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... 1 Party Pooper: A Bowel & Bladder Program for Relieving Chronic Constipation in Pediatrics Brenna Menke May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Erin Peterson, DHSc, OTR, CHT Running head: PARTY POOPER: A BOWEL & BLADDER PROGRAM 2 Abstract Functional constipation and bedwetting are common problems in pediatrics. However, a common misconception about bedwetting in children is that it is behavioral, and they will outgrow it while dismissing the role constipation plays in these accidents. An 8-week occupation-based therapy protocol was developed for rehabilitating chronic constipation in pediatrics. The manual was written for occupational therapy practitioners at Youre in CONTROL! which included educational handouts for parents, habit-tracking worksheets, therapeutic activities, manual techniques, a kid-friendly high-fiber cookbook, and a home exercise program. Protocol assessment with stakeholders included feedback from three occupational therapists who concurred that the therapy protocol material was presented clearly and effectively (100%), the therapeutic activities were sufficient for pediatrics (70%), the protocol is readily adaptable (100%), and has feasibility (100%). Finding the right rehabilitation program for children experiencing symptoms such as bedwetting or stool withholding is critical for resolving chronic constipation. Keywords: encopresis, enuresis, bedwetting, occupation-based, pelvic floor therapy PARTY POOPER: A BOWEL & BLADDER PROGRAM 3 Party Pooper: A Bowel & Bladder Program for Relieving Chronic Constipation in Pediatrics Across their lifespan, people will spend an average of one and a half years of their life in the bathroom (Jayden, 2020). The running tally of this time begins during a monumental milestone in childhood development: the toilet transition. While many children transition with little to no trouble, others experience bedwetting and hygiene issues; these occur in about five to seven million children in the United States and are more common among boys than girls (American Academy of Pediatrics, 2021). However, a common misconception about bedwetting in children is that it is behavioral or sensory-based, and they will outgrow these accidents with time. This completely dismisses constipation's role in elimination disorders (Caldwell et al., 2005; Hodges, 2017). Youre in CONTROL! (YIC), a private practice outpatient therapy clinic in Kokomo, Indiana, provides occupational therapy (OT) services for treating bowel, bladder, and other pelvic floor dysfunction (PFD) issues. The mission of YIC is to move each woman to take control of their body and rehabilitate them to feel like a natural woman again (Galles, n.d.). This clinic services primarily women (95% caseload) with care for men and children under certain circumstances. The demographics of the client caseload within the Kokomo, IN, and surrounding areas are predominantly Caucasian, middle-to-lower socioeconomic class, with about 88% only obtaining a high school diploma (U.S. Census Bureau, 2021). Caregivers and children seeking medical assistance for bedwetting and chronic constipation often present frustrated from ongoing accidents and defeated by the strain it causes on their relationship. There is a growing demand for the clinic to see children experiencing PFD due to the limited medical intervention options from physicians and the lack of pediatric pelvic floor specialists available in the area. Currently, no standardized treatment programs consider the PARTY POOPER: A BOWEL & BLADDER PROGRAM 4 individual needs of the treating clinicians, caregivers, and children addressing all areas of occupations from a biopsychosocial lens. Therefore, this doctoral capstone project is focused on developing a bowel and bladder therapy protocol to inform and guide practitioners in rehabilitating chronic constipation from an occupation-based perspective. Background Bladder & Bowel Issues Constipation is a medical condition impacting the colon, leading to various symptoms such as fewer than three bowel movements a week; stools that are hard, dry, or lumpy; pain with passing stool; and a feeling of incomplete stool emptying with bowel movements (National Institute of Diabetes and Digestive and Kidney Diseases, 2018). Chronic constipation is the presence of constipation symptoms ongoing for a minimum of four weeks and is the number one cause of accidents and bedwetting (O'Regan et al., 1986). Encopresis is a medical condition in which an individual has recurring poop accidents, often without noticing, due to the loss of tone and sensation from an overstretched rectum (Hodges & Schlosberg, 2020, p. 4). Likewise, enuresis is involuntary wetting, occurring during the day or nighttime, caused by an impacted rectum pressing on the bladder (Hodges & Schlosberg, 2020, p. 4). Enuresis that occurs at night is called nocturnal enuresis, or bedwetting. These accidents become a