THERAPY OUTCOME MEASURE (TOM)

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[email protected]

Leeds

Therapy Outcome Measures

•Background

•Context

•Purpose

•Use of the tool

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Data to support quality assurance Donabedian

(1980)

Structure Process Outcome

Staff grades,

costs of

assessment

tools,

quality of

accommodatio

n

No. of

interventions

provided; no of

patients seen

Changes in

patients

communication

, wellbeing

Outcomes ‘addresses the effects, not the process, of

particular interventions’ (Hesketh & Sage,

1999)

“ results or visible effects of interventions….

form part of the quality cycle….. provide

information on the impact of

interventions….identify the effectiveness of

practices….” (Enderby, John & Petheram,

2006)

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How can we improve our therapy?

• Reflection

• Learning from research

• Learning from others

• Learning from experience

• Data collection

• Reflection

• Reflection

The NHS Outcomes Framework 2013/14

• Preventing people from dying prematurely

• Enhancing quality of life for people with long-term

conditions

• Helping people to recover from episodes of ill-health or

following injury

• Ensuring that people have a positive experience of care

• Treating and caring for people in a safe environment and

protecting them from harm.

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Rosamond Roughton, National Director for Commissioning

Development

Emphasises the importance of good governance for CCGs.

Oct 2013

• ' where CCGs wish to make changes to their commissioning support arrangements, it is critical that the rationale behind these decisions is transparent and properly documented, that they can demonstrate that the new arrangements represent value for money and improved quality, and that the impact on the local health community and in particular neighbouring CCGs has been taken into account.

• Setting this out clearly and agreeing with the Governing Body the way in which these key decisions have been made is critical to ensure that CCGs can demonstrate they are conducting business in an appropriate and legally sound manner. '

How can outcome measurement help

you with your service?

• Examine changes over time

• Investigate particular issues e.g. intensity of therapy

• Identifying areas of strength

• Identifying areas of weakness

• Communicate with the client, other professionals and

commissioners

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THE COMMISSIONERS AGENDA---QUALITY

HEALTHCARE

•Effectiveness - use of treatments of known worth

•Efficient - best use of resources

•Equitable - equality and fairness

•Responsive

- meets the needs of the individual and their carers

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MUST BE OUR AGENDA

•Effectiveness - use of treatments of known worth

•Efficient - best use of resources

•Equitable - equality and fairness

•Responsive

- meets the needs of the individual and their carers

‘The world has to be different given

what you do.’

World Class Commissioning (WCC) www.institute.nhs.uk/commissioning

‘Adding life to years and years to life’

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Quality, Innovation, Productivity and

Prevention • QIPP is a collection of evidence to support quality and

productivity at a local level

• ‘There are lots of really powerful examples around of

things we can do to improve quality while improving

productivity.’

David Nicholson, NHS Chief Executive.

Rehabilitation/Enablement

• The process of trying to help people who have suffered

some injury/disease or developmental delay to maximise

psychological well being, functional ability and social

integration (Wade, 1992)

• An often complex process which enables individuals after

impairment by illness, developmental delay or injury to

regain as far as possible control over their own lives

(King’s Fund, 1999)

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What For?

• Impairment/disorder reduction

• Improved Function

• Psycho social gain

• Wellbeing

Measures of Performance

•Health Gain •Social Gain

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Therapy treatment goals

• to identify and reduce the disorder/ dysfunction

• to improve or maintain the function and ability

• to assist to achieve potential or integration

• and to alleviate anxiety or frustration.

What it says on the tin!

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Choosing an Outcome Measure

• Relevance

• Validity

• Reliability

Other considerations

• Ease of use

• Communication

Measures Available for Consideration

• Assessments

• Goal attainment scales

• Specialised measures

• Generic measures e.g.

SF36, Teller, COPM

etc

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Now for something different!

What is the International Classification of

Function, Disability and Health (ICF)

• An international classification of function and

disability and its effects on the individual

• Classifies body structure and function

• Classifies activity/independence

• Classifies social participation

• Classifies how the environment impacts upon the

disabled individual

We have added wellbeing as a domain

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Impairments are problems of body function or structure as a significant

deviation or loss

• A deviation from

accepted population

standards

• Can be temporary or

permanent

• Slight or severe or vary

over time

• Not dependent upon the

presence of disease

• Broader than disease or

disorder

• Impairments may result

from other impairment

Activity is the execution of a task or action by an individual

• Occurs at the level of the

individual

• Is essential

• Composite of various

functions

• May be limited by

impairment

• Covers full range of life

areas

Examples:

• Maintaining a body

position

• Reaching and grasping

• Walking

• Self care

• Communicating

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Participation is involvement in life situations

• Occurs at the social

level

• Covers the full range of

life areas

• Limitation may not occur

as a result of impairment

• Is culturally defined

Examples:

• Shopping

• Voting

• Attending school

• Working

• Being part of a

relationship

• Being a carer

Foundations of ICF

Human Functioning - not merely disability

Universal Model - not a minority model

Integrative Model - not merely medical or social

Interactive Model - not linear progressive

Context - inclusive - not person alone

Cultural applicability - not western concepts

Operational - not theory driven alone

Life span coverage - not adult driven

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THERAPY OUTCOME MEASURE (TOM)

• Based on:

World Health Organisation Classification - ICF

• 11 point ordinal scale with 6 defined points

Therapy Outcome Measure

A cross-disciplinary method of gathering information on a broad spectrum of issues associated with therapy and rehabilitation

• It allows therapists to describe the abilities of a patient in four ways:

1. Impairment (problems in body structure or function)

2. Activity (performance of activities)

3. Participation (disadvantages experienced in life situations)

4. Wellbeing (emotional level of upset or distress)

• Rating Severity Scale from 0 – 5 is given for each domain

• 0 = severe, 3 = moderate and 5 = normal 1 /2 are allowed

• Administered at the beginning and again at the end of care

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Eight programmes of care

• Patient needs prevention/maintenance programme

• Patient needs convalescence

• Patient needs slow-stream rehabilitation

• Patient needs regular rehabilitation programme

• Patient needs intensive rehabilitation

• Patient needs specific treatment for individual acute

disabling condition

• Patient needs medical care and rehabilitation

• Patient needs rehabilitation for complex, profound,

disabling condition

So when do we do it?

