over the internet and have them delivered. Not checking prices of products or having difficulty identifying the price, clients may then impulsively pick the first item they see, may choose anything that has special thinking that it is the cheapest product, may pick Homebrand thinking that is the cheapest. The client may need education about pricing and calculating value or use compensatory strategies (below). Being tricked by products that advertise they are lite, low calorie, low fat etc. when these products are often low fat but high calorie, or marginally different to other products. The client may need education about this type of advertising and about how to read labels.
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Intervention
Verbal prompting
The following example demonstrates how the worker can use prompting as a way of offering a minimal amount of assistance, to help the client to the next step of the task, to see if they can complete it from that step. If a client has difficulty locating items in the store, for example a tin of tuna, the worker could verbally prompt them to check the signs at the end of the aisles. If they cannot find the correct aisle, the worker could show the client the correct aisle and explain how they found it for example they located tinned fish on the sign, then ask the client to find the tuna in the aisle. If the client cannot find it in the aisle then the worker could walk the aisle with the client showing how products are grouped together and show the client the signs in these sections, then ask the client to find the product. If the client cannot find the right section the worker could take the client to the right section explaining how they found it and ask the client to find the tuna. If the client is unable to find tuna or decide which tuna to buy the worker could show the client the tuna area and explain the differences between the varieties and allow the client to choose which one they want.
Written prompting
If the client has difficulty finding where items are located in the store, a list of what items and the aisles they can be found in could be made. There are also lists kept at the end of aisles of most supermarkets that could be used to make this list. The clients shopping list could be arranged in the order of the aisles to make this easier.
Demonstration
Clients may benefit from demonstration of things such as how to use overhead signs in the store, how to ask for goods in the delicatessen, how to select the best fruit and vegetables, how to weigh produce and how to judge value for money. For example, to demonstrate how to select bananas, show the client bananas and explain the differences between the varieties, how to tell if they are ripe, not to buy ones that are bruised, explain that if client bought green ones that they will ripen at home and how long this might take. Show the client how to find the price of the bananas and how to weigh them and estimate the cost. The client should then demonstrate these steps to the worker, explaining their reasoning for choices.
Grading
An example of grading for a client who becomes overwhelmed and stressed in the supermarket would be to start with a small amount of items on their shopping list and gradually increase it. Alternatively the worker could find some of the items for the client and the client could find the others, and over time the amount of items the client is required to find could be increased.
Education
Clients can benefit from education about some aspects of shopping such as reading labels on products, how to calculate value for money and how to shop on a budget.
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Intervention
5. Cleaning
5.1 Lounge room
Common problems encountered in cleaning and strategies to address these
Not cleaning things adequately. Give feedback, demonstrate and prompt. Cleaning around objects instead of moving them, e.g. cleaning around an ashtray. Give feedback, demonstrate and prompt. Cleaning the room in an illogical order, eg vacuum the floor then do the dusting and wipe the coffee table. Give feedback, educate about a logical order, give verbal prompts while cleaning and / or write down order to clean in if necessary. Cleaning in a haphazard sequence, eg vacuum one part of the room, then switch to the hallway, then vacuum another part of the room then do the first part again. This results in some areas being done several times and others neglected. Give feedback, educate about a logical order, verbally prompt, write down order to clean in if necessary. Not cleaning frequently enough. Educate about how often tasks should be done. Use a roster of when to do each cleaning task, include a space to tick when each is completed if necessary. Give feedback and prompt client verbally when cleaning is required. Not knowing what cleaning products to use, or the amounts to use. Label products to make it clear what they are used for and the amount to use, eg. floor cleaner, window cleaner. When mopping, not rinsing the mop frequently enough. Educate, prompt verbally while mopping. If necessary teach to rinse the mop after cleaning a certain amount of the room. Not changing the mopping water. Demonstrate what happens when mopping with dirty water. Demonstrate when to change the water. If client cannot judge when to change water, teach them to change it after mopping a certain number of areas. When mopping, not wringing the mop out, causing excess water to pool on the floor. If the water has not been changed this results in dirty puddles and when these dry they become grey areas. Demonstrate and prompt. Not mopping effectively, may be because client is not pushing the mop hard enough. Provide feedback, demonstrate, prompt.
Not noticing that an area that they have attempted to clean, is still dirty (i.e. bits stuck to the floor are neglected, dirty marks remain). This can happen for a number of reasons such as vision, perception and attention. Check if the client should be wearing glasses, if not give client feedback and demonstrate if necessary. When wiping surfaces with a wet cloth, not rinsing the cloth. Prompt the client to rinse it. Some clients have difficulty rinsing the cloth (they have problems with coordinating the action of rinsing and it does not get rinsed as a result) and require demonstration and practice. Unwinding too much vacuum cord and it becoming an obstacle, then tripping on it or vacuuming over it. Give feedback. The client may physically or mentally fatigue if they try to do all the house cleaning at once. Have rests, or spread it out over the week. Lack of motivation to clean. Amotivation is one of the effects of schizophrenia and can result in clients failing to do their cleaning even if they have the ability to do so. Try to find things that will help motivate the client to clean, eg. a friend coming to visit. Try to establish a routine for cleaning. Some clients may not be motivated to take care of their home because they have such a history of transience that it does not feel permanent to them. Consider ways to make it feel permanent, such as encouraging them to decorate it and help them set it up. If the client continues to have difficulty with cleaning, some may be eligible for council Home Help.
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Intervention
Verbal prompting
While the client is cleaning the lounge room, make suggestions about how to do the cleaning. This could involve telling them the tasks that need to be done, suggesting the order of tasks, or how to do tasks. It may involve observing what the client does and then giving feedback and suggesting what to do; for example if the client cleans around furniture the worker might show the client what they have missed and suggest the client move the furniture to clean. Verbal prompting might also take the form of asking the client a question in order to draw their attention to something that needs to be corrected. This encourages the client to identify the issue and correct it without being directive. Your goal is for the client to do things independently and this involves them being able to recognise errors and self-correct them. An example of this is if you notice that the coffee table has a full ashtray on it, you might ask the client if they have finished cleaning the coffee table. For clients who have simply overlooked this, this would be enough to prompt them to clean it. For other clients you may need to give feedback and be more directive.
Demonstration
If the client is unable to perform the cleaning with verbal prompting, then demonstrate it to them. In some tasks, it is much more effective to show how something should be done than to explain it. There are less frequent aspects of cleaning that the worker should ensure the client knows, such as how to change a vacuum bag or what to do when it becomes blocked. When a client has learned the basic tasks it is also important to ensure they know how to clean walls and windows.
Grading
If the clients lounge room gets very messy and it becomes a big task, you could grade cleaning by giving them some assistance. You could make a deal with the client that if they clean one area you will clean another. Over subsequent sessions however, the amount of assistance you provide should be reduced.
Written prompting
This is useful if the client does not remember all the steps of a cleaning task, or how often to do it, or they do not know the best sequence for the tasks involved in cleaning. The prompts involve written instructions such as what to clean, how often the tasks should be done, what products or equipment to use, or the order of doing the tasks. The level of detail required depends on the client. To determine this you would need to observe the client doing the task with verbal prompting and keep a note of what prompting they need. Write these prompts into instructions of how to clean the room. At the next session, give the instructions to the client and observe if they are able to clean the room using them. If they require further detail then add these to the instructions and use this next time.
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Intervention
5.2 Bathroom and toilet
When teaching to clean these areas, do not forget to also teach how to clean shower walls, mirrors, shower screens and curtains. It may b e appropriate to wait until the client has mastered the basic tasks. The client should also be taught how frequently to do each of these tasks.

