"This interprofessional home health case is realistic and shows what the home health team would likely look like in the field. Going over responsibilities and how the home health team works together was helpful."--OTA Student
By the end of this self-paced course, the learner will demonstrate foundational understanding of evaluations and interventions from an inter- and intraprofessional home health care collaborative perspective. The team in this scenario includes OT, PT, SLP, RN, OTA, PTA, client, and caregiver.
Learners are introduced to the intra- and interprofessional collaborative process, common evaluation tools, intervention strategies, documentation, and terminology related to treatment of an individual with a CVA/ TBI within the home environment.
This case is particularly relevant as the US Bureau of Labor Statistics projects that home healthcare employment will grow by 21% from 2021 to 2031.
Case Trailer
FREE PREVIEWClinEdWeb Instructions (Pre-Brief)
FREE PREVIEWWelcome (Pre-Brief)
Home Health Team (Pre-Brief)
FREE PREVIEWClinical Pearl: Funding Information - Home Health Coverage
FREE PREVIEWClinical Pearl - Homebound
Safety - Home Health Care Professionals
Intake and Referral Information
History of Present Illness (HPI)
FREE PREVIEWRequisitions
Precautions
Social History
Work History
Past Medical History
Chart Review Questions Preparation
Chart Review Questions
Occupational Therapist (OT) Introduction
FREE PREVIEWAdmission and OT Evaluation Documentation
Clinical Pearl - Medicare Regulations for Home Health Admissions Assessment
Greeting a Client in Their Home
FREE PREVIEWGreeting Quiz
Clinical Pearl - MAHC-10 Fall Risk Assessment Tool
Admissions Assessment
Admissions Assessment Quiz
Occupational Therapy Assessment Selection
FREE PREVIEWOccupational Therapy Functional ROM Assessment
Occupational Therapy Functional ROM Assessment Quiz
Occupational Therapy Gross Manual Muscle Test
Occupational Therapy Gross Manual Muscle Test Quiz
Safety Assessment
FREE PREVIEWSafety Quiz
FREE PREVIEWADL Interview
ADL Interview Quiz
Cognitive Screen
Cognitive Screen Quiz
Clock Drawing Test (CDT) Preparation
Clock Drawing Test
Clock Drawing Test Quiz
Medical Complications - Diabetes Mellitus
Medical Complications - Diabetes Mellitus Quiz
Vitals
Vitals Quiz
Client-Centered Goal Planning
Client-Centered Goal Planning Quiz
Clinical Pearl - Documenting Assistance Levels
Bed Mobility and Skin Integrity Assessment
Bed Mobility and Skin Integrity Assessment Quiz
Toilet Transfer Assessment
Toilet Transfer Assessment Quiz
Intervention Planning
Intervention Planning Quiz
OT Evaluation Form Documentation
Physical Therapist (PT) Introduction
FREE PREVIEWPhysical Therapy Evaluation Documentation
Physical Therapy - Greeting the Client
FREE PREVIEWPhysical Therapy - Greeting the Client Quiz
Physical Therapy Interview
Physical Therapy Interview Quiz
Lower Extremity Manual Muscle Testing
Lower Extremity MMT Quiz
Tinetti Balance Assessment Preparation
Balance - Tinetti Balance Assessment
Balance - Tinetti Balance Assessment Quiz
Timed Up and Go (Tug) Test Preparation
TUG Test
TUG Test Quiz
Bed Mobility Preparation
Bed Mobility
Bed Mobility Quiz
Stairs Preparation
Stairs
Stairs Quiz
Car Transfer
Car Transfer Quiz
Outdoor Ambulation
Outdoor Ambulation Quiz
Treatment Planning
Treatment Planning Quiz
PT Evaluation Form Documentation
Registered Nurse (RN) Introduction
FREE PREVIEWNursing Introduction
Nursing Introduction Quiz
Diabetes - Medication Management
Diabetes - Medication Management Quiz
Diabetes Management - Hyper vs. Hypoglycemia
Diabetes Management - Hyper vs. Hypoglycemia Quiz
