Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iohc20 Download by: [Hogeschool Van Amsterdam] Date: 14 March 2016, At: 02:37 Occupational Therapy In Health Care a journal of contemporary practice ISSN: 0738-0577 (Print) 1541-3098 (Online) Journal homepage: http://www.tandfonline.com/loi/iohc20 Application of the Model of Human Occupation Screening Tool (MOHOST Assessment) in an Acute Psychiatric Setting Sue Parkinson BA, DipCOT, Andrew Chester BSc, Sarah Cratchley BSc & Julie Rowbottom BHSc (hons) To cite this article: Sue Parkinson BA, DipCOT, Andrew Chester BSc, Sarah Cratchley BSc & Julie Rowbottom BHSc (hons) (2008) Application of the Model of Human Occupation Screening Tool (MOHOST Assessment) in an Acute Psychiatric Setting, Occupational Therapy In Health Care, 22:2-3, 63-75, DOI: 10.1080/07380570801989465 To link to this article: http://dx.doi.org/10.1080/07380570801989465 Published online: 10 Jul 2009. Submit your article to this journal Article views: 3955 View related articles Citing articles: 1 View citing articles
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Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=iohc20
Download by: [Hogeschool Van Amsterdam] Date: 14 March 2016, At: 02:37
Occupational Therapy In Health Carea journal of contemporary practice
Application of the Model of Human OccupationScreening Tool (MOHOST Assessment) in an AcutePsychiatric Setting
Sue Parkinson BA, DipCOT, Andrew Chester BSc, Sarah Cratchley BSc & JulieRowbottom BHSc (hons)
To cite this article: Sue Parkinson BA, DipCOT, Andrew Chester BSc, Sarah Cratchley BSc & JulieRowbottom BHSc (hons) (2008) Application of the Model of Human Occupation Screening Tool(MOHOST Assessment) in an Acute Psychiatric Setting, Occupational Therapy In Health Care,22:2-3, 63-75, DOI: 10.1080/07380570801989465
To link to this article: http://dx.doi.org/10.1080/07380570801989465
Application of the Model of HumanOccupation Screening Tool (MOHOST
Assessment) in an Acute Psychiatric Setting
Sue Parkinson, BA, DipCOTAndrew Chester, BScSarah Cratchley, BSc
Julie Rowbottom, BHSc (hons)
Sue Parkinson, BA, DipCOT, is Practice Development Advisor for OccupationalTherapists at Derbyshire Mental Health Services NHS Trust, Room 14, main corridor,Kingsway Hospital, Kingsway, United Kingdom.
Andrew Chester, BA, BSc, is Senior Occupational Therapist at Hartington Unit,Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield, S44 5BL,United Kingdom.
Sarah Cratchley, BSc, is Senior Occupational Therapist at Derby City Psychi-atric Unit, Derby City General Hospital, Uttoxter Road, Derby, DE22 3NE, UnitedKingdom.
Julie Rowbottom, BHSc (hons), is Occupational Therapist at Hartington Unit,Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield, S44 5BL,United Kingdom.
Address correspondence to: Sue Parkinson, Derbyshire Mental Health ServicesNHS Trust, Room 14, main corridor, Kingsway Hospital, Kingsway, Derby DE223LZ, United Kingdom (E-mail: [email protected]).
With thanks to Dr. Kirsty Forsyth, Director of UK CORE, Occupational Thera-pist Bryony Robinson who created the MOHOST self-assessment, and all who havereviewed this article.
ABSTRACT. The Model of Human Occupation Screening Tool(MOHOST) plays a key role in the occupational therapy assessment pro-tocol at an acute psychiatric unit in Britain. This paper incorporates a casestudy and discussions with the occupational therapists to explore how theassessment influences practice from initial assessment to final outcomemeasure and how single observation forms and prototype self-assessmentforms based on the MOHOST have contributed to the assessmentprocess.
KEYWORDS. Assessment, mental health, model of practice
INTRODUCTION
The Model of Human Occupation Screening Tool (MOHOST) ver-sion 2.0 (Parkinson, Forsyth, & Kielhofner, 2006) originated in Britain(Parkinson, 2006), and allows occupational therapists to rate how 24 fac-tors relating to a person’s volition, habituation, performance, and envi-ronment combine to influence occupational participation. The therapistrates each item as to whether the factor represented by the item facili-tates (F), allows (A), inhibits (I), or restricts (R) the person’s occupationalparticipation.