Verbal prompting
Supervise the client cleaning the bathroom and toilet and offer feedback and prompting as necessary. Examples of when to give prompting are if you observe the client miss areas, skip steps, not clean areas adequately, use the wrong product or use cleaning equipment incorrectly or for the wrong purpose, use too much or not enough product, or to help the client do the task more efficiently. Decide how to give the prompting depending on your knowledge of the client. You could say you forgot to use floor cleaner or you could say is there something else that you should use to mop the floor?
Common problems encountered in cleaning the bathroom and toilet and strategies to address these
Lack of knowledge of how to clean. Educate, demonstrate, supervise and prompt when cleaning. Using the same cloth to clean all the areas of the house. This can sometimes include the toilet. Provide feedback. Store cloths in containers which are labelled with the areas that they are used for. When wiping surfaces with a wet cloth, not rinsing the cloth. Provide feedback, prompt the client to rinse the cloth. Some clients have difficulty rinsing the cloth (they have problems with coordinating the action of rinsing and it does not get rinsed as a result) and require demonstration and practice. Not knowing how to use products or cleaning equipment. Demonstrate, prompt. Not knowing what cleaning products to use, or the amounts to use. Label products to make it clear what each is used for and the amount to use, eg. floor cleaner, window cleaner. Not doing the cleaning frequently enough. Educate, make a roster. Provide feedback and prompt when the bathroom looks unclean. Lack of motivation to clean. Try to find things that will help motivate the client to clean, eg. a friend coming to visit. Aim to make cleaning part of clients routine. Not cleaning things adequately eg. mouldy areas around taps. May be due to not knowing the technique for cleaning. Provide feedback, prompt when cleaning, demonstrate how to clean. Not noticing that an area that they have attempted to clean, is still dirty (i.e. bits stuck to the floor are neglected, dirty marks remain). This can happen for a number of reasons such as vision, perception and attention. Check if the client should be wearing glasses, if not give client feedback and demonstration. Not mopping effectively, may be because client is not pushing the mop hard enough. Provide feedback, demonstrate, prompt. Not changing the mopping water. Demonstrate what happens when mopping with dirty water. Demonstrate when to change the water. If client cannot judge when to change water teach them to change after cleaning a certain number of areas. When mopping, not wringing the mop out causing excess water to be spilled on the floor which does not get mopped up causing it to pool. If the water has not been changed this results in dirty puddles and when these dry they become grey areas. Demonstrate and prompt. If client is unable to learn to clean effectively, Council Home Help may be used if they are eligible.
Written prompting
Write the steps involved in cleaning the bathroom and toilet. This may include the order to do them in, the products to use and how much of the product to use. Observe the client and adjust the instructions depending on whether the client requires additional information to do the cleaning.
Demonstration
If the client is unfamiliar with cleaning it is likely that the worker will need to demonstrate how to clean the bathroom and toilet. It is difficult to describe to someone the techniques used in cleaning, like how hard to scrub, how to clean the mould around taps, how to clean a mirror and concepts like how clean a toilet should be; it is much easier to show them. Demonstrate the cleaning and ensure the client practices it while you supervise and prompt them. Demonstrate again if necessary.
Grading
Session 1: Show client how to clean the mirror and have them complete it. Show the client how to scrub the bath and basin and have them complete these. Have the client sweep the floor. Show them how to mop the floor and have the client complete it. Session 2: Have the client clean the mirror with you prompting verbally and demonstrating if necessary. The client scrubs the bath and basin with you prompting verbally and demonstrating if necessary. The client sweeps and mops the floor with you prompting and demonstrating if necessary. Session 3: Aim to provide supervision only, but provide prompting and demonstration if necessary. Give feedback. If assistance was provided then continue sessions until client does not need any prompting.
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Intervention
5.3 Bedroom
Common problems encountered in bedroom cleaning and strategies to address these
Disorganisation in the bedroom, compounded by a lack of furniture to help organise it, eg no laundry basket. Help the client purchase items for organising the bedroom and prompt client to use them. Amotivation to clean, resulting in a build up of dirty clothes and other items. Try to find things that will help motivate the client to clean. Aim to make cleaning part of the clients routine. Infrequent cleaning of the bedroom. Provide feedback and verbal prompting or a roster. Lack of knowledge about the frequency of tasks, eg sheets never get changed. Provide education, written information or a roster. Lack of knowledge or familiarity with how to perform cleaning tasks. Provide demonstration and prompting and encourage practice. Not cleaning things adequately. Give feedback and prompt client on how to do the cleaning properly. Demonstrate if necessary. Cleaning around objects such as laundry basket, instead of moving them. Give feedback and prompt client to move items. Illogical sequencing of the cleaning, eg vacuum first and then dust the room. Provide feedback and prompting, write down the order of cleaning tasks if necessary. Lack of knowledge about products or equipment to use. Educate, prompt. Development of habits. Some clients develop habits that make the room dirty or offensive smelling eg. using objects such as drawers as ashtrays and not cleaning them, leaving clothes that have been worn repeatedly lying around eg. socks. Educate, prompt, encourage use of appropriate household goods to organise clothes.