Diabetes Management - Wounds
Diabetes Management - Wounds Quiz
Cognition Screen
Cognition Screen Quiz
Physical Assessment
Physcial Assessment Quiz
Bladder Health
Bladder Health Quiz
Bowel Health
Bowel Health Quiz
Vitals
Vitals Quiz
Foot Check
Foot Check Quiz
Wrap Up
Wrap Up Quiz
Documentation - RN
Speech-Language Pathologist (SLP) Introduction
FREE PREVIEWSLP Introduction
SLP Introduction Quiz
Picture Description Task Preparation
Picture Description Task
Picture Description Task Quiz
Boston Naming Test (BNT) Preparation
Boston Naming Test (BNT)
Boston Naming Test (BNT) Quiz
Oral Motor Musculature Assessment Preparation
Oral Motor Musculature Assessment
Oral Motor Musculature Assessment Quiz
Swallowing Assessment
Swallowing Assessment Quiz
Language Fluency Test Preparation
Language Fluency Test
Language Fluency Test Quiz
Treatment Planning
Treatment Planning Quiz
Aphasia - Psychosocial Factors
Aphasia - Psychosocial Factors Discussion
Certified Occupational Therapy Assistant (COTA) Introduction
FREE PREVIEWCOTA Intervention Documentation
Clinical Pearl - Vitals
COTA Introduction
FREE PREVIEWCOTA Introduction Quiz
Clinical Pearl - Montreal Cognitive Assessment (MoCA) Training
MoCA Documentation Preparation
Cognitive Assessment - Montreal Cognitive Assessment (MoCA)
MoCA Performance
Cognitive Assessment - Montreal Cognitive Assessment (MoCA) Quiz
Meal Prep 1 - Navigating Environment
Meal Prep 1 - Navigating environment Quiz
Meal Prep 2 - Cutting
Meal Prep 2 - Cutting Quiz
Treatment Planning and Wrap Up of Session
Treatment Planning and Wrap Up of Session Quiz
COTA SOAP Note and OTA Responsibilities related to Outcomes
Physical Therapist Assistant (PTA) Introduction
FREE PREVIEWPTA Intervention Documentation
Clinical Pearl - Vitals
PTA Introductions
FREE PREVIEWPTA Introductions Quiz
Balance Activity
Balance Activity Quiz
Gait Training
Gait Training Quiz
Stairs
Stairs Quiz
PTA Wrap-Up
PTA Wrap-Up Quiz
Intervention Documentation Completion
Completion Checklist
FREE PREVIEWSummative Exam Preparation
FREE PREVIEWSummative Exam
ClinEdWeb Paul Case Scenario: Simulation Effectiveness Tool -‐ Modified *Leighton, K., Ravert, P., Mudra, V., & Macintosh, C. (2015)
By the end of this case scenario, learners will be able to:
❏ Identify roles and responsibilities for collaborative practice.
❏ Recognize the value of inter- and intraprofessional communication.
❏ Demonstrate understanding of teamwork and team-based care.
❏ Recall the scope of practice and educational requirements for physical therapists, occupational therapists, certified occupational therapy assistants, physical therapy assistants, and nurses.
❏ Demonstrate understanding of overlap between professions in home health care.
❏ Demonstrate understanding of psychosocial aspects of caregiving and expressive aphasia.
❏ Recall common home health examination assessments for an individual with a neurological injury such as a CVA/ TBI.
❏ Identify commonly used evaluation tools appropriate for assessing baseline performance skill level.
❏ Glean salient information from a chart review.
❏ Identify client-centered goals.
❏ Complete point-of-service electronic documentation.
❏ Recognize common interventions and safety precautions implemented in home health care with an individual with a neurological injury such as CVA/ TBI.
❏ Recognize the value of the consultative process and specialist referral in a home health setting.
❏ Demonstrate understanding of commonly used assistive technologies/ mobility equipment used in home health care with an individual with a neurological injury such as CVA/ TBI.
