Goal setting and interventions to improve engagement in self care, productivity (i.e., work) & leisure (e.g., sports, exercise, hobbies) activities.

Transcription

1 Care Cluster: 2 Non-psychotic (Low Severity with greater need) self engage in & interaction engage in Work Assessment Work Work readiness productivity (work) & engage in & interaction within engagement in Motivation to engage in daily Increase ability to identify short term goal Communication Develop ability to build and sustain positive relationships with a variety of people while engaged in Organisation & Develop ability to maintain concentration for consistently completing all of one s routine Mobility & and energy to participate in daily Environment supporting engagement in daily Adjust demands to fit service s abilities, interest, and a satisfying routine. Building self efficacy to engage with Exploring future options for Vocational Enablement Vocational guidance, signposting and advice Complete OT measure Occupational Circumstances Assessment Interview & Rating Scale Occupational Self Assessment Occupational Questionnaire Work Environment Impact Scale Level 5-6 Extended sessions generally weekly decreasing as engagement in increases. Monitoring monthly when commencing employment, Individual Placement and Support or education. Range: 1-6 months Average: 3 months audit (OT 5-6) Range: hours Average : 20 hours Materials for and -related goals Delayed need for other service involvement To organisation sick pay, sickness level and benefit

2 Care Cluster: 3 Non-psychotic (Moderate Severity) self engage in & interaction engage in Work Assessment Work Work readiness productivity (work) & engage in & interaction within engagement in Motivation to engage in daily Increase ability to identify short term goal participation in roles Communication Develop ability to build and sustain positive relationships with a variety of people while engaged in Organisation & Develop ability to maintain concentration for consistently completing all of one s routine Mobility & and energy to participate in daily Environment supporting engagement in daily Adjust demands to fit service s abilities, interest, and a satisfying routine. Building self efficacy to engage with Exploring future options for Lifestyle adjustment Developing / maintaining communication & interaction Supporting engagement in leisure and exercise Vocational Enablement Vocational guidance, signposting and advice Review Self care, productivity (work) & leisure interventions Audit of interventions Complete measures Level 5-6 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Monitoring monthly when commencing employment, Individual Placement and Support or education. Range: 2 12 months Average: 6 months audit (OT 5-6) Range: hours Average : 26 hours intervention, supervised by OT (5-6); Range: 8-24 hours Average : 10 hours Materials for and -related goals Improved communication with others Delayed need for other service involvement To organisation Contribution to formation of diagnosis Occupational Circumstances Assessment Interview & Rating Scale Occupational Self Assessment Occupational Questionnaire Work Environment Impact Scale

3 Care Cluster: 4 Non-psychotic (Severe) self engage in engage in & interaction Work Assessment Work Work readiness productivity (work) & engage in within engagement in & interaction Motivation to engage in daily Increase ability to identify short term goal Organisation & Mobility & and energy to participate in daily Environment supporting engagement in daily Adjust demands to fit service s abilities Communication Develop ability to build & sustain positive relationships with a variety of people. Building self efficacy to engage with Exploring future options for symptoms Developing / maintaining communication & interaction Supporting engagement in leisure and exercise Vocational Enablement Vocational guidance, signposting and advice occupational intervention with CPA care Complete OT measures Level 5-6 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Monitoring monthly when commencing employment, Individual Placement and Support or education. Range: 6-18 months Average: 9 months audit (OT 5-7) Range: hours Average : 36 hours intervention, supervised by OT (5-7); Range: 8-36 hours Average : 13 hours Materials for and -related goals Improved communication with others Enhance Reduced uptake of health and social care resources Decrease in self harming behaviour continue their a service Occupational Circumstances Assessment Interview & Rating Scale Occupational Self Assessment Occupational Questionnaire Work Environment Impact Scale