barrier to optimal occupational performance at school, in sports, during sleepovers with friends, and straining relationships with their caregivers, who are desperate to find a solution. Medical Interventions Treatment for encopresis and enuresis can vary based on the preferences of the pediatrician, caregiver, and child. Behavior modifications and bedwetting alarms are commonly used for enuresis, with limited evidence to identify the effectiveness of staying dry with an alarm PARTY POOPER: A BOWEL & BLADDER PROGRAM 5 (Caldwell et al., 2020). Common medical interventions for constipation relief include various laxatives, prescription medications for specific gastrointestinal disorders, bowel cleanout procedures, and pelvic floor physical therapy. Unfortunately, these interventions are a temporary fix to incontinence and constipation and do not address the lifestyle modifications required to maintain hygiene and routine bowel movements across the lifespan. Laxatives. The primary function of the large intestine (colon) is to reabsorb water from the chyme/stool mixture leading to soft, well-formed stool and moving stool through the colon to the rectum. Lack of water in the stool contributes to constipation and is a barrier to complete bowel movements (Boilsen et al., 2017). The most common laxative, Polyethylene glycol 3350 (Miralax), uses a top-down approach that draws water back into the colon to soften stools to make bowel movements less painful. Enemas such as saline solution, mineral oil, and glycerin suppositories use a bottom-up approach to apply fluid directly to the stool within the rectum to encourage a bowel movement. Occasional use of laxatives can help temporarily relieve constipation symptoms; however, they do not address the underlying cause of constipation or the role an overstretched rectum has in incontinence. The Modified ORegan Protocol (M.O.P.) was published in 2014 by Dr. Steven Hodges, who adjusted the original protocol from Dr. Sean ORegan, a pediatric kidney specialist. ORegan published the protocol in the 1980s after vowing to solve his own sons issues with bedwetting (Hodges & Schlosberg, 2019). The central premise of the M.O.P. protocol is resolving constipation by using a combination of laxatives and enemas for complete daily bowel movements. This allows the rectum to empty entirely and return to within the average size range, tone, and nerve sensation. Resolving constipation reduces the pressure on the bladder, which leads to a reduction in daytime accidents and bedwetting. This protocol must be completed under PARTY POOPER: A BOWEL & BLADDER PROGRAM 6 physician supervision, but can be supported by therapists. Children find great relief in completing the M.O.P. However, this protocol only manages the gastrointestinal system; it does not address PFD and is conducted over a long period. Pelvic Floor Therapy. Pelvic floor therapy (PFT) addresses musculoskeletal dysfunction that occurs in various bowel and bladder diagnoses through manual techniques, biofeedback, and neuromuscular retraining. In the adult population, the literature supports the use of biofeedback and PFT to achieve normal defecation for resolving constipation (Woodward, Norton, & Chiarelli, 2014). There is limited evidence for pediatrics supporting children through PFT and utilizing biofeedback to improve chronic constipation (van Engelenburg-van Lonkhuyzen et al., 2017). However, these approaches only address musculoskeletal dysfunction and do not consider the impact of sleep, toileting habits, routines, nutrition, education, and environment on chronic constipation. Additionally, these approaches require therapists to be certified and have access to biofeedback equipment in the clinic. Currently, no standardized therapy protocols utilize an occupation-based approach with age-appropriate therapeutic activities for resolving chronic constipation in pediatrics. Addressing lifestyle modification through an occupation-based therapeutic protocol in combination with manual PFT is warranted. Role of Occupational Therapy Occupational therapy practitioners are uniquely positioned to incorporate holistic interventions across multiple domains through meaningful occupations to improve an individuals occupational performance and quality of life. Occupations are valuable, everyday activities that clients engage in for health and overall well-being. Through the therapeutic use of occupations, OT practitioners help individuals who have difficulty completing the occupations they want or need to do because of various illnesses, injuries, or disabilities (American PARTY POOPER: A BOWEL & BLADDER PROGRAM 7 Occupational Therapy Association, 2011). The Occupational Therapy Practice Framework (OTPF) defines the occupational therapy professions scope; it categorizes occupations as activities of daily living (ADL), instrumental activities of daily living (IADL), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). Toileting and toilet