Verbal prompting
Supervise the client cleaning the bedroom. Provide prompting as necessary and ensure that you also provide positive feedback about what the client does well. The kinds of things you would prompt about are ways the cleaning could be made easier, how to do things more effectively, any areas that have been missed or to offer advice if the client has problems doing the cleaning.
Written prompting
Write down instructions of how to clean the bedroom. This may be the order of the tasks, the procedure for certain things, products to use and how much to use. Observe the client use these instructions to clean the room and add more instructions or detail if necessary.
Demonstration
Demonstrate to the client how to change sheets, change a doona cover, vacuum the floor and ways to keep a room tidy, eg. Put dirty clothes in a laundry basket, hang clean clothes or put them in drawers. Demonstrate the task, explaining what you are doing and then have the client practice it, e.g. make the bed, then take the sheets and doona off and ask the client to make it so that they practice what they have observed you do. Alternatively you can start making the bed and have the client complete it.
Grading
Cleaning the bedroom could be graded by the amount or type of assistance you provide. The client could start the cleaning and if they are unable to complete it, you could complete it for them, with the understanding that next time they will try to do a bit more. Alternatively they could leave the task unfinished and complete it later, eg after a break or the next day. In this instance grading would involve trying to increase the amount of cleaning that the client is able to do before having to discontinue the task.
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Intervention
5.4 Laundry
Common problems encountered in laundry cleaning and strategies to address these
Not cleaning the lint filter. Check that the lint filter is clean due to the fire risk this can present if not cleaned. Educate the client about this risk, prompt and put a note near the dryer if necessary. Not cleaning things adequately. Give feedback, demonstrate and prompt. Neglecting to clean the laundry. Provide feedback and prompt when the laundry looks unclean. Make a roster if necessary. Cleaning the room in an illogical order, eg mop the floor then wipe the benches. Give feedback, educate about a logical order, prompt, write down order to clean the laundry in, if necessary. When wiping surfaces with a wet cloth, not rinsing the cloth. Provide feedback and prompt the client to rinse it. Using the same cloth to clean all the areas of the house. Educate client. Place cloths in containers and label what areas they are used for. Not knowing what cleaning products to use, or the amounts to use. Label products to make it clear what is used for which task and the amount to use, eg. floor cleaner, window cleaner. Lack of motivation to clean. Explore things that might help motivate the client to clean.

Verbal prompting
Supervise the client clean the laundry and prompt if this is required. Some examples of things you might prompt are what to clean, the order of cleaning, equipment to use, products to use and the quantity of these to use. Also prompt if the client is having difficulty, if the task is left incomplete, and if there is a more efficient way of doing the task.
Written prompting
A note on the dryer or on a wall to remind the client to change the lint filter is an example of written prompting. Other examples would be labelling of products to use for each task and quantities to use, or a note on the calendar of when to clean the laundry.
Demonstration
Demonstrate to the client how to remove, clean and replace the lint filter. Allow them to practice this after showing them. Explain the importance of cleaning it after each load.
Grading
Cleaning the laundry is one of the smaller tasks involved in housecleaning and it does not usually get very dirty anyway. It normally involves wiping the benches, changing the lint filter and sweeping and mopping the floor. The floor is usually cleaned when other areas of the house are being cleaned. So if grading is required it might involve cleaning the laundry less frequently than other areas of the house (provided it is relatively clean).
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Intervention
5.5 Kitchen
Cleaning the kitchen is one of the more complicated areas of the house to clean and requires the client to know how to clean and how frequently to clean a variety or areas. This involves tasks that need to be done at least daily, weekly and other tasks that are less frequent. Some tasks that we may consider to be very simple and assume the client would know how to do, are not done well by clients and can complicate cleaning. It is important not to make assumptions about what the client can do. An example of something we might assume clients to be able to do is filling the sink; however some clients fill the sink so full that if they add dishes afterwards water overflows onto the floor. If client is unable to clean kitchen adequately, use council Home Help if they are eligible, for the heavier cleaning tasks and focus efforts on light tasks such as cleaning up after themselves and cleaning dishes.