❏ Recognize the role of third-party payers to support services in the home health setting.
❏ Recall the requirements for home health services under Medicare/ Medicaid.
❏ Recommend direct interventions to achieve client-centered goals.
The following 2018 Accreditation Council for Occupational Therapy Education (ACOTE) Standards are addressed in the “Paul” Case Scenario.
Standard Number |
Skill |
Standard Definition |
Evidence of Standard Met |
| B.3.2. |
Interaction of Occupation and Activity |
Apply, analyze, and evaluate the interaction of occupation and activity, including areas of occupation, performance skills, performance patterns, context(s) and environments, and client factors. |
Evaluation within home environment (Home Health) Cognition, strength, ROM, ADL, and fall assessments Interview (skills and patterns) Completion of Case Scenario Formative assessments to ensure understanding of these dynamic interactions |
| B.3.5. |
Effects of Disease Processes |
Analyze and evaluate the effects of disease processes including heritable diseases, genetic conditions, mental illness, disability, trauma, and injury on occupational performance. |
Evaluation within home environment (Home Health) Cognition, strength, ROM, ADL, and fall assessments in relation to CVA/ TBI Interview (skills and patterns) Completion of Case Scenario Formative assessments to ensure understanding of the effects of the CVA/ TBI on performance Completion Certificate: Passing score on summative assessment |
| B.3.6. |
Activity Analysis |
Demonstrate activity analysis in areas of occupation, performance skills, performance patterns, context(s) and environments, and client factors to formulate the intervention plan |
Planning with patient and spouse – video and related formative questions Observing interventions that address performance skills and client factors within home environment Completion Certificate: Passing score on summative assessment |
| B.3.7. |
Safety of Self and Others |
Demonstrate sound judgment in regard to safety of self and others and adhere to safety regulations throughout the occupational therapy process as appropriate to the setting and scope of practice. This must include the ability to assess and monitor vital signs (e.g., blood pressure, heart rate, respiratory status, and temperature) to ensure that the client is stable for intervention. |
Throughout the case scenario the user is alerted with verbal, visual, and written prompts about safety concerns such as vital sign norms, gait belt use, wheelchair and walker safety during functional mobility Completion of Case Scenario Formative assessment |
| B.4.1. |
Therapeutic Use of Self |
Demonstrate therapeutic use of self, including one’s personality, insights, perceptions, and judgments, as part of the therapeutic process in both individual and group interaction |
Practitioners in the case scenario model therapeutic use of self |
| B.4.2. |
Clinical Reasoning |
Demonstrate clinical reasoning to evaluate, analyze, diagnose, and provide occupation based interventions to address client factors, performance patterns, and performance skills |
Chart review Interview Assessments addressing client factors, performance skills, and performance patterns Occupation-based interventions addressed in case scenario are based on results of assessments performed to include but not limited to: safety during ADL (performance patterns), cognitive challenges(client factors), ADL and mobility skills (performance skills), and assistive technology training (performance skills) Completion of Electronic Initial Evaluation Form Completion of Case Scenario Formative assessment Completion Certificate: Passing score on summative assessment |
| B.4.3. |
Occupation-Based Interventions |
Utilize clinical reasoning to facilitate occupation-based interventions that address client factors. This must include interventions focused on promotion, compensation, adaptation, and prevention |
Physical Environment (Home) Adaptations Occupation-based interventions addressed in case scenario are based on results of assessments performed to include but not limited to: safety during ADL (performance patterns), cognitive challenges(client factors), ADL and mobility skills (performance skills), and assistive technology training (performance skills) Completion of Electronic Initial Evaluation Form Completion of Case Scenario Formative assessment Completion Certificate: Passing score on summative assessment |
| B.4.4. |
Standardized and Nonstandardized Screening and Assessment Tools |
Contribute to the evaluation process of (OTA) or evaluate (OTR) client(s)’ occupational performance, including occupational profile, by analyzing and selecting standardized and non-standardized screenings and assessment tools to determine the need for occupational therapy intervention(s). Assessment methods must take into consideration cultural and contextual factors of the client. Explain the importance of using psychometrically sound assessment tools (OTA) or Interpret evaluation findings of occupational performance and participation deficits (OTR) to develop occupation-based intervention plans and strategies. Intervention plans and strategies must be client centered, culturally relevant, reflective of current occupational therapy practice, and based on available evidence. |