4 Care Cluster: 5 Non-psychotic Disorders (Very Severe) self engage in engage in network/carers) Work Assessment Work Work readiness productivity (work) & engage in within engagement in Motivation to engage in daily Organisation & Develop capacity to maintain concentration for consistently completing all of one s routine tasks Mobility & and energy to participate in daily Communication Develop ability to build and sustain positive relationships with a variety of people Environment supporting engagement in daily Adjust demands to fit service s abilities, interest, and a satisfying routine. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in symptoms Developing / maintaining communication & interaction Supporting transitions in new physical and social s Supporting engagement in leisure and exercise Vocational Enablement occupational intervention with CPA care Complete OT measures Occupational Questionnaire Work Environment Impact Scale Level 5-7 intervention. Extended sessions (more than 1 hour) generally weekly, decreasing as function increases, or until personal goals of socially inclusive and productive lifestyle achieved Range: 3-24 months Average: 12 months audit (OT 5-7) Range: hours Average : 37 hours intervention, supervised by OT (5-7); Range: hours Average : 21 hours Materials for and -related goals interaction with social Enhance Increased feeling of control over Reduced uptake of health and social care resources Decrease in self harming behaviour continue their a service. Contribution to formation of diagnosis

5 Care Cluster: 6 Non-psychotic Disorder of Over-Valued Ideas self engage in engage in network/carers) productivity (work) & engage in engagement in within Motivation to engage in daily participation in roles Communication Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in symptoms Supporting transitions in new physical and social s Supporting engagement in leisure and exercise occupational intervention with CPA care Complete OT measures Occupational Questionnaire Level 5-7 intervention. Extended sessions (more than 1 hour) generally weekly, decreasing as function increases, or until personal goals of socially inclusive and productive lifestyle achieved Range: 6 24 months Average: 15 months audit (OT 5-7) Range ; hours Average 40 hours intervention, supervised by OT (5-7); Range: 12-33hours Average : 20 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable interaction with social Enhanced capacity to concentrate Increased feeling of control over Decrease in self harming behaviour continue their service Contribution to formation of diagnosis

6 Care Cluster: 7 Enduring Non-Psychotic Disorders (High disability) self engage in engage in network/carers) productivity (work) & engage in daily engagement in within Motivation to engage in daily Communication Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in symptoms Developing / maintaining communication & interaction Supporting transitions in new physical and social s Liaison to enable independent living occupational intervention with CPA care Complete OT measures Level 6-7 intervention. Extended sessions (more than 1 hour) generally weekly, decreasing as function increases. Range: 6-36 months Average: 18 months Range: hours Average : 41 hours intervention, supervised by OT (6-7); Range: 30-57hours Average : 43 hours Materials for and service s, carers, MDT Maintained Improved enjoyment of positive and socially acceptable interaction with social Enhanced capacity to concentrate Increased feeling of control over Reduction in risk of injury / accident / falls that would result in accessing physical service Decrease in self harming behaviour continue their service Contribution to formation of diagnosis

7 Care Cluster: 8 Non-Psychotic Chaotic and Challenging Disorders self engage in engage in (incl. physical & social support network/ carers & ) productivity (work) & engage in daily engagement in within Motivation to engage in daily Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Communication Develop ability to build and sustain positive relationships with a variety of people Mobility & and energy to participate in daily. Exploring future options for Developing / maintaining communication & interaction Consultation, liaison and advice occupational intervention with CPA care Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Occupational Questionnaire Level 6-7 intervention. Extended sessions (more than 1 hour) generally weekly, decreasing as function increases. Range: 6-24 months Average: 15 months Range: hours Average : 52 hours intervention, supervised by OT (6-7); Range: hours Average : 43 hours Materials for and Improved enjoyment of positive and socially acceptable interaction with social Enhance Enhance capacity to concentrate on Decrease in self harming behaviour continue their a service. Contribution to formation of diagnosis

8 Care Cluster: 10 First Episode Psychosis self engage in engage in ) Work Assessment Work Work readiness productivity (work) & engage in engagement in daily within Motivation to engage in daily Communication Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for symptoms Lifestyle adjustment social s Supporting engagement in leisure and exercise Vocational Enablement Vocational guidance, signposting and advice occupational intervention with CPA care Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Occupational Self Assessment Occupational Questionnaire Interaction Work Environment Impact Scale Level 6-7 Extended sessions (more than 1 hour) generally weekly, decreasing as function increases. Range: 3-36 months Average: 12 months Range: hours Average : 45 hours Materials for and -related goals interaction with social continue their a service. Contribution to formation of diagnosis