The MOHOST is designed so that the instrument can be scored basedon a variety of data sources and approaches to collecting information.This paper highlights two specific methods of applying the MOHOST: (a)to provide a “shapshot” picture of the client following a single interven-tion and (b) to function as a comprehensive summary after a period ofinformation gathering.
Many publications have described the MOHOST’s use (Abelenda, 2002;Colville, 2005; Duncan & Moody, 2003; Forsyth & Kielhofner, 2005;Hatton, 2005; Kielhofner, 2008; Kramer, Hinojosa, & Royeen, 2003;Larty & Lucas, 2004; Mitchell & Neish, 2007; Parkinson, 2002) and astudy of its psychometric properties is forthcoming (Forsyth et al., inpress). This paper adds to the discussion by describing how the assess-ment has been embedded into the occupational therapy process acrossa large mental health service in Britain where occupational therapistsare based at more than 40 separate sites. We illustrate how the MO-HOST influences practice from initial assessment to conceptualizinga client’s situation (Kielhofner, 2008), goal setting, and evaluation oftreatment.
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STRATEGIC PARTNERSHIP
The process of incorporating the MOHOST and other Model of Hu-man Occupation (MOHO) assessments was undertaken as part of a courseof action aimed at guarding against fragmentation of occupational ther-apy services (Craik, Chacksfield, & Richards, 1998), and meeting gov-ernment calls for an integrated approach to service, organizational, andprofessional development (Department of Health, 1999). The process in-volved a partnership between academics and clinicians (Parkinson, 2006)in tune with the British College of Occupational Therapists call for thegap to be bridged between practice and theory (College of Occupa-tional Therapists, 2002), and the call from the Health Professions Councilfor practitioners to utilize theoretical concepts and standardized assess-ments (Health Professions Council, 2007). Throughout the partnership,therapists’ perspectives on the MOHOST and other MOHO assessmentshave been systematically gathered and are used in this paper to pro-vide anecdotal information regarding therapists’ experiences applying theMOHOST.
DECIDING TO USE THE MOHOST AS AN INITIAL ASSESSMENT
Deciding which assessments to use required that we first identify, se-lect, and become familiar with relevant tools. Reviewing the availabletools clarified not only what therapists needed to know about their clientsbut also how they defined their roles and expertise (Phillips & Renton,1995). In addition, consideration was given to which assessments wouldsupport evidence-based practice through the routine collection of rele-vant client data (Lloyd, King, & Bassett, 2005; Melton, 2001; Parrott,2001).
Assessment protocols were established for each service area. Each pro-tocol was depicted in flowchart form (see Figure 1, for an example) andsupported by a clinical reasoning document (see excerpt in Figure 2).These described the assessments of choice for gaining a broad overviewof a client’s occupational participation as well as more secondary assess-ments that could provide greater detail concerning a client’s strengths andchallenges. The majority of assessments chosen were based on MOHO,reflecting the findings of practitioners that MOHO can provide them with atheoretical understanding of occupation and support an occupation-focusedpractice (Forsyth, 2001).
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FIGURE 1. Example assessment protocol.
The protocols identified the MOHOST as being the most appropriateassessment to use in acute adult psychiatric settings in Britain where lengthof stay is often brief (in the majority of instances, less than 2 weeks). Itwas also chosen for use in learning disability and some rehabilitation set-tings where clients are less able to engage in verbal interview procedures.
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FIGURE 2. Excerpt from inpatient clinical reasoning document.
Therapists found the MOHOST quick to administer and useful for summa-rizing what was learned about a client. Moreover, as one therapist noted,“It helps me to work with clients holistically, because it takes a broad lookacross all aspects of a person’s occupational participation.”