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Referral/Case history/Assessment

Referral /case history/ assessment

Aim/Goal

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Intervention

Aim/Goal


Intervention

Aim/Goal


Measure performance

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Intervention

Aim/Goal


Measure performance

Normal limits

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

MildProfound Severe Severe/ Moderate Moderate


Ordinal Rating Scale

Impairment/

Body

Disability/

Activity Participation Well-being

Carer

Well-being Date

Admission

Intermediate

Final

Reason for

discharge

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Let's Address the Concerns

• sensitivity

• no measure can reflect our work

• no measure is good enough

• our own measures are better

• bureaucracy

• etc etc etc


0 The most severe presentation of this impairment

1 Severe presentation of this impairment

2 Severe/moderate presentation

3 Moderate presentation

4 Just below normal/mild presentation

5 No impairment

Impairment

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0 Totally dependant/unable to function

1 Assists/co-operates but burden of task/achievement falls on

professional carer

2 Can undertake some part of task but needs a high level of

support to complete

3 Can undertake task/function in familiar situation but required

some verbal/physical assistance

4 Requires some minor assistance occasionally/or extra time to

complete task

5 Independent/able to function

Activity


Participation

0 No autonomy, isolated, no social/family role

1 Very limited choices, contact mainly with professionals, no social or

family role, little control over life

2 Some integration, value and autonomy in one setting

3 Integrated, valued and autonomous in limited number of settings

4 Occasionally some restriction in autonomy, integration, or role

5 Integrated, valued, occupies appropriate role

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Therapy Outcome Measure Well-being

0 Severe constant: High and constant levels of distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy, unable to express or control emotions appropriately.

1 Frequently severe: Moderate distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy. Becomes concerned easily, requires constant reassurance/support, needs clear/ tight limits and structure, loses emotional control easily.

2 Moderate consistent: Distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy in unfamiliar situations, frequent emotional encouragement and support required.

3 Moderate frequent: Distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy. Controls emotions with assistance, emotionally dependant on some occasions, vulnerable to change in routine, etc., spontaneously uses methods to assist emotional control.

4 Mild occasional: Distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy. Able to control feelings in most situations, generally well adjusted/stable (most of the time/most situations), occasional emotional support/encouragement needed.

5 No inappropriate: Distress/ upset/ concern/ frustration/ anger/ distress/ embarrassment/ withdrawal/ severe depression/ or apathy. Well adjusted, stable and able to cope emotionally with most situations, good insight, accepts and understands own limitations.

List of Toms Adapted Scales

• Child speech and language impairment

• Phonological Disorder

• Dysarthria

• Dysfluency

• Dysphagia

• Dysphasia/Aphasia

• Dysphonia

• Hearing Impairment

• Laryngectomy

• Learning Disability (communication)

• Dyspraxia (children with developmental coordination difficulties)

• Cerebral Palsy

• Cognition

• Head Injury

• Stroke

• Neurological Disorders

• Complex and Multiple Difficulty

• Cardiac Rehabilitation

• Multifactorial Conditions

• Musculoskeletal

• Respiratory Care (COPD)

• Incontinence

• Wound Care

• Mental Health

• Anxiety

• Schizophrenia

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List of Toms Adapted Scales

• Autism

• Bulimia

• Chronic Pain

• Forensic

• Podiatry (different conditions)

• Dementia

• Anorexia

• Postnatal Depression

• Complex Brain Injury

• Undernutrition

• Obesity

• Cleft Palate

• Assistive and Augmentative Communication

• Equipment Services

• Enteral Feeding

• Gastrointestinal

• Diabetes

Impairment

Activity

Participation

Wellbeing

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Stephen

Hawking

Impairment

Activity

Participation

Wellbeing

Benchmarking

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Enderby P, John A, Petherham B Therapy Outcomes Measures for Physiotherapists,

Occupational Therapists & Rehabilitation Nurses. Wiley 2007

Wellbeing

Participation

Activity

Impairment

Rating

TOMs: Enter a score from 0 – 5 for each category in the box to the right.

Use half points if appropriate.

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Importance of Benchmarking

Identifying variation in outcomes can expose:

• Clinical Inefficiency

• Poor quality of services

• And---- good quality services

Benchmarking study

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0

2

4

6

8

10

12

14

16

18

All cases Trust 1 Trust 2 Trust 3 Trust 5 Trust 6 Trust 7

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OT - Acquired Neurological - Impairment

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Trust 2 Trust 3 Trust 4 Trust 5 Trust 7

OT

Trust 7

RN

Trust 8

imp St.

Imp Fin.

Imp Ch.

OT - Acquired Neurological - Disability/Activity

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Trust 2 Trust 3 Trust 4 Trust 5 Trust 7

OT

Trust 7

RN

Trust 8

Dis St.

Dis Fin

Dis Ch.

Occupational Therapy - Acquired Neurological

Beware of causality

THERAPY OUTCOME MEASURE (TOM)

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