Evaluation within home environment and recommended adaptations Cognition, strength, ROM, ADL, and fall assessments (standardized) Chart review Interview - nonstandardized Completion of Electronic Initial Evaluation Form |
| B.4.5. |
Application of Assessment Tools and Interpretation of Results |
Select and apply assessment tools, considering client needs, and cultural and contextual factors. Administer selected standardized and nonstandardized assessments using appropriate procedures and protocols. Interpret the results based on psychometric properties of tests considering factors that might bias assessment results (e.g., culture and disability status related to the person and context). |
Evaluation within home environment and recommended adaptations Selection of appropriate cognition, strength, ROM, ADL, and fall assessments (standardized) Chart review Interview (nonstandardized) Completion of Case Scenario Formative assessment Completion Certificate: Passing score on summative assessment |
| B.4.6. |
Reporting Data |
Collect, analyze, and report data in a systematic manner for evaluation of client and practice outcomes. Report evaluation results and modify practice as needed. (OTR) or Under the direction of an occupational therapist, collect, organize, and report on data for evaluation of client outcomes (OTA) |
Completion of Electronic Initial Evaluation Form (OT) Completion of standardized cognitive assessment (MoCA) by COTA and report in progress note |
| B.4.7. |
Interpret Standardized Test Scores |
Interpret criterion-referenced and norm referenced standardized test scores on the basis of an understanding of sampling, normative data, standard and criterion scores, reliability, and validity. |
Completion of Case Scenario Formative questions related to performance on standardized tests, i.e. MOCA |
| B.4.8. |
Interpret Evaluation Data |
Interpret the evaluation data in relation to accepted terminology of the profession and explain the findings to the interprofessional team |
Completion of Home Health evaluation form and progress notes by all practitioners on interprofessional team |
| B.4.10. |
Provide Interventions and Procedures |
Recommend and provide direct interventions and procedures to persons, groups, and populations to enhance safety, health and wellness, and performance in occupations. This must include the ability to select and deliver occupations and activities, preparatory methods and tasks (including therapeutic exercise), education and training, and advocacy. |
Completion of Case Scenario Formative assessment questions related to occupation-based and therapeutic exercise interventions Completion Certificate: Passing score on summative assessment Completion of Electronic Initial Evaluation Form |
| B.4.11. |
Assistive Technologies and Devices |
Assess the need for and demonstrate the ability to design, fabricate, apply, fit, and train in assistive technologies and devices (e.g., electronic aids to daily living, seating and positioning systems) used to enhance occupational performance and foster participation and well-being. |
Occupation-based interventions addressed in case scenario are based on results of assessments such as adapted cutting board, visual contrast, use of 4WW for functional mobility during meal prep |
| B.4.13. |
Functional Mobility |
Provide recommendations and training in techniques to enhance functional mobility, including physical transfers, wheelchair management, and mobility devices |
Occupation-based interventions include functional mobility for meal prep, bed and toilet transfers with wheeled walker |
| B.4.15. |
Technology in Practice |
Demonstrate knowledge of the use of technology in practice, which must include: · Electronic documentation systems |
Completion of Electronic Initial Evaluation and progress note forms |
| B.4.18. |
Grade and Adapt Processes or Environments |
Assess, grade, and modify the way persons, groups, and populations perform occupations and activities by adapting processes, modifying environments, and applying ergonomic principles to reflect the changing needs of the client, sociocultural context, and technological advances. |
Home health environment context – modifying tasks for energy conservation and safety within home environment (i.e. toilet transfers, dressing, meal prep) |
| B.4.19. |
Consultative Process |
Demonstrate, evaluate, and plan the consultative process with person, groups, programs, organizations, or communities in collaboration with inter-and intraprofessional colleagues |
OT practitioner provides recommendations for consults with SLP, RN, OTA and PT demonstrating the consultative process in a home health setting |
| B.4.20. |
Care Coordination, Case Management, and Transition Services |
Demonstrate, evaluate, and plan care coordination, case management, and transition services in traditional and emerging practice environments. |