9 Care Cluster: 11 Ongoing or Recurrent Psychosis (Low symptoms) self engage in engage in ) Work Assessment Work Work readiness productivity (work) & engage in engagement in daily within Motivation to engage in daily Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Communication & Interaction Develop ability to build and sustain positive relationships with a variety of people Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for symptoms Supporting engagement in leisure & exercise Vocational Enablement occupational intervention with CPA care Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Occupational Self Assessment Occupational Questionnaire Work Environmental Impact Scale Level 5-7 intervention. Extended sessions (more than 1 hour) generally weekly, decreasing as function increases, or until personal goals of socially inclusive and productive lifestyle achieved Range: 2-24 months Average: 6 months audit (OT 5-7) Range: hours Average : 24 hours intervention, supervised by OT (5-7); Range: hours Average : 24 hours Materials for and Maintained -related goals Enhance Delayed need for other service involvement Reduced uptake of health and social care resources continue their a service

10 Care Cluster: 12 Ongoing or Recurrent Psychosis (High disability) self engage in engage in ) productivity (work) & engage in engagement in daily within Motivation to engage in daily Communication & Interaction Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Exploring future options for symptoms Developing / maintaining communication & interaction Environmental modification to support engagement in social s Liaison to enable independent living Supporting engagement in leisure & exercise occupational intervention with CPA care Complete OT measures Level 6-7 intervention. Sessions generally weekly, decreasing as function increases, usually to a maximum of 12 months or until personal goals of socially inclusive and productive lifestyle achieved Range: 2-24 months Average: 12 months Range: hours Average : 30 hours intervention, supervised by OT (6-7); Range: hours Average : 20 hours Materials for and Maintained -related goals Improved communication with others interaction with social Enhanced Increased feeling of control over Reduce vulnerability continue their service

11 Care Cluster: 13 Ongoing or Recurrent Psychosis (High symptom and disability) self engage in engage in ) productivity (work) & engage in engagement in daily within Motivation to engage in daily Communication & Interaction Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Exploring future options for Building enjoyment when engaged in Re motivation process symptoms Developing / maintaining communication & interaction Environmental modification to support engagement in social s Liaison to enable independent living Supporting engagement in leisure and exercise occupational intervention with CPA care Complete OT measures Level 6-7 intervention. Extended sessions (more than 1 hour) generally 1-2 times weekly, decreasing as function increases. Range: 2-24 months Average: 12 months Range: hours Average : 38 hours intervention, supervised by OT (6-7); Range: hours Average : 23 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable -related goals interaction with social Enhance Enhanced capacity to concentrate Increased feeling of control over Reduced impact on engagement in as illness progresses Reduce vulnerability continue service

12 Care Cluster: 14 Psychotic Crisis self engage in engage in ) Work Assessment Work Work readiness productivity (work) & engage in engagement in daily within Motivation to engage in daily Communication & Interaction Organisation & Environment supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in symptoms Lifestyle adjustment Developing / maintaining communication & interaction Environmental modification to support engagement in social s Consultation, liaison and advice Supporting engagement in leisure & exercise Vocational guidance, signposting and advice occupational intervention with CPA care Complete OT measures Level 5-7 intervention. Daily during crisis or while on ward, decreasing as function improves or following discharge. Range: 1-3 months Average: 2 months audit (OT 5-7) Range: hours Average : 22 hours intervention, supervised by OT (5-7); Range: hours Average : 22 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable -related goals Improved communication with others Enhance Enhance capacity to concentrate Increased feeling of control over Reduce vulnerability Decrease in self harming behaviour continue their service. Contribution to formation of diagnosis

13 Care Cluster: 15 Severe Psychotic Depression self engage in engage in ) productivity (work) & Severe challenges engage in within engagement in daily Motivation to engage in daily Communication Organisation & Mobility & and energy to participate in daily Environment supporting engagement in daily Adjust demands to fit service s abilities. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in Re motivation process Lifestyle adjustment Environmental modification to support engagement in social s Consultation, liaison and advice Supporting engagement in leisure & exercise occupational intervention with CPA care Complete OT measures Work Environment Impact Scale Level 5-6 intervention. Daily during crisis or while on ward, decreasing as function improves or following discharge. Range: 2-6 months Average: 4 months audit (OT 5-6) Range: hours Average : 20 hours intervention, supervised by OT (5-6); Range: hours Average : 24 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable -related goals Improved communication with others interaction with social Enhance Enhance capacity to concentrate Ability to negotiate Reduce vulnerability Decrease in self harming behaviour placements / housing panels / continue their a service. Contribution to formation of diagnosis