In the acute adult psychiatric settings, it was decided that the MOHOSTwould be used to gain a baseline assessment of a person’s occupational par-ticipation following engagement in four therapy sessions. This use of theMOHOST as a summary of the therapist’s accumulated knowledge of theclient allows ample opportunity to collect necessary information. It allowsthe therapist to get to know the client and triangulate information gleanedthrough reading case notes, talking with clients, and by observing them ina range of situations along with discussing findings with team membersand/or relatives (Parkinson, Forsyth, & Kielhofner, 2006). In the meantime,occupational therapists can use the single observation MOHOST form tocapture information about their clients on a day-by-day basis. This useof the MOHOST provides a snapshot of occupational functioning. Eachitem on the single observation form corresponds with an item on the sum-mary MOHOST and the information noted will contribute to the summaryrating that is completed following 4 therapy sessions. For example, observ-ing whether an individual “shows awareness of strengths and limitations”on the single observation form during a given session will contribute tothe therapist’s understanding of the client’s overall “Appraisal of ability,”which is then rated on the summary MOHOST. As one therapist remarked,“I’ve found the single observation MOHOST form very helpful as a wayof assessing and comparing clients’ responses to a variety of different en-vironments and activities, as well as monitoring and recording change overtime.”
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FIGURE 3. Sandra extract of a single observation MOHOST (4 items of 24).
Figures 3 and 4 show extracts from MOHOST assessments for San-dra, a 61-year-old inpatient who was admitted to hospital feeling de-pressed and who remained suicidal having attempted to cut her wrists.A member of occupational therapy support staff completed the single
FIGURE 4. Sandra first summary MOHOST—Report and ratings.
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observation MOHOST form (extract shown in Figure 3) after Sandraattended a multi-gym session 2 days into her admission. It was notedthat she demonstrated a high level of process and motor skills and vo-lition in this particular environment, although she withdrew from socialinteraction. The occupational therapist used the information along withreports from other sources (talking to Sandra, the nursing team, andother therapy staff) to complete the first summary MOHOST (ratingsshown in Figure 4), giving a broader overview of Sandra’s occupa-tional participation as a whole. The summary MOHOST highlightedthe fact that Sandra was much less able to maintain her motivationfor occupation and pattern of occupation in the hospital environmentgenerally.
UTILIZING MOHOST ASSESSMENTS AS THE BASIS FORCONCEPTUALIZING A PERSON’S OCCUPATIONAL NEEDS
(CASE FORMULATION) AND SETTING GOALS
Assessments provide little benefit if they do not inform the treatmentprocess (Thorner, 1991) and lead to the setting of collaborative treatmentgoals (Lloyd, King, & Bassett, 2002). The findings of the MOHOST shouldtherefore be converted into goals, helping to define the key occupationalchanges that a client agrees to work towards. One therapist noted1 in thisregard,
Some clients find it helpful to see the assessment form itself, par-ticularly the report of their strengths and limitations and the visualprofile provided by the ratings scale. This can be a good focus fortalking about occupational needs and goal setting. With other clients,it’s more helpful to share the findings orally, translating the languageof the assessment into a form which meets the client’s needs.
The results of the MOHOST are made more relevant when they contributeto a comprehensive case formulation explaining the client’s circumstances,rather than simply giving a list of performance strengths and limitations(Kielhofner, 2008). Accordingly, we organize the information gained fromthe MOHOST into an ordered and cohesive formulation that conveys anacute respect for the person’s unique circumstances and highlights keyissues (Chesworth, Duffy, Hodnett, & Knight, 2002). MOHO theory sup-
1The quotes in this paper come from therapists who were involved in a programdevelopment project and were included as authors in this manuscript.
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ports this process by providing therapists with concepts for understandingthe elements of a client’s occupational situation and how they are inter-related. Moreover, the emphasis of MOHO on volition and the uniqueinteraction of personal characteristics with the environment (Kielhofner,2008) supports client-centered practice. It encourages therapists to viewthe strengths and limitations outlined in the MOHOST in the context of:
� The client’s occupational identity, which includes awareness of abili-ties, expectation of success, their sense of self and belonging in currentand past roles, plus life turning points and direction as revealed in theiroccupational narrative
� Occupational competence, especially the extent to which occupationalabilities and participation match identity
� Key issues that prevent and support occupational adaptation in relationto self-care, productivity, leisure, performance of activities, and skillsdevelopment (including contributing volitional, organizational, andenvironmental factors, strengths and supports, and limitations andchallenges)
The aforementioned considerations are then encapsulated in a statementthat summarizes the “nature, balance, pattern, and context of occupationsand activities” (Creek, 2003, p. 8) in the individual’s life and clearly iden-tifies the focus for occupational therapy.