The OTR completes the initial admissions assessment – the person who completes this assessment in home health coordinates the care plan. |
| B.4.21. |
Teaching–Learning Process and Health Literacy |
Demonstrate, evaluate, and utilize the principles of the teaching–learning process using educational methods and health literacy education approaches: · To design activities and clinical training for persons, groups, and populations. · To instruct and train the client, caregiver, family, significant others, and communities at the level of the audience. |
Practitioner in the case scenario models clinical training for person receiving services with health literacy considerations |
| B.4.23. |
Effective Communication |
Identify occupational needs through effective communication with patients, families, communities, and members of the interprofessional team in a responsive and responsible manner that supports a team approach to the promotion of health and wellness. |
Completion of Electronic Initial Evaluation and progress note forms |
| B.4.25. |
Principles of Interprofessional Team Dynamics |
Demonstrate knowledge of the principles of interprofessional team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient- and population-centered care as well as population health programs and policies that are safe, timely, efficient, effective, and equitable |
Interprofessional case demonstrating the roles and delivery of services to evaluate and provide care for patient (OT, PT, OTA, PTA, SLP, and RN) |
| B.4.26. |
Referral to Specialists |
Evaluate and discuss mechanisms for referring clients to specialists both internal and external to the profession, including community agencies |
OT practitioner provides recommendations for consults with SLP, RN, OTA and PT demonstrating the consultative process in a home health setting |
| B.4.28. |
Plan for Discharge |
Develop a plan for discharge from occupational therapy services in collaboration with the client and members of the interprofessional team by reviewing the needs of the client, caregiver, family, and significant others; available resources; and discharge environment. |
Completion of Electronic Home Health Initial Evaluation Form |
ACOTE Accreditation Standards adapted from: https://acoteonline.org
The following Commission on Accreditation in Physical Therapy Education (CAPTE) Standards are addressed in the “Paul” Case Scenario.
Standard # |
Required Element |
Evidence of Standard Met |
7D7 |
Communicate effectively with all stakeholders, including patients/clients, family members, caregivers, practitioners, interprofessional team members, consumers, payers, and policymakers. |
|
7D17 |
Obtain a history and relevant information from the patient/client and from other sources as needed. |
|
7D19 |
Select, and competently administer tests and measures52 appropriate to the patient’s age, diagnosis and health status |
|
7D20 |
Evaluate data from the examination (history, health record, systems review, and tests and measures) to make clinical judgments. |
|
7D24 |
Establish a safe and effective plan of care in collaboration with appropriate stakeholders, including patients/clients, family members, payors, other professionals and other appropriate individuals. |
|
7D25 |
Determine those components of the plan of care that may, or may not, be directed to the physical therapist assistant (PTA) based on (a) the needs of the patient/client, (b) the role, education, and training of the PTA, (c) competence of the individual PTA, (d) jurisdictional law, (e) practice guidelines policies, and (f) facility policies |
|
7D27 |
Competently perform physical therapy interventions to achieve patient/client goals and outcomes. |
|
7D28 |
Manage the delivery of the plan of care that is consistent with professional obligations, interprofessional collaborations, and administrative policies and procedures of the practice environment. |
|
7D29 |
Delineate, communicate and supervise those areas of the plan of care that will be directed to the PTA. |
|
7D32 |
Complete accurate documentation related to 7D15 - 7D30 that follows guidelines and specific documentation formats required by state practice acts, the practice setting, and other regulatory agencies. |
|
7D33 |
Respond effectively to patient/client and environmental emergencies in one’s practice setting |
|
7D37 |
Assess and document safety risks of patients and the healthcare provider and design and implement strategies to improve safety in the healthcare setting as an individual and as a member of the interprofessional healthcare team |
|
7D39 |
Participate in patient-centered interprofessional collaborative practice. |
|
The following AACN Core Competencies for Professional Nursing Education Standards are addressed in the “Paul” Case Scenario:
THE ESSENTIALS: CORE COMPETENCIES FOR PROFESSIONAL NURSING EDUCATION (APPROVED BY THE AACN MEMBERSHIP ON APRIL 6 , 2021)
Clinical Expectations
Clinical learning provides opportunities for a student to enhance the provision of care and gain the skills needed to be an effective member of an interprofessional team; thus, interprofessional experiences in a variety of practice settings are essential.