14 Care Cluster: 16 Dual Diagnosis self engage in engage in ) productivity (work) & Severe challenges engage in engagement in daily within Motivation to engage in daily Communication Organisation & Environment not supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Building self efficacy to engage with Exploring future options for Building enjoyment when engaged in symptoms Lifestyle adjustment social s Consultation, liaison and advice Liaison to enable independent living Supporting engagement in leisure & exercise occupational intervention with CPA care Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Level 6-7 Extended sessions (more than 1 hour) generally weekly, decreasing as function increases, or until personal goals of socially inclusive and productive lifestyle achieved. Range: 4-18 months Average: 9 months Range: hours Average : 48 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable -related goals Enhance Reduce vulnerability placements / housing panels / continue their a service

15 Care Cluster: 17 Psychosis and Affective Disorder (Difficult to engage) self engage in engage in ) Work Assessment Work Work readiness productivity (work) & Severe challenges engage in engagement in within Motivation to engage in daily Communication Organisation & Environment not supporting engagement in daily Adjust demands to fit service s abilities Mobility & and energy to participate in daily. Exploring future options for Building enjoyment when engaged in Re motivation process symptoms Developing / maintaining communication & interaction social s Consultation, liaison and advice Liaison to enable independent living Supporting engagement in leisure and exercise Vocational enablement occupational intervention with CPA care Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Volitional Questionnaire Level 6-7 intervention. Extended sessions (more than 1 hour) initially bi -weekly weekly, decreasing as function increases. Range: 6-24 months Average: 15 months Range: hours Average : 95 hours intervention, supervised by OT (6-7); Range: hours Average : 101 hours Materials for and Maintained Improved enjoyment of positive and socially acceptable interaction with social Enhance capacity to concentrate Reduce vulnerability Decrease in self harming behaviour placements / housing panels / continue their a service

16 Care Cluster: 18 Cognitive Impairment (low need) self engage in Cognitive ability engage in ) productivity (work) & engage in engagement in within Motivation to engage in Organisation & Environment not supporting engagement in daily Adjust demands to fit service s abilities Communication Develop ability to build and sustain positive relationships with a variety of people Mobility & and energy to participate in daily engagement in self care, productivity (i.e., work) & leisure (e.g., sports, exercise, hobbies). Building self efficacy to engage with symptoms Lifestyle adjustment Developing capacity to assure adequate stability, movement and energy to participate in Environmental modification to support engagement in Assistive Technology Consultation, liaison and advice Liaison to enable independent living Supporting engagement in leisure & exercise Liaise with carers, care coordinator & wider MDT occupational intervention with CPA care Liaise with voluntary organisations, other health professionals Complete OT measures Occupational Circumstances Assessment Interview & Rating Scale Level 5-7 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Range: 2-6 months Average: 4 months audit (OT 5-7) Range: 3-23 hours Average : 18 hours intervention, as guided by OT (5-7); Range: 2-38 hours Average : 21 hours Materials for and Specialist enabling disability and technological telecare related equipment, orientation aids interaction with social Enhance Increased feeling of control over Ability to negotiate Reduced impact on engagement in as illness progresses Reduced uptake of health and social care resources Reduction in risk of injury / accident / falls that would result in accessing physical service continue their a service. Contribution to formation of diagnosis