hygiene is one of eight subcategories of ADLs and includes: Obtaining and using toileting supplies, managing clothing, maintaining toileting position, transferring to and from the toileting position, cleaning the body, caring for menstrual and continence needs, maintaining intentional control of bowel movements and urination, and if necessary, using equipment or agents for bladder & bowel control (Uniform Data System for Medical Rehabilitation, 1996, pp. 324). Occupational therapy practitioners can also address feeding, meal preparation, and nutrition management. Performance patterns are acquired behaviors (i.e., habits, routines, roles, and rituals) used to consistently engage in occupations (AOTA, 2020, p. 12). Likewise, client factors are individual characteristics, values, and body structures/functions that influence occupational performance (AOTA, 2020, p. 15). With toileting and ADL management, the habits and routines established by clients can become maladaptive, negatively impacting body structures and functions and creating a barrier to occupational performance and satisfaction. Theory The person, environment, occupation, and performance (PEOP) model was developed and modified by Baum, Christiansen, and Bass (2015) to describe a client-based approach to occupational therapy. The PEOP model considers the clients personal (intrinsic) and environmental (extrinsic) factors that impact their occupational participation and performance. PARTY POOPER: A BOWEL & BLADDER PROGRAM Specifically, the model utilizes a biopsychosocial perspective that promotes or inhibits an individual's occupational performance, maximizing their quality of life (Baum, Christiansen, & Bass, 2015). The PEOP model was well suited for considering all aspects of children's intrinsic and extrinsic factors, which is critical for maintaining holistic and client-centered interventions throughout the program. The therapeutic activities developed within the protocol utilized PEOP, and the contexts of the model can be found in Figure 1. Specifically, the activity analysis completed for each activity identified areas that the PEOP model view as influential with occupations. Frame of Reference To best suit the projects needs, the biomechanical, applied behavioral, and sensory integration frames of reference (FOR) guided the development of the bowel & bladder program. The biomechanical FOR utilizes a remedial approach by engaging in therapeutic activities to improve occupational performance (McMillian, 2011). Therapists practicing under this FOR address the structural and muscular dysfunction within the pelvic floor that children are experiencing with encopresis and nocturnal enuresis. The applied behavioral FOR is based on behavioral theories occurring along a continuum, including behavior modification, cognitive behavioral therapy (CBT), and social cognitive theories of learning (Cole & Tufano, 2020). One of the main contributors to helping children with elimination disorders are addressing behaviors, habits, and routines with toileting. The therapeutic interventions within the program utilizing this FOR include CBT, behavior modification, and education. Since the issues with enuresis, encopresis, and chronic constipation are multifactorial, addressing the sensory needs of children is necessary. Therapists can utilize the sensory 8 PARTY POOPER: A BOWEL & BLADDER PROGRAM 9 integration FOR to assist in identifying underlying sensory dysfunction that is a barrier to success with toileting, hygiene, meal preparation, feeding and eating. Aims & Purpose While toilet training is part of the development process, some children have difficulty transitioning from diapers to independently using the toilet and self-managing their habits, routines, and hygiene to be successful with continence. While the M.O.P. and PFT programs successfully help children reach continence, they do not take an occupation-based approach to help develop the life skills children need to maintain continence and hygiene independently as they grow and develop. The aim of the doctoral capstone project was to develop an occupational therapy-based rehabilitation protocol for therapists to address constipation and incontinence issues in children. Educational information and therapeutic activities provided to patients and their caregivers during therapy will empower them to regain control of constipation and resolve incontinence issues. Doctoral Capstone Project Protocol Design Within rehabilitation, evaluation and intervention protocols are implemented to assist therapists in clinical decision-making, utilizing evidence-based practice and clinical expertise to maximize patient outcomes. For the capstone project, an eight-week, occupation-based therapy protocol was developed to address chronic constipation in pediatrics-called Party Pooper. An indepth literature review was completed to identify current interventions for rehabilitating constipation, enuresis, and encopresis. The