Verbal prompting
Observe the client clean the kitchen and prompt as necessary. This may involve drawing the clients attention to areas they have missed, suggestions for how to be more efficient with cleaning, and help with any problems they encounter. The client could be prompted when it is time to do the less frequent tasks, such as clean the refrigerator.
Common problems encountered in cleaning and strategies to assist these

Not cleaning frequently enough. Teach client about when items need to be cleaned by providing feedback. Establish a routine for cleaning the kitchen through education, providing feedback and prompting when the kitchen looks unclean. Not storing things appropriately, eg leaving milk out on bench. Educate. Prompt when necessary. Infrequently emptying bin in kitchen causing it to attract insects, mice or to smell. Provide feedback and prompt when necessary. Forgetting to put rubbish out on collection days. Prompt, use a note, calendar, roster, or council information stuck on refrigerator to remind of collection days. Not cleaning thoroughly, neglecting to clean areas, cleaning around objects. Client may benefit from feedback, prompting and demonstration to develop better methods of cleaning. Not paying attention to areas that require extra effort, eg when food is stuck to benches the client may lightly wipe over it and not try to remove food. Check if the client should be wearing glasses, provide feedback and demonstration. Illogical sequence for cleaning, causing areas that have been cleaned to become dirty, eg. clean floor then wipe bench scraps onto floor. Provide feedback, prompt, write down the order for cleaning the kitchen if client does not learn it after several sessions. Using the same cloth to wipe the dishes and the floor, provide feedback, store cloths in separate labelled containers. Not knowing what cleaning products to use, or the amounts to use. Label products to make it clear what is used for which task and the amount to use, eg. floor cleaner, window cleaner. Not rinsing cloths, not rinsing the mop or changing water used for mopping. Educate the client about this and provide feedback, demonstration and prompting as required. When mopping, not wringing the mop out causing excess water to pool on the floor. If the water has not been changed this results in dirty puddles and when these dry they become grey areas. Not mopping effectively, may be because client is not pushing the mop hard enough. Provide feedback, demonstrate, prompt.
Written prompting
A roster of what to clean each week, ensure that tasks like putting out the rubbish and cleaning the microwave are not overlooked. A calendar can be used to remind of the less frequent tasks like the refrigerator or the oven. If the client does not know how to approach the task of kitchen cleaning, a list of what tasks to do and the order to do them in could be made. The level of detail will depend on what they require, it may be simply a list of tasks or it may describe each task. For example washing the dishes - Collect all the dishes from around the kitchen. Discard any scraps on them in the rubbish bin. Place all dishes next to the sink. Put water and detergent in the sink. Wash dishes using brush or sponge. If any food remains stuck, scrub with scourer. Place each dish in dish drainer after it has been washed. Leave to dry, then place in cupboards.
Demonstration
Sometimes when a client is unfamiliar with a task it is more effective to demonstrate it to clients than to describe it; examples of this are how soapy the dish water should be, how to wash dishes, how to rinse dishes, how to dry dishes (if not drip drying). The refrigerator and oven are more difficult items to clean and may need demonstration. Start the cleaning, demonstrating how to clean and explaining what you are doing and have the client finish the cleaning. In the task of cleaning the refrigerator you would also demonstrate how to judge when food should be discarded and reinforce how long foods can be stored or frozen for.
Grading
An example of grading the kitchen cleaning is Session 1: Demonstrate the main kitchen cleaning tasks, having the client practice each with prompting as required. Session 2: Observe the client doing the cleaning, provide prompting as required and provide demonstration if prompting is not sufficient. Session 3: Aim to supervise cleaning, however prompt if required.
53
Intervention
8. Budgeting
To teach budgeting, work out all the clients expenses over a period of time, it might be convenient to do the pay period. Divide these into essential and non-essential expenses. Ensure that the budget includes some money for clothing and personal items. Envelopes can be used to help the client budget. This method helps to ensure that there is enough money for each of the clients expenses. The client writes on a number of envelopes what each is to be used for eg. rent, food, bills, entertainment, cigarettes and how much money is allocated to each. Their pay is then divided amongst the envelopes. Money is taken from the appropriate envelope when needed. Encourage the client not to borrow from other envelopes. Some of the skills from the shopping and bill paying sections of this manual will help with budgeting. Also teach ways to save money such as shopping around for deals on expensive items, such as mobile phones, and where to shop for cheaper items such as markets.
Running out of money and being unsure of where their money has gone. Encourage them to keep a diary of what they spend for a week. Sometimes clients have poor judgement and planning which affects their ability to plan ahead and consider what will happen later if they spend all their money at once. If they do not respond to being educated about this and it is a continuing issue which impacts a lot on them, then it may be necessary to use strategies that limit how much they can spend, make agreements about what they can spend each day, use State Trustees. If client does not keep track of their bank balance, it may help to use an ATM instead of Eftpos and keep the statement. Having difficulty with self-advocacy if a pay does not go into the bank or the wrong amount goes in. Educate the client about their rights and practice what they should say to Centrelink. Supervise and prompt their phone call if necessary. Not setting aside money for bills. In the short-term, teach client that bills can be paid off and how to do so. In the long term teach the client to set aside an amount per pay in a savings account or in an envelope. Not sticking to the set budget. If this becomes so problematic that the client does not pay rent or bills then consider EasyPay, Centrepay and direct debit. If the client uses EasyPay and direct debit and is unable to budget for their other expenses and runs out of money quickly, State Trustees can split their payment and pay this to them more frequently. They also keep an amount aside for things such as emergencies and clothing. Credit cards can be a problem as some clients do not understand how interest works. Some clients do not plan ahead well and when offered a credit card are attracted to the idea of being able to access a lot of money quickly without considering how they will repay it. Educate clients about the costs of credit cards. Giving money to others, giving money to charities or anyone who asks for it. Explore with client why they give it away. They may benefit from assertiveness training, or strategies to manage when people try to take advantage of them.
Common problems encountered in budgeting and strategies to assist these