17 Care Cluster: 19 Cognitive impairment or dementia complicated (Moderate Need) self engage in Cognitive ability engage in ) productivity (work) & engage in within engagement in Motivation to engage in Communication Organisation & Mobility & and energy to participate in daily Environment not supporting engagement in daily Adjust demands to fit service s abilities engagement in self care, productivity (i.e., work) & leisure (e.g., sports, exercise, hobbies). Building self efficacy to engage with Building enjoyment when engaged in Lifestyle adjustment Developing capacity to assure adequate stability, movement and energy to participate in Engaging in meaningful that maximise sensory opportunities to allow more engagement in a broader range of s Environmental modification to support engagement in Assistive Technology social s Consultation, liaison and advice Liaison to enable independent living Supporting engagement in leisure & exercise Liaise with carers, care coordinator & wider MDT occupational intervention with CPA care Liaise with voluntary organisations, other health professionals Complete OT measures Volitional Questionnaire Level 5-7 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Range: 2-9 months Average: 6 months Range: 5-68 hours Average : 23 hours intervention, as guided by OT (5-7); Range: 3-55 hours Average : 24 hours Materials for and Specialist enabling disability and technological telecare related equipment, orientation aids Maintained interaction with social Enhance Increased feeling of control over Ability to negotiate Reduced impact on engagement in as illness progresses Reduce vulnerability Reduced uptake of health and social care resources Reduction in risk of injury / accident / falls that would result in accessing physical service continue their a service

18 Care Cluster: 20 Cognitive Impairment or Dementia complicated (High Need) self engage in engage in ) Life story productivity (work) & Severe Challenges engage in within engagement in Increase ability to take on a simple role in a group Organisation & Develop capacity to retain and follow simple instructions for 2-3 step. Motivation to engage in Communication Mobility & and energy to participate in daily Environment not supporting engagement in daily Adjust demands to fit service s abilities engagement in self care, productivity (i.e., work) & leisure (e.g., sports, exercise, hobbies). Building self efficacy to engage with Building enjoyment when engaged in Developing capacity to assure adequate stability, movement and energy to participate in Engaging in meaningful that maximise sensory opportunities to allow more engagement in a broader range of s Environmental modification to support engagement in Assistive Technology social s Consultation, liaison and advice Liaise with carers, care coordinator & wider MDT occupational intervention with CPA care Liaise with voluntary organisations, other health professionals Complete OT measures Volitional Questionnaire Level 6-7 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Range: 2-12 months Average: 6 months Range: 6-64 hours Average : 31 hours intervention, as guided by OT (6-7); Range: 2-55 hours Average : 27 hours Materials for and Specialist enabling disability and technological telecare related equipment, orientation aids Maintained interaction with social Enhance Increased feeling of control over Ability to negotiate Reduced impact on engagement in as illness progresses Reduce vulnerability Reduced uptake of health and social care resources Reduction in risk of injury / accident / falls that would result in accessing physical service continue their a service

19 Care Cluster: 21 Cognitive Impairment or Dementia complicated (High Need) self engage in engage in ) Life story productivity (work) & Severe Challenges engage in within engagement in Increase ability to take on a simple role in a group Organisation & Increase ability to take on a simple role in a group Motivation to engage in Communication Mobility & and energy to participate in daily Environment not supporting engagement in daily Adjust demands to fit service s abilities engagement in self care, productivity (i.e., work) & leisure (e.g., sports, exercise, hobbies). Building self efficacy to engage with Building enjoyment when engaged in Developing capacity to assure adequate stability, movement and energy to participate in Engaging in meaningful that maximise sensory opportunities to allow more engagement in a broader range of s Environmental modification to support engagement in Assistive Technology social s Consultation, liaison and advice Liaise with carers, care coordinator & wider MDT occupational intervention with CPA care Liaise with voluntary organisations, other health professionals Complete OT measures Volitional Questionnaire Level 6-7 Level 3-4 to intervention. Extended sessions generally weekly decreasing as engagement in increases. Range: 1-4 months Average: 2 months Range: 6-34 hours Average : 24 hours intervention, as guided by OT (5-7); Range: 2-70 hours Average : 50 hours Materials for and Specialist enabling disability and technological telecare related equipment, orientation aids Maintained connected through roles Enhance capacity to concentrate Ability to negotiate Reduced impact on engagement in as illness progresses Reduced vulnerability Reduced uptake of health and social care resources admission through prompt analysis of areas of risk and identification of Reduction in risk of injury / accident / falls that would result in accessing physical service continue their a service