M.O.P. protocol and a PFT pediatric protocol from Herman and Wallace Pelvic Floor Institute were identified and assessed for implementation within occupational therapy practice. PARTY POOPER: A BOWEL & BLADDER PROGRAM 10 Information from both protocols was used to influence the development of Party Pooper. Lifestyle modification is critical to improving long-term outcomes; therefore, occupation-based therapeutic activities were developed and listed by functional tasks with age-appropriate level modifications. The PEOP model approach was used for each activity to complete an occupationbased task analysis template (Appendix A). Diaphragmatic breathing and therapeutic exercises are addressed at the beginning of each session after reviewing any present symptoms and therapy goals. Additionally, since compliance is a barrier for most children, habit-tracking charts were included and reviewed. Each session had an educational section for the patient and caregiver to develop trust, understanding of the childs condition, and therapeutic buy-in. Manual interventions are listed for the most frequent diagnoses, and consent is obtained each visit before implementation. All information was organized within a 3-ring binder, including evaluation tools, session layouts, educational handouts, therapeutic activity details with directions, a home exercise program, evidence-based reference articles, and discharge recommendations for a total of eight sessions. One of the objectives for project implementation was to begin the protocol at YIC with three patient-caregiver pairs. However, due to limited referrals during my 14-week capstone, the few patients seen presented with diagnoses that were not appropriate for protocol implementation. Therefore, direct implementation with patients was not achieved. Protocol Assessment and Evaluation Formal and informal evaluations are utilized to measure the effects of a protocol in comparison with the goals to collect accurate data that encompasses the entire project and improve the process or final product. The CIPP Evaluation PARTY POOPER: A BOWEL & BLADDER PROGRAM 11 is a comprehensive framework for guiding evaluations of programs, projects, and products, assessing four key areas: Context, Inputs, Process, and Product (Stufflebeam, 2000). The CIPP model was utilized to assess the Party Pooper program, which included a needs analysis, protocol development, protocol analysis, and completed protocol. A needs analysis identified a gap in the care of pediatric patients with PFD at YIC. Meeting with the primary stakeholders, goals and objectives were set to develop the protocol aimed for utilization by staff occupational therapy practitioners. The original objectives for the project were to (1) develop the protocol, (2) analyze pre- and post-knowledge checks from patient/caregiver pairs, and (3) demonstrate the efficacy of programming within YIC. However, due to limited patient referrals, the knowledge checks transitioned to product appraisal from stakeholders as the primary evaluation to identify how well the protocol was translated into practice. A primary stakeholder provided feedback to refine the protocol based on the original goals and objectives outlined. A presentation was created on the protocol for stakeholders to view and provide additional feedback on useability, translation into practice, and sustainability within YIC. Upon viewing the presentation on Party Pooper, the stakeholders were provided with the Protocol Appraisal Survey. Protocol Outcomes Feedback from the Protocol Appraisal Survey was analyzed (Table 1). Three occupational therapists provided feedback. Two therapists practiced at the primary YIC location and the third was working in home-based practice in the greater Chicago, IL area. The therapists concurred that the therapy protocol material was presented clearly and effectively (100%) and would be feasibility with pediatric patients (100%) for implementation within the clinic. However, one therapist said PARTY POOPER: A BOWEL & BLADDER PROGRAM 12 she is unlikely to use it due to only treating womens health patients and not men or pediatrics. A key theme the therapists reported for protocol improvement was incorporating descriptions of modifying the therapeutic activities and more in-depth caregiver education. Likewise, a key theme for protocol success was how hands-on the activities were and how the activities teach kids to take control of their health. Although a definitive conclusion on the protocols effectiveness for resolving chronic constipation in pediatrics cannot be established, the therapists concurred that it would help improve patient buy-in and compliance. Summary The misconception that children outgrow bedwetting and resolve chronic constipation naturally is a barrier to improving their quality of life. Specifically, teenage bedwetting is more common (1 in 50) than autism (1 in 54) (Yeung, 2006), and contributes to higher rates of depression, anxiety, low self-esteem, and lack of social participation in these patients. When addressed with their primary care physician, patients are provided with pharmacological interventions. However, due to appointment time constraints, they are unable to provide other therapeutic interventions or support that the children and caregivers need and deserve. Implementing an occupation-based therapeutic protocol that utilizes a biopsychosocial approach at Youre in CONTROL! can provide a foundation for children and teens to resolve chronic constipation and take control of their health across their lifespan. Notably, a standardized therapeutic protocol for OT practitioners can provide an evidence-based holistic approach to care and improves the continuum of care for pediatrics with PFD. Conclusion The objectives for the doctoral capstone experience included gaining advanced clinical skills in pelvic floor therapy and developing an occupation-based therapeutic protocol for PARTY POOPER: A BOWEL & BLADDER PROGRAM 13 implementation at YIC. The protocol aimed to develop a bowel and bladder therapy protocol to inform and guide practitioners in rehabilitating chronic constipation from an occupation-based perspective. Within the protocol, the aim was to provide health management information for caregivers and incorporate a kid-friendly, high-fiber cookbook written by the student to provide education and nutritional strategies for managing chronic constipation. In Appendix B, the knowledge, skills, and attitudes (KSA) assessment provides an overview of the OT students experience in pelvic floor therapy. Additionally, the DCE Planning Guide provides a timeline and weekly breakdown of what was accomplished across the 14 weeks (see Appendix C). At YIC, Party Pooper was developed, disseminated to key stakeholders, and prepared for translation to practice by the student during the doctoral capstone experience. Translation included marketing for the program to increase referrals for pediatric patients, pediatric treatment room assessment, therapeutic activity organization, and program implementation in a digital format to provide access through the home exercise program mobile app. Each component of the project increases the value of the therapy services received at YIC and will impact the greater Kokomo, IN area for generations to come. While Party Pooper could not be assessed for effectiveness, future research should focus on the programs efficacy and improving the quality of life of children and teens. Current bowel cleanout programs focus only on pharmaceutical interventions for short-term relief; assessing the efficacy of the Party Pooper program in combination with a bowel cleanout on long-term management could also be studied. With a client-centered therapy protocol, OT practitioners can collaborate with other medical professionals to resolve constipation in children and teens while emphasizing the importance of rehabilitation from a biopsychosocial approach. PARTY POOPER: A BOWEL & BLADDER PROGRAM 14 References American Academy of Pediatrics [AAP]. (2021, December 22). Bedwetting: 3 common reasons & what families can do. Healthychildren.org. https://www.healthychildren.org/English/ages-stages/toddler/toilettraining/Pages/Bedwetting.aspx American Occupational Therapy Association [AOTA]. (2011). Definition of occupational therapy practice for the AOTA Model Practice Act. Retrieved from: http://www.aota.org//media/Corporate/Files/Advocacy/State/Resources/PracticeAct/Model%20Defin ition%20of%20OT%20Practice%20%20Adopted%2041411.pdf American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), Article 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 Baum, C. M., Christiansen, C. H., & Bass, J. D. (2015). The Person-Environment-OccupationPerformance (PEOP) model. In. C. H. Christiansen, C. M. Baum, & J. D. Bass (Eds.), Occupational therapy: Performance, participation, and wellbeing (4th ed., pp. 49-56). Thorofare, NJ: SLACK Incorporated. Boilesen, S.N., Tahan, S., Dias F.C., Melli L.C., Morais M.B. (2017). Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence? Journal of Pediatria (Rio J). 93:320-7. Caldwell, P. H., Hodson, E., Craig, J. C., & Edgar, D. (2005). 4. Bedwetting and toileting problems in children. Medical journal of Australia, 182(4), 190-195. https://doi.org/10.5694/j.1326-5377.2005.tb06653.x PARTY POOPER: A BOWEL & BLADDER PROGRAM 15 Caldwell, P. H., Codarini, M., Stewart, F., Hahn, D., & Sureshkumar, P. (2020). Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews, (5). Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). Thorofare, NJ: SLACK Incorporated. Galles, T. (n.d.). Womens therapy and fitness: About/FAQ. Youre in Control. http://www.youreincontrol.org/en/rehabilitation-for-women/about.html Gronski, M. P. (2021). Occupational therapy interventions to support feeding and toileting in children from birth to age 5 years. The American Journal of Occupational Therapy, Vol. 75(5). Hodges, S. (2017). Dont assume your child will outgrow bedwetting. In BedwettingAndAccidents.com. https://www.bedwettingandaccidents.com/singlepost/2017/06/22/don-t-assume-your-child-will-outgrow-bedwetting Hodges, S. & Schlosberg, S. (2019). The Pre-M.O.P. plan: How to resolve constipation in babies & toddlers and overcome potty-training struggles. ORegan Press. Hodges, S. & Schlosberg, S. (2020). The M.O.P. Book: A guide to the only proven way to stop bedwetting and accidents in toddlers through teens (Anthology-4th ed.). ORegan Press. McMillan, I. R. (2011). The biomechanical frame of reference in occupational therapy. In E,. A. S. Duncan (Ed.). Foundations for practice in occupational therapy (5th ed., pp. 179-194). Edinburgh: Churchill Livingstone. PARTY POOPER: A BOWEL & BLADDER PROGRAM 16 National Institute of Diabetes and Digestive and Kidney Diseases [NDDK] (2018). Constipation: Definition and Facts. NDDK. https://www.niddk.nih.gov/health-information/digestivediseases/constipation/definition-facts ORegan, S., Yazbeck, S., Hamberger, B., & Schick, E. (1986). Constipation a commonly unrecognized cause of enuresis. American journal of diseases of children (1960), 140(3), 260261. https://doi.org/10.1001/archpedi.1986.02140170086039 Stufflebeam, DE. (2000). The CIPP Model for Evaluation. In: Stufflebeam DE, Madaus GF, Kellaghan T, eds. Evaluation Models: Viewpoints on Educational and Human Services Evaluation. Boston: Kluwer Academic Publishers. pp. 279-317. Uniform Data System for Medical Rehabilitation. (1996). Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM instrument). Buffalo, NY: Author. U.S. Census Bureau. (2021). U.S. Census Bureau quickfacts: Kokomo City, Indiana. Retrieved from https://www.census.gov/quickfacts/kokomocityindiana van Engelenburg-van Lonkhuyzen, M. L., Bols, E. M., Benninga, M. A., Verwijs, W. A., & de Bie, R. A. (2017). Effectiveness of pelvic physiotherapy in children with functional constipation compared with standard medical care. Gastroenterology, 152(1), 82-91. Woodward, S., Norton, C., & Chiarelli, P. (2014). Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Database of Systematic Reviews, (3). Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. (2006). Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int.; 97(5):1069-73. doi:10.1111/j.1464-410X.2006.06074.x. PARTY POOPER: A BOWEL & BLADDER PROGRAM Table 1 Protocol Appraisal Survey Results Survey questions Responses n = 3 Did the occupational therapy student present the Very clear & very effective (100%) material clearly and effectively? Was the objective of the program explained Very clear (100%) clearly? How easy was the program to follow and Very easy (100%) understand? How easy is the program to adapt? Very easy (100%) How likely are you to use the program? Very likely (70%) Neither likely nor unlikely (30%) Do you feel 8 therapy sessions with associated activities are sufficient for this population? How feasible will the project be implemented into practice? Moderately sufficient (70%) Neither sufficient or insufficient (30%) Very feasible (100%) 17 PARTY POOPER: A BOWEL & BLADDER PROGRAM Figure 1 PEOP Model within Pediatrics & PFD 18 PARTY POOPER: A BOWEL & BLADDER PROGRAM 19 Appendix A Occupational Activity Analysis Template Occupational Activity Task Analysis Adapted from Thomas, H. (2015). Appendix C. Occupation-based activity analysis (2nd ed., pp.213-223). Thorofare NJ: SLACK Incorporated. Occupational Roles Occupational Performance Areas Objective Occupational Analysis Student Classification: Activities: List in sequential order all activities required to complete the occupation Activity Analysis Tasks: List in sequential order all tasks required to complete the chosen activity Task Analysis Actions: List in sequential order all actions required to complete the chosen task, list the stimulus for each task. Materials List all of the required equipment, tools, and materials needed to complete this occupation/activity/task Environmental Circumstances Outcomes Time Space Social Context Physical Context Sensory Context Physiological Context Cultural Context Spiritual Context Political Context Economic Context Occupation: PARTY POOPER: A BOWEL & BLADDER PROGRAM Appendix B KSA Learning Framework Pre-Capstone Post-Capstone Knowledge Knowledge Condition management: Condition management: Overactive Bladder Incontinence Dyspareunia Diastasis Recti Process of program development & evaluation Referrals process Insurance authorization process Skills Clinical Skills: Occupational therapy process General pelvic floor therapy (PFT) assessment Basic PFT interventions Interpersonal skills: Therapeutic Relationship Motivation Chronic constipation Nocturnal enuresis Encopresis Prolapse Ehlers-Danlos syndrome Sensory processing with PFD Retained primative relfex with PFD Strategies for program development & evaluation Insurance reimburesement process Skills Advanced Clinical Skills: Colorectal conditions manual interventions Prolapse manual interventions Pediatric assessment & intervention planning Lifestyle modification interventions for PFD Psychosocial interventions for PFD Clinical judgement & reasoning Interpersonal Skills: Confidence Communication with patients, caregivers, referring providers Project management Attitudes Attitudes Ambivalent Apprehensive Tentative Confident Passionate Fulfilled 20 PARTY POOPER: A BOWEL & BLADDER PROGRAM 21 Appendix C DCE Planning Guide Week DCE Stage 1 Orientation Weekly Goal Objectives Tasks Administrative Tasks Document supervision plan and update MOU with site mentor Finalize MOU Create a timeline that aligns the goals and objectives listed in the MOU between the experience and project 1/10 Meet with site mentor and other OT to discuss needs for pediatric program 1/9 Screening/Evaluation Update Needs Assessment Finalize questions for needs assessment Exploration Cookbook Development Thematic development Identify theme and brainstorm title and preliminary ideas for the cookbook research Identify sections to be included for educational information and recipe organization Date complete 1/9 1/13 1/13 PARTY POOPER: A BOWEL & BLADDER PROGRAM 22 Appendix C (continued) 2 Exploration Screening/Evaluation 3 Exploration Evaluation Obtain full-text articles from the library to include in the program as resources 1/20 Literature Search Update the search of the literature for program development Cookbook Development Thematic development Finalize the title of the cookbook 1/20 Protocol Development Treatment room planning 1/18 Organize the treatment room and create a kid-friendly space Plan and obtain tools & toys needed for treatment, with a focus on pediatric patients Continuing Education Gain advanced clinical Completed OT Elevate: The skills in treating Biopsychosocial Approach to colorectal conditions Colorectal Conditions course Literature Search 1/18 1/25 Learn nutrition information for cookbook Read Inchausp, J. (2022). Glucose 1/25 Revolution. (S&S, Simon Element). Complete search of literature for program evaluation measures Identified Outcome Assessment 1/27 PARTY POOPER: A BOWEL & BLADDER PROGRAM 23 Appendix C (continued) 4 5 Exploration Continuing Education Gain advanced clinical Completed Herman & Wallace skills in treating Pediatric Incontinence & colorectal conditions Dysfunction course 2/6 Screening/Evaluation Cookbook Development 2/3 Screening/Evaluation Cookbook Development Identify recipes for cookbook Created and sourced recipes to be included in the cookbook that are high in fiber & child-friendly Identify age-appropriate Read French, D. (2015). The meal preparation tasks & Cookbook for Children with cookbook elements Special Needs. (Jessica Kingsley Publishers). Identify recipes for cookbook 6 Exploration Breakfast recipes selected/written for the cookbook Continuing Education Gain advanced clinical Completed Advanced Treatment of Enuresis and Encopresis with M.O.P. skills in treating course colorectal conditions Read Kushnir, B. (2019). Encopresis You Can Beat It! Game-Changing Solutions for Toilet Anxiety, Soiling, and Constipation in Children. (Independently Published). Screening/Evaluation Protocol Development Outline for treatment protocol Wrote the outline for eight-week occupation-based therapy protocol 2/10 2/10 2/14 2/16 2/17 PARTY POOPER: A BOWEL & BLADDER PROGRAM 24 Appendix C (continued) 7 Screening/Evaluation Cookbook Development Protocol Development 8 9 Thematic Development Read Davidson, D. & Shaffer, R. (2013). Autocourse Official History of the Indianapolis 500. (Icon Publishing Ltd; 2nd Edition Revised). 2/23 Identify recipes for cookbook Snack recipes selected/written for the cookbook 2/24 Create occupationbased therapeutic activities Identified activities for corresponding education for the week in the protocol 2/20 Completed an activity analysis for each activity to ensure depth & age-appropriate for specific occupations addressed during the activity Dinner recipes selected/written for the cookbook 2/24 Draft of the scholar report, poster, and PowerPoint presentation completed Review feedback and implement changes within the therapy protocol 3/3 Screening/Evaluation Cookbook Development Identify recipes for cookbook Dissemination Presentation Development Design & write the draft for dissemination Screening/Evaluation Protocol Development Review feedback of protocol draft from site mentor 3/2 3/10 PARTY POOPER: A BOWEL & BLADDER PROGRAM 25 Appendix C (continued) 10 Screening/Evaluation Cookbook Development 11 Dissemination Presentation Development 12 Screening/Evaluation Program Assessment 13 Exploration Discontinuation 14 Exploration Dissemination Write introduction for cookbook Wrote the introduction and educational section for cookbook 3/17 Identify recipes for cookbook Review feedback of drafts from faculty advisor Demonstrate efficacy of therapy protocol Drink recipes selected/written for the cookbook Review feedback and implement changes within scholarly report 3/17 3/24 Key stakeholder assessment of 3/31 efficacy and feasibility of use within the clinic Continuing Education Gain advanced clinical Read Mumma, L. (2023). Your 4/4 skills in treating pelvic Pelvic Floor Sucks: But It Doesnt floor dysfunction Have To: A Whole Body Guide to a Better Pelvic Floor. (Independently Published). Project Completion Translation of protocol Gathered protocol materials and within clinic organized for therapist use Assembled patient folders with habit tracking sheets, educational handouts, and activity worksheets Continuing Education Gain advanced clinical Read Nagoski, E. (2021). Come as skills in treating pelvic You Are. (Simon & Schuster, floor dysfunction updated edition). Stakeholder Presentation Disseminate DCE Outcomes Present the therapy protocol and cookbook and demonstrate advanced clinical skills gained 4/7 4/7 4/13 4/12 26  ...

... Evaluation of Adult Volunteer Program to Update Overall Course and Lessons Hayley Martin April 24, 2023 A capstone project submitted in partial fulfillment of the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jennifer Fogo, Ph.D., OTR EVALUATION OF ADULT VOLUNTEER PROGRAM 1 Abstract After completing the needs assessment with my site mentor, we discovered a lack of resources for adults with Down syndrome. With this information, we wanted to evaluate the current adult program at GiGis Playhouse to create new resources and activities. This program evaluation and its research is provided to help show that new resources can improve an individuals perceived communication skills, collaboration, and independence. A binder was created to include a literature review, lesson plans, goals, resources, interviews, and applications for the program. Parents voiced their opinions on wanting participants to learn and practice communication (71%), teamwork (29%), and independence skills (29%) through a Google Form. The pre-survey was used to determine which skills would be most important to include in the binder. A final Google Form was sent out to parents and caregivers on satisfaction with program content, 57% reported to be extremely satisfied, 29% reported satisfied, and 14% reported that it meets expectations. Based on participants communication skills, 14% were extremely satisfied, 71% reported satisfied, and 14% reported that it meets expectations. The E.P.I.C. binder can be utilized for future capstone students, volunteers, and staff members within GiGis Playhouse to support adults with Down syndrome engaging in the community. Introduction My doctoral capstone experience will occur at GiGis Playhouse in Indianapolis, Indiana. GiGis Playhouse is a Down Syndrome Achievement Center where individuals with Down Syndrome can participate in various group or one-on-one programs free of cost. Down syndrome (DS) is the most common chromosomal disorder in humans, affecting about one of every 675 births (Mai et al., 2019). A mother whose daughter, GiGi, was diagnosed with Down Syndrome created GiGis Playhouse. GiGis mother wanted to change how others looked at individuals EVALUATION OF ADULT VOLUNTEER PROGRAM 2 with a Down Syndrome diagnosis. At this time, GiGis mother wanted to create a safe environment or organization just for them. In addition, she wanted to create an environment for families to come for resources and networking so that they could celebrate their diagnosis. So, a few months later, GiGis family opened the doors to the countrys first Down Syndrome awareness center, GiGis Playhousethe programs at this site range from the prenatal stage of life to adulthood (About GiGis, 2022). GiGis Playhouses mission statement is to change how the world views Down Syndrome and to send a global message of acceptance for all. Their purpose is to change how the world views Down syndrome and to send a global message of acceptance for all. The different programs directed within GiGis Playhouse are for individuals of all ages with Down syndrome. Programs include language, music, fitness, art, cooking, volunteering, career preparation, and tutoring. GiGis Playhouse also provides programs for adults looking for resources in careers and volunteering. Within GiGis Playhouse, there are two different tracks that the adults can choose to take. Both of these opportunities are built and created to increase participants participation through either volunteering or working (Hardee & Fetters, 2017). One route takes them on the volunteer track through E.P.I.C., and the other on the career track through GiGi University. GiGi University or GiGi U is for motivated adults with Down syndrome to achieve their highest potential in the real world. They will develop their wellness, communication, and career skills, emphasizing job interviewing, communication, money management, public speaking, customer service, computer skills, team building, and health (About GiGi's, 2022). This program is suited for adults interested in looking for employment opportunities in the future. There