Communicating this conceptualization to the client in order to negotiatetreatment goals is the next step (Kielhofner, 2008). The case formulationsare shared with and validated by clients enabling all involved to “understandthe rich complexity of occupational behavior,” (Hagedorn, 2000, p. 63).Based on the summary MOHOST shown in Figure 4, Figure 5 illustratesthe case formulation for Sandra. Presenting the case formulation to Sandrahelped her to understand why she felt so depressed and angry and shecould appreciate that the occupational therapist was able to identify theissues facing her. Having previously been skeptical about the benefitsof occupational therapy and reluctant to engage in interview procedures,Sandra agreed to negotiate measurable goals and explore possible solutions.
REVIEWING PROGRESS USING THE MOHOST AS ANOUTCOME MEASURE
It is a challenge to discover “appropriate tools to measure the quality ofour work” (Clarke, Sealey-Lapes, & Kotsch, 2001, p. 1). The MOHOSTis well placed to evaluate the effectiveness of occupational therapy inter-
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FIGURE 5. Sandra example case formulation.
ventions because it focuses on engagement in occupation. Also, it does notrequire practitioners to set aside a specific time in order to re-assess theclient. Instead, information is gathered over a period of time as treatmentunfolds. This ability of the MOHOST to be administered unobtrusively onrepeat occasions as an outcome measure is particularly valued by occupa-tional therapists, as illustrated by the following comment:
When completing multiple MOHOST assessments across differentenvironments, I found the results were often startlingly different (e.g.marked differences in motivation, communication skills or processskills displayed). Careful comparison and reflection really helpedto identify the key factors involved and led to much more effectiveintervention planning. This often included helping others to mod-ify aspects of each environment to help maximize the individual’soccupational performance.
In those cases where occupational therapy services extend over time, theMOHOST can be used to document progress. In Sandra’s case, she was dis-charged from hospital after 18 days but continued to receive occupational
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FIGURE 6. Sandra Extract of Self-Assessment MOHOST (4 items of 24).
therapy as an outpatient. The focus of her goals therefore changed fromperforming activities in the hospital setting to reengaging in previouslyheld occupations in the community. She became more able to evaluateher own progress, and Figure 6 shows an extract from a newly developedself-assessment form based on the single observation MOHOST that shecompleted after attending a badminton session. The form was originallydesigned in collaboration with service users to evaluate their participationin a group program. It allowed Sandra to be more actively involved in theassessment process by drawing on the MOHO concepts which were nowfamiliar to her.
UTILITY OF THE MOHOST FOR COMMUNICATION
Figure 7 gives details from a summary MOHOST completed as a finaloutcome measure prior to Sandra’s discharge. Like all the other MOHOSTassessments, this would have been discussed with Sandra and filed incare notes accessed by the whole care team. The ability of the MOHOSTto provide a useful format for report writing and to structure the verbalfeedback given to multidisciplinary teams (MDTs) is clearly appreciatedby occupational therapists, as evidenced by the following comments:
Sharing MOHOST assessments with other members of the MDT hasraised the profile of occupational therapy—people understand ourrole much more fully and as a result, referrals are more appropriate.
Other MDT members have welcomed our use of MOHOST. They sayit helps them to understand the role of Occupational Therapy morefully. They like the concepts and language used and have begun to
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FIGURE 7. Sandra final summary MOHOST—Report and Ratings.
use these themselves when talking about client’s strengths and needs.This helps with referrals and collaborative working.
Using MOHOST can help therapists maintain a clear sense of identityand role within their MDT, countering the pressures which sometimespush OTs towards generic working in mental health teams. It helpsthe therapist maintain a truly occupational focus in their assessmentand clinical reasoning and it helps to communicate this to the rest ofthe MDT.
CONCLUSION
Our annual audits of the assessment process in occupational therapyservices continue to demonstrate that the MOHOST is the most commonlyused, standardized, occupation-focused assessment in our acute mentalhealth settings. Routine use of the MOHOST in these settings has allowed
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occupational therapists to embed theory into practice and to define their rolewithin the team and to their clients by articulating their unique contributionto the treatment process (Forsyth et al., in press). In the future, we will beconsidering how to draw on the wealth of data generated through the useof MOHO assessments to research the effectiveness of the occupationaltherapy services. We have no doubt that the MOHOST will play its part incontributing to this much-needed evidence base.
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