Buying impulsively. Encourage client to make a shopping list and not to buy anything that is not on it. Supervision and prompting during shopping may help. Not being familiar with strategies to live economically. Teach strategies as in the shopping section of the manual and teach cheap places to shop. Clients who receive their money in instalments through State Trustees do not receive enough money at any one time to go to the supermarket and do their fortnights shopping. This can deter them from buying in bulk and from supermarket shopping. A trial can be arranged for State Trustees to give client enough money to do their shopping; accompany and supervise client. Worker could accompany client to State Trustees to collect the money and then to the supermarket if necessary. Not being able to judge how much can be bought with an amount of money, eg they have $20 for shopping and think they can buy much more than $20 worth of food. Encourage client to estimate what each product will cost when writing the list and to add these up. Provide feedback about the accuracy of this. Teach client to prioritise items when shopping and to put these through the checkout first.
54
Intervention
Verbal prompting
A strategy to help manage a budget is to pay rent and bills and buy essential items as soon as the client is paid. Verbal prompting could involve telephoning the client to remind them to pay their bills, rent and do their shopping as soon as they get paid.
Written prompting
A calendar or diary of when to shop and pay bills may help to ensure these are done on time. Having a list of all things that need to be paid in the pay period may help budgeting.
Demonstration
One aspect of budgeting is being able to shop economically. This could be demonstrated by accompanying the client shopping and encouraging and showing them how to select cheap products. If the client wants to buy items that are not on the shopping list, the worker could demonstrate how the shopping budget will be affected and ask the client to choose which items they will remove from their shopping list in order to meet the budget.
Grading
If the client is unable to follow their budget then they may have some of their expenses paid by EasyPay while they work on their budgeting skills. For example, for a client who has difficulty paying rent and bills and having enough money for food, grading may involve having bills and rent paid through EasyPay and direct debit while they work on a goal of learning to budget so that they have enough money for food for a fortnight. Once that goal is met they may work on paying the bills with the worker supervising and assisting them use the envelope method. The next step could be for the client to pay the bills with no assistance from staff. The next step may then be paying rent using the envelope system and with assistance and supervision from staff. Then managing their own budget using the envelope system.
55
Intervention

9.1 Banking
Common problems encountered in banking strategies to assist these
Forgetting the PIN. Write it down and keep it in a secure place. Being unable to use an ATM. Using Eftpos can be easier as shop assistants will prompt what to do and assist if necessary. Withdrawing money by going into the branch is easier too as tellers will assist. Losing key cards. Encourage to keep them in a wallet. If client can not use a bank, they can collect money from State Trustees.
9.2 Money handling

Common problems encountered in money handling and strategies to assist
Carrying money in their hand, sometimes with other items, risking losing it. Ask why they carry it in their hand. Encourage use of a wallet. Carrying loose notes in pockets which can slip out easily. Encourage use of a wallet. Losing wallets frequently. Some wallets that have key holders can be attached to a chain which can be attached to the clients clothing, such as their belt loops. Not checking change. Prompt the client to calculate how much change they should receive and to check it. Not being able to calculate exact change. Client may be able to roughly calculate change, for example they may calculate change from $20 for a $9.65 purchase to be around $10. If client withdraws all their money at once and has a tendency to lose money, suggest they withdraw smaller amounts several times over the pay period.

Verbal prompting
Observe and prompt the client through the steps involved in using an ATM.

Verbal prompting
For a client who does not check their change, encourage them to check that the change they are given is correct; when they hand over money at a shop ask them how much change they should get before the shop assistant gives them the change. When they receive the change, tell them to count it and ask the client if it is correct.
Written prompting
If the client forgets their PIN, keep it written down and stored in a secure place.
Demonstration
To teach the client how to use Eftpos for purchases; at the supermarket the worker could purchase something using an Eftpos machine to show the client how to use it, and then the client could purchase something using Eftpos with the worker supervising.
Demonstration
If the client is not very assertive, or if they do not have good communication skills, the worker could demonstrate how to ask the shop assistant if the change is correct. The client would then purchase an item and practice asking the shop assistant if the change is correct. It does not matter if the change is correct, as the goal is to teach the client how to ask.
Grading
Session 1: The worker demonstrates using an Eftpos machine and the client uses it with supervision and prompting. Session 2: The worker supervises the client using an Eftpos machine and prompts as necessary. Session 3: The client uses an Eftpos machine and the worker supervises from a distance, eg at the end of the checkout. Session 4: The client uses Eftpos independently.
Education
If the client wants to learn how to calculate change, you could first demonstrate subtracting using a pen and paper. If they have difficulty with this, teach them how to make an estimate of change they should receive.
56
Intervention
10. Bill paying

Common problems encountered in bill paying and strategies to assist
Clients sometimes come from accommodation where bills have been paid for them and need education and practice with paying bills. Forgetting to pay bills, misplacing bills. Create a system to keep track of bills. Place them in an obvious place to remind client to pay them. Write due dates in diary or on calendar and prompt client to check this daily. Not reading bill correctly, eg a bill arrives for an ex-tenant or for a neighbour and the client believes it is for them. Teach client how to read bills and prompt to read all bills thoroughly. Not knowing about the options of paying off a bill (or a fine) or asking for an extension. Educate client about these and demonstrate how to ask for them. Difficulty problem solving when unable to pay bill. Educate client about options, assist client to work through their options and grade assistance with subsequent bills. Not able to self-advocate to a collection agency, eg. if agency says the amount must be paid in full. Educate client about their rights, demonstrate and practice phone call to agency, with client. If client is unable to pay bills and rent, set up EasyPay and/or Centrepay and if that does not work then State Trustees may be necessary.

