For those who work in social care or housing, we are all too familiar with the time it can take from the original assessment to the point where work on installing the adaptation begins. As occupational therapists, we want to avoid being a cause of any unnecessary delay in the adaptation process, which is why I struggle to understand the practice of ‘reassessment’ in those cases where significant time has passed from the original assessment.
The rationale for the reassessment is that the person’s needs may have changed from the original assessment, which I fully understand and, on the surface, appears logical – but my question is, why did we not account for these changes in the original assessment and recommendations? The answer, I believe, is that when we use our professional reasoning to recommend adaptations, we give greater emphasis to what we objectively observe through activity analysis and give less time and consideration to future-proofing.
What is activity analysis, and why is it an essential part of what occupational therapists do on a home visit?
When you observe someone on a home visit, you are watching a complex transaction between the person, the environment and the occupation they are doing. Activity analysis is the critical tool occupational therapists use to objectively make sense of what we observe. In the first part of activity analysis, we develop an abstract map or list of the components usually required to successfully complete the task. Those components include the following:
- Motor, processing, sensory, and communication skills required to perform the task
- Environmental features and tools required to perform the task
- Sequence and steps of the task
By comparing the objective observations of the person with the abstract map, occupational therapists analyse and ‘diagnose’ the components impacting the overall performance of the activity. From the analysis, we can then identify the most appropriate intervention.
In my professional practice, activity analysis enables me to understand the impact the home environment has on the person’s ability to do those everyday activities important to them. It helps me identify if an adaptation is the most effective solution or whether other interventions, such as reablement or medication review, are more appropriate. Just as important as the above, it is through activity analysis that I find the language to objectively and clearly articulate to funders why adapting the home is the most cost-effective solution.
What is future-proofing, and why is it essential to the design of adaptations?
The Cambridge Dictionary defines future-proofing as:
design [ing] software, a computer, etc. so that it can still be used in the future, even when technology changes.
If we apply this definition to adaptations, future-proofing is the process of designing adaptations so that they can still be used in the future, even when the person’s needs change. There are several advantages of ensuring we future-proof adaptations, two of the key ones are explored below.
Advantage 1. The Centre for Sustainable Healthcare has argued that there are hidden financial and environmental costs to society when we fail to future-proof adaptations. First, there are the health and social care costs associated with repeated assessments as the person’s needs change. Second is the environmental cost of disposing of the low-level equipment no longer required by the person.
Advantage 2. Humans are animals; like all animals, we constantly adapt the environment to meet our needs. When this becomes difficult, we feel unsafe and insecure and experience physical and psychological discomfort. Adapting the environment also takes time and energy; speak to anyone who has had to navigate the DFG process. So if we future-proof adaptations, we naturally extend the period that someone feels safe, secure and comfortable in their home. As occupational therapists, we should also be arguing that this approach supports health and social care’s reduce, prevent and delay agenda. In other words, providing future-proofed adaptations prevents or delays people needing more expensive formal care.
When it comes to equipment and adaptations, should activity analysis be driving our recommendation, or should future-proofing?
As already discussed, activity analysis is a snapshot in time that helps us objectively observe the issues occurring in the transaction between the person, the environment, and the activity they are performing. It is easy to recommend solutions based on the activity analysis because we can easily articulate and justify what we are recommending.
As stated at the start of the article, the weakness of this approach is the need for reassessment when there has been a long wait prior to installation – due to the risk of recommendations not meeting the needs. Or where adaptations are installed based on the original activity analysis, there is the risk of it only meeting the person’s needs for a short time.
Interestingly, Heywood, observed in her research the phenomena of adaptations being ripped out precisely because occupational therapists had either not been allowed or failed to future-proof adaptations. Heywood went on to list nine factors that should be incorporated in the assessment and design of adaptations, and future-proofing, particularly for children, is included. These nine assessment principles have now been adopted into the new Disabled Facilities Grant Guidance for England.
Future-proofing is not simply a case of considering the person’s diagnosis and prognosis. Instead, it requires a framework that supports the occupational therapist’s professional reasoning and helps them articulate and justify their recommendations. For example, many occupational therapists use the inclusive design principles described by the Centre for Excellence in Universal Design. Using these principles, therapists have an evidence-based way of recommending or designing adaptations that naturally accommodate the person’s needs as they change – providing a long-term sustainable solution.
Activity analysis is a critical tool to help occupational therapists objectively observe the transaction of the person, the environment and the task they are performing. And the evidence from the analysis helps us justify to funders why adapting the home will prevent, reduce, or delay health and social care needs. However, we should not be informing the design of our recommendation solely on the activity analysis. As has been discussed, future-proofing should be a cornerstone of the professional reasoning used by occupational therapists who use equipment and adaptations as an intervention for improving health and well-being.
By making the best use of the observations we make through activity analysis and our knowledge and skills around future-proofing, we have the opportunity to reduce the need for reassessment and ensure that the equipment and adaptations installed provide long-term and sustainable solutions for people.