Occupational Therapy Functional Assessments

Whether you are a Support Coordinator, a Team Leader, or a Support Worker, we’re pretty sure you’ve heard about an NDIS Participant recently wanting, needing, or having an Occupational Therapy (OT) Functional Assessment (FA). There’s also a good chance that you may have heard some people use the term “Functional Assessment” interchangeably with the recently cancelled NDIS “Independent Assessment” plan. They are definitely not the same thing, and below we explore how FAs are different from the abandoned IAs and what OT FAs are all about. 

BUT FIRST… WHAT EXACTLY IS AN OCCUPATIONAL THERAPIST?

An OT is an Allied Health Professional who facilitates a person to be as independent as possible in their everyday lives. OTs conduct holistic, comprehensive, and objective observations which help to identify challenges, goals, and support needs so that people can most effectively and enjoyably live their lives. 

By conducting skilled assessments, OTs can be “storytellers” for Participants, translating their goals, aspirations, and support needs into meaningful and evidence-based recommendations to facilitate Capacity Building. OTs were working within a Capacity Building framework long before Capacity Building became an NDIS “Support Purpose”, and we were working within an Insurance Scheme. 

SO THEN… WHAT IS AN OCCUPATIONAL THERAPY FUNCTIONAL ASSESSMENT?

OTs can conduct an in-depth, holistic, and functional capacity evaluation of a person’s life. 

An FA answers the following questions: 

• What does function look like for this person in the context of their day-to-day life?

• How does the person complete certain tasks?

• What level of support or assistance does the person need to achieve these tasks, to increase safety, and to build capacity?

• What external supports are required if the person cannot achieve certain tasks independently?

• How do the person’s individual goals genuinely relate to their “bigger picture”, not just to fulfilling a token section of an NDIS Plan? 

One of the original goals in designing the NDIS was that investment in Capacity Building supports could mean that a person’s support needs would not increase as much as they would have without the Capacity Building Intervention. 

OTs understand this. 

OTs also understand that we all have our own individual capacity “ceilings”, and we all have limitations (and “all” really means everybody, not just NDIS Participants). Some Participants have limitations in which the goal of the insurance model will not provide a full “return on investment”, so the aim of Capacity Building supports may become about maintaining and preventing loss of function rather than pushing for an increase in function. A skilled OT is able to assess when someone may have reached their capacity in a certain skill or task and make recommendations for different support at that point, instead of pushing ahead with therapies or interventions that are no longer making an impact.

By conducting comprehensive FAs, OTs see beyond assessment recommendations, short-term goals, and Assistive Technology (AT) requests to the bigger meaning that these incremental goals will play in the Participant’s everyday life. 

For example, a short-term goal with an OT may be that seven-year-old Becky receives the support she needs to increase her gross motor skills, but the meaningful outcome is that she can now join her friends on the mainstream soccer team. A shorter-term goal for Finn is that he requires approval for a lift to improve access within his home; the meaningful outcome is that fifteen-year-old Finn can now independently access the bathroom to manage his toileting and personal hygiene – for the first time in his life. 

In the absence of an NDIA-generated template for an FA, OTs tend to cover four main areas through skilled and thorough observation and task analysis, often in multiple settings and environments:

1. General Function (e.g., mobility, transfers, communication, relationships, behaviour, vision, upper limb function)

2. Self-Care (e.g., dressing, eating, toileting, continence, showering, grooming)

3. Self-Management (e.g., domestic activities such as shopping, meal preparation, laundry, cleaning, gardening, decision-making, financial management, life administration, budgeting, other cognitive tasks)

4. Community Access (e.g., driving, mobility within the community, transportation, leisure and social activities, work, study, day programs)

Every domain that is observed includes an analysis of how the task may be broken down and accomplished by the individual. For tasks that cannot be modified or supported for independent achievement, the OT can make recommendations about the external assistance that may be required (such as support from another person, including support ratios, task modifications, AT, retraining, and home modifications). 

Please take note: it is critical that each Participant choose an OT that best matches their support needs. Not all OTs have decided to practice and develop their skills in FAs and make it a specialisation, so it is essential to choose an OT who has FA skills. 

OH OK, SO OCCUPATIONAL THERAPY FUCTIONAL ASSESSMENTS ARE THE SAME AS THE RECENTLY CANCELLED NDIS INDEPENDENT ASSESSMENTS, THEN?

Hell, no! 

When the NDIA first started talking about IAs, they used the term “Functional Assessments” interchangeably, and OT Australia was very quick to point out that they were NOT the same thing, leading the Agency to take these terms out of the IA framework and agree to no longer refer to IAs as FAs. However, even recently, Minister Linda Reynolds said that she prefers the term “Functional Assessment” to “Independent Assessment”.

So, what is the big deal, and how are they so different?

When OTs use standardised assessments (which is what the IAs were based on), they come second: they are used to back up the extremely comprehensive assessments and observations carried out by a skilled therapist. Assessment, observation, and reporting will often take 10–12 hours. The primary assessment is the skill of the OT’s observation, assessment of sometimes literally hundreds of tasks, reporting, and bringing together information from many environments, assessments, and feedback. Once again, standardised assessments are used as backups of – not substitutes for – OTs’ observation and assessment. 

IAs, on the other hand, had flipped this around. During an IA, the standardised tools were the priority, and IAs were to require a minimum of only 20 minutes of observation and a minimum of one task. In the proposed NDIS IAs, the focus was on completing tools, not observation. Therefore, IAs ran an enormous risk of a lack of context in the assessment result and an inability to see the “big picture”. For example, during an IA, if a young woman answered “yes” when asked whether she could independently shower herself, she could be documented as “independent with showering”. However, an OT would observe that she has grab rails and a shower chair in her shower and that she was dependent on her informal support for reminders, prompts, task set-up, and supervision. The OT’s holistic observation and understanding of a given context lead to very different answers. 

Now is the time for true collaboration and discussion about better alternatives to the cancelled IA pilot, and we can’t help but think that OTs need to be a key voice in these conversations. 

For the record, while we now have the chance to ask “Where To From Here?”, it must be said that the NDIA’s concern that that there will be a “sympathy bias” if someone is assessed by a known therapist is offensive to OTs and other Allied Health Professionals: it assumes a lack of objectivity and professionalism. 

OTs have a code of ethics that requires them to strive to facilitate independence and an ordinary life for the people they support, not continually refer back to themselves for unnecessary intervention; suggesting this may be the case is, simply put, offensive.

So, here is the lesson: if you would like to truly understand how to support someone to live the best life of their choosing in as safe and independent a way as possible, suggest an OT FA, where individual observation, assessment, and understanding come first, ahead of standardised assessment tools.