Verbal prompting
If the client does not know how to ask for an extension on a bill, verbal prompting could the worker could tell them how to do so and rehearse this with them, supervise their phone call to the company and prompt them with what to say if they have difficulty.
Written prompting
If the client does not keep track of when bills are due, a written prompt could be to use a calendar or diary to remind when each bill is due. Alternatively a reminder note stuck somewhere obvious could be used.
Demonstration
If the client wants to learn to pay bills at the Post Office, this could be taught in the following way. You could accompany the client to the Post Office, present the bill to the staff and tell them that you want to pay the bill, get the client to hand over the money or use their key card. If the client has another bill they could then repeat the entire process with you supervising, alternatively the next time they get a bill they could pay it themselves with you supervising.
Education
If the client does not know that a bill can be paid in instalments or that they can ask for an extension, educate them about these options.
Grading
If a client has money managed by State Trustees and wants to increase independence in bill paying grading could be used in the following way. Step 1: State Trustees pays the bills. Step 2: Client pays bills with EasyPay and with worker supervising account statements. Step 3: Cease using EasyPay and the client pays bills themselves with worker supervising and prompting as necessary.
57
Intervention
11. Medication
Common problems encountered in medication and strategies to assist these
If client does not remember if and when they took their medication they can use a dosette. Keep medication in an obvious place so that client will be reminded to take it each day. Set an alarm to remind client to take medication each day either a standard alarm clock or a pillbox with alarm (see appendix 1, products list). If client needs a number of medications or to take them more than once daily an alarm can be set either on a watch or pillbox (see appendix 1, products list). If client can not measure out the correct dose to take, first ensure it is not a problem with vision (e.g. put glasses on), they can have the pharmacy fill the dosette. If client does not have the money for medication, some services will assist payment of medications in the short term, eg. RDNS. In the meantime work with the client on budgeting for medications and prioritising them. If client does not pick up medications and is at risk, some services will deliver medications e.g. RDNS.

Verbal prompting
To help the client to remember to collect their medication and to take it, the worker may prompt the client by asking if they have done so.
Written prompting
To help the client remember to take medication, they could keep a reminder note somewhere obvious. For example if medication is taken in the morning, keep a note on the cupboard where the coffee is kept.
Demonstration
If the client does not know how to fill a prescription at the pharmacy demonstration could be used to teach them. Describe to the client how to fill a prescription and tell the client what they might say to the pharmacist. Then accompany the client to the pharmacy, supervising and prompting if necessary. Have the client hand over the prescription and pay for it.
Grading
To increase independence in taking medications. Step 1: Client uses dosette and reminder note to take medications. Step 2: Client uses reminder note and prompting by worker to check that they have taken medications. Step 3: Client uses reminder note alone to take medications.
58
Intervention
12. Appointments
Common problems encountered in keeping appointments and strategies to assist these
Forgetting appointments. Use a diary, a calendar, an appointment card placed somewhere obvious, an alarm, or prompting from worker to remind client. Not knowing what the day or the time is. Ensure client has a clock or watch, educate client about ways to find out what the day or date is, eg. on mobile phone, radio, newspapers, on TV. Difficulty attending appointments due to lack of motivation. Prompt and accompany the client to the appointment if appropriate. Losing Medicare card. Keep in a wallet and attach this to clothing with a chain. Not being able to tolerate waiting in clinics or emergency departments when required to. In the short term assist client to wait by supporting them in the waiting room and if necessary in the clinic, request to have them fasttracked. In the long term work on coping strategies and social skills to enable client to wait for appointments and over time grade the client in appointments (see grading example below).
Grading
To address forgetting appointments Session 1: Use a note stuck on fridge to remind of appointment and remind client of appointment the day before and arrange to accompany them to the appointment. Session 2: Use a note stuck on the fridge and remind client on day of appointment. Session 3: Use a note stuck on the fridge.
For difficulty waiting in waiting rooms for appointments

Session 1: Prior to appointment rehearse with client what they will say to the doctor. Advise client that they may have to wait for the appointment and discuss strategies to be used to manage this. Accompany client to appointment. Wait with them in waiting room assisting them to use strategies (eg. distraction, self-talk) and providing reassurance and support as required. Accompany them in doctors appointment. Session 2: Prior to appointment rehearse with client what they will say to the doctor and discuss how they will manage if they have to wait for the appointment. Accompany client to appointment. Wait with them in waiting room, prompt client to use strategies, and provide reassurance and support as required. Session 3: Accompany client to the appointment. Supervise client in waiting room and prompt to use strategies if client appears to be getting agitated or wants to leave. Supervise in the doctors surgery. Session 4: Meet client at the clinic. Supervise in the waiting room and in the doctors surgery. Session 5: Meet client at the clinic. Wait in waiting room while they see the doctor. After appointment discuss with client how the appointment went. Session 6: Meet client outside clinic. Wait for them outside while they go in alone. After appointment discuss with client how the appointment went. Session 7: Client goes to appointment alone and afterwards reports back to worker how it went.

Verbal prompting
If client forgets appointments, verbal prompting could involve a phone call reminder to go to their appointments.
Written prompting
If client forgets appointments, written prompting could involve the use of a diary, a calendar, or a note stuck somewhere obvious.
59
Intervention
13. Communication
Common problems encountered in communication and strategies to assist
Difficulty remembering phone numbers. Keep a list in a safe place e.g. an address book, a laminated list beside the telephone, keep numbers on speed dial or stored in mobile phone; ensure there is a backup list in case mobile phone is lost. Losing their mobile phone. Keep in a phone case and clip to clothing such as jeans. Not having a phone. Encourage client to get to know neighbours so that they could use their phone in an emergency. Connect an emergency/ incoming calls phone.