Clinical Sites
The program faculty assesses clinical sites to determine that, on the aggregate, clinical experiences provide students learning opportunities to foster interprofessional team practice and to provide care within the four spheres of care and with care recipients from diverse backgrounds and cultures, from different genders and age groups and with different religious and spiritual practices, including those who may be considered most vulnerable.
5.2 Contribute to a culture of patient safety.
5.2b Articulate the nurse’s role within an interprofessional team in promoting safety and preventing errors and near misses.
Domain 6: Interprofessional Partnerships
Descriptor: Intentional collaboration across professions and with care team members, patients, families, communities, and other stakeholders to optimize care, enhance the healthcare experience, and strengthen outcomes.
Contextual Statement: Professional partnerships that include interprofessional, intraprofessional, and paraprofessional partnerships, build on a consistent demonstration of core professional values (altruism, excellence, caring, ethics, respect, communication, and shared accountability) in the provision of team-based, person-centered care. Nursing knowledge and expertise uniquely contributes to the intentional work within teams and in concert with patient, family, and community preferences and goals. Interprofessional partnerships require a coordinated, integrated, and collaborative implementation of the unique knowledge, beliefs, and skills of the full team for the end purpose of optimized care delivery. Effective collaboration requires an understanding of team dynamics and an ability to work effectively in care-oriented teams. Leadership of the team varies depending on needs of the individual, community, population, and context of care.
6.1 Communicate in a manner that facilitates a partnership approach to quality care delivery.
6.1a Communicate the nurse’s roles and responsibilities clearly.
6.1b Use various communication tools and techniques effectively.
6.1c Elicit the perspectives of team members to inform person-centered care decision making.
6.1d Articulate impact of diversity, equity, and inclusion on team-based communications.
6.1e Communicate individual information in a professional, accurate, and timely manner.
6.1f Communicate as informed by legal, regulatory, and policy guidelines.
6.2 Perform effectively in different team roles, using principles and values of team dynamics.
6.2a Apply principles of team dynamics, including team roles, to facilitate effective team functioning.
6.2b Delegate work to team members based on their roles and competency.
6.2c Engage in the work of the team as appropriate to one’s scope of practice and competency.
6.2d Recognize how one’s uniqueness (as a person and a nurse) contributes to effective interprofessional working relationships.
6.2e Apply principles of team leadership and management. performance to improve quality and assure safety.
6.2f Evaluate performance of individual and team to improve quality and promote safety.
6.3 Use knowledge of nursing and other professions to address healthcare needs.
6.3a Integrate the roles and responsibilities of healthcare professionals through interprofessional collaborative practice.
6.3b Leverage roles and abilities of team members to optimize care.
6.3c Communicate with team members to clarify responsibilities in executing plan of care.
6.4 Work with other professions to maintain a climate of mutual learning, respect, and shared values.
6.4a Demonstrate an awareness of one’s biases and how they may affect mutual respect and communication with team members.
6.4b Demonstrate respect for the perspectives and experiences of other professions.
6.4c Engage in constructive communication to facilitate conflict management.
6.4d Collaborate with interprofessional team members to establish mutual healthcare goals for individuals, communities, or populations
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