There is no intervention section for this.
The methods of teaching are not applicable here.
60
Intervention

Common problems with emergencies and first aid and strategies to address these
Lack of knowledge about minor ailments and treatments and when to seek professional help for them. Educate about these. Provide with a simple first aid handbook. Ensure client has basic first aid items, eg aspirin, bandaids. Not knowing when urgent medical assistance is required. Educate about when to call an Ambulance or go to hospital. Educate about dialling 000 in emergency. If client is at risk, assist them to access a personal alarm if eligible. Lack of knowledge of where local GP is. Demonstrate how to find local doctors in the phone book. Alternatively, educate about whereabouts of local GPs, dentist and hospital. Provide written information if necessary. Ensure client has map of local area. Failure to seek assistance when unwell, due to disconnection from services. (Not so much something that can be trained as client needs to gain trust in services, however is included here because it is a problem for independent living). Assist to access assistance with the aim of facilitating positive experiences from health service providers.

Verbal prompting
For clients who do not seek assistance when unwell, prompt to make an appointment if you suspect that they are in need of health services.
Education
The client may require education about how to manage minor ailments, when to seek medical assistance and what to do in emergencies.
Demonstration
If the client does not know how to locate medical centres, you could demonstrate how to use the phone book to locate and select a local one.
Grading
If the client does not initiate contact with services when unwell assist them to access services by helping to make appointments, help with transport and if appropriate accompany them in appointments. Reduce the level of assistance provided as the client becomes more engaged with health services, for example you might prompt them to make their own appointments, provide transport or a travel card and encourage them to see the practitioner alone.
61
Intervention
16. Daily routine

Why a daily routine is important.
Through development, people learn and acquire skills. When skills are performed repeatedly, over time they become habits. Habits enable people to perform skills without having to make decisions about them or pay attention to how they are performed. They enable people to complete activities in an automatic fashion which takes much of the effort out of them. Many of the activities that compose peoples daily routines are habitual; examples are bathing, grooming and travelling a familiar route. In a similar way we develop habits of when to perform tasks, for example when to have breakfast, when to shower and these become a daily routine (Keilhofner & Forsyth, 1997). Some clients do not have these habits of daily living and completing these tasks requires effort. Difficulties with habits and routines are sometimes attributable to amotivation or not having developed these, or from loss of these when living in environments that do not support them. Interventions should aim to assist clients to develop necessary habits and routines. This is often achieved through verbal prompting or written prompting such as a daily or weekly roster. It is through practice and repetition that these become routine. Examining clients routines sometimes also reveals limited activities in their days and weeks. Participation in meaningful activity is important for health and wellbeing. The occupations that people engage in are the means through which they derive meaning and a sense of purpose in their lives. Additionally, like habits, occupations that people regularly engage in provide structure and organisation to time and help provide a sense of order (Keilhofner & Forsyth, 1997). Occupations also provide opportunity for social interaction and social support and these have been shown to have health promoting benefits (Wilcock, 1998). If the client has limited activities a goal of intervention may be to increase the amount of activities they are involved in.

Verbal prompting
Remind the client of any aspects of their daily routine as required.
Written prompting
The client could use a roster or a list of what to do each day.
Grading
To increase independence in the weekly routine. The worker and client could together make a list of when each household task or personal hygiene task should be conducted. The worker could verbally prompt the client to remind them when each are meant to be completed. Over time reduce this to the client having a list of when they are meant to be done and the worker prompting only when it is obvious they have not been done. When the client is more reliable with doing the tasks do not prompt them.
17. Fire hazards

A final area of concern can be potential fire hazards in the clients home. If the client is a smoker and there is a risk that this could start a fire, they should be encouraged to adopt practices that will minimise this risk. Some risks are If the client falls asleep while smoking, especially if affected by alcohol or substances. Encourage client not to smoke in bed and if they fall asleep watching television, not to smoke while watching television. Encourage the client to only smoke outside. Gas stoves can be a risk if the client is a smoker and if they have memory problems that may result in them leaving the gas on. Gas detectors can be installed, that operate similar to smoke detectors, gas ovens can be replaced with electric ovens, gas ovens can have a timer fitted that will automatically turn them off after a period of time (see appendix 1, products list). The client may leave clothes or other items over heaters presenting a potential fire risk. Educate the client and replace heater with safer type if required. Smoke detectors should be installed in all houses and batteries replaced annually. In some houses smoke alarms will start if someone smokes inside and this can be used to encourage clients to smoke outside.
Common problems with daily routine and strategies to address these:

Lack of activities in the day. Explore activities the client may enjoy and try to schedule some of these into their week and to support client to attend them. Reversed sleep/ wake cycle (sleeps all day and awake most of the night). This creates problems if trying to involve the client in community activities, attend appointments and build social networks, etc. Educate about how this affects activities, prompt, try to make a routine that involves daytime activities. If the worker has been prompting the client with their weekly routine, ensure client is independent (i.e. can do it without prompting) before withdrawing your service. Sometimes clients can do the tasks but require prompting and do not initiate them without this. Gradually reduce and then cease this support and monitor how the client manages before withdrawing service.
62
Introduction
Bibliography
Aviles, A & Helfrich, C. (2006) Homeless Youth: Causes consequences and the role of Occupational Therapy in Swenson Miller, K, Herzberg, G, Ray, S (eds) Homelessness in America: Perspectives, Characterisations and Considerations for Occupational Therapy, The Haworth Press Inc. pp.99-114. Berkeland R & Flinn, N (2005). Therapy as Learning. In Christiansen, C, Baum, C & Bass-Haugen (eds), Occupational Therapy: Performance, participation and well-being (3rd ed). pp.421- 442. Thorofare, NJ: SLACK Incorporated. Godden & Baddeley, 1975 in Berkeland R & Flinn, N (2005). Therapy as Learning. In Christiansen, C, Baum, C & Bass-Haugen (eds), Occupational Therapy: Performance, participation and well-being (3rd ed). pp.421- 442. Thorofare, NJ: SLACK Incorporated. Helfrich, C, Aviles, A, Badiani, C, Walens, D, Sabol, P (2006) Life Skills Interventions with Homeless Youth, Domestic Violence Victims and Adults with Mental Illness in Swenson Miller, K, Herzberg, G, Ray, S (eds) Homelessness in America: Perspectives, Characterisations and Considerations for Occupational Therapy, The Haworth Press Inc. pp.189-207. Helfrich, C. & Fogg, L (2007) Outcomes of a life skills intervention for homeless adults with mental illness. Journal of Primary prevention, 28 pp. 313-326 Jones, A, McAuliffe, T, Marston, G, Thompson, A (2004) Sustaining tenancies in public housing: Understanding and supporting tenancies at risk. Queensland Department of Housing, Brisbane. Keilhofner, G & Forsyth, K, 1997. The Model of Human Occupation: An overview of current concepts, British Journal of Occupational Therapy, March 1997, 60 (3), pp 103-110. Morse, G, Calsyn, R, Allen, G, Tempelhoff, B, Smith, R (1992). Experimental comparison of the effects of three treatment programs of homeless mentally ill people, Hospital and Community Psychiatry, v 43, no 10, pp 1005-1010 Mosby, I. 1996. A guide to the responsibilities of occupational therapists and their managers in regard to homeless people who use their services. British Journal of Occupational Therapy, 1996, 59 (12), p. 557- 560. Nemec, P., McNamara, S. & Walsh, D. (1992). Direct skills teaching. Psychosocial Rehabilitation Journal, 1992, 16(1), 13-25 Wilcock, A. 1998. An Occupational Perspective of Health. Thorofare, NJ: SLACK Inc. Wong, S, Flanagan, S, Kuehnel, T, Liberman, R, Hunnicutt, R and Adams-Badgett, J (1988) Teaching chronic mental patients to independently practice personal grooming skills, Hospital and Community Psychiatry, v 39, no 8, pp 874-879. World Federation of Occupational Therapists, 2004. WFOT website. www.wfot.org.au/information.asp
63
Introduction
Introduction
Appendix
Products list
Key Safe. Available from Mount Eliza Personal Alarm Call Systems (MEPACS) www.phcn.vic.gov.au/mepacs. $77.00. Ph 9788-1300. Gas detectors. Available from System Control Engineering, ph. 9877-3211. These need to be installed by an electrician or gas fitter. 1. Gas Detector - $140.00 plus GST. Operates in the same manner as a smoke detector. 2. Gas Detector with valve. This will shut off the gas until all gas has dissipated - $220.00 plus GST. 3. Gas Timer and valve - $240.00 plus GST. The gas turns off automatically after 15 minutes and the client has to push a button to turn it back on. Easy Cookbooks. $27- $44. Available from Independent Living Skills Inc. 14 Green Street, Camberwell, 3124. Ph. 9386- 7040. www.easycookbook.org. Ezydose adult lock remind N time pillbox, Amcla pty ltd, ph. (02) 9437 6899 Parsons Cadex Medication watch, available from Medtex, www.medtex.com.au ph 9543 4800.
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Western Region Health Centre
Phone 8398 4100

72-78 Paisley Street Footscray 3011 Fax 9687 9330
www.wrhc.com.au

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Western Region Health Centre

Why this manual was produced

Living Skills assessment and intervention

Why a personalised training program is important

Occupational therapy and living skills training

How to use the manual

Living Skills assessment and intervention

Initial Assessment Interview

Is Comprehensive assessment possible?

of clients home (from comprehensive assessment)

Is client willing to answer further questions?

No further assessment at this stage

Living Skills assessment and intervention

Description of each living skill

10. Bill paying

3. Cooking & meals

15. Emergencies & First aid

9. Banking & money handling

Living Skills assessment and intervention

Information to accompany the

Information to accompany the initial assessment

Living Skills assessment and intervention

3. Cooking & Meals

Living Skills assessment and intervention

13. Support services

9. Banking & money handling.

10. Bill paying

Living Skills assessment and intervention

Living Skills assessment and intervention

3. Cooking & meals

3. Do you have any difficulty with cooking? If so describe

Evidence of skills deficit

Skills need assessment

2. Do you have any difficulty with shopping? If so describe

3. Where do you do your shopping?

4. How do get there? (eg. walk, public transport)

5. How do you get groceries home? (eg. carry in bags, delivered)

6. How often do you go shopping? Evidence of skills deficit

Skills need assessment

Living Skills assessment and intervention

2. Do you have any problems with cleaning? If so, describe

Evidence of skills deficit

Skills need assessment

4. Do you have any problems doing laundry? If so describe

Evidence of skills deficit

Skills need assessment

Evidence of skills deficit

Skills need assessment

Living Skills assessment and intervention

3. Do you have debts? If so, describe

4. Do you run out of money between pays? If so describe

Evidence of skills deficit

Skills need assessment

9. Banking & Money Handling

Evidence of skills deficit

Skills need assessment

10. Bill paying

3. How do you pay your rent?

4. Do you have difficulty paying bills? If so describe

Evidence of skills deficit

Skills need assessment

Living Skills assessment and intervention

Evidence of skills deficit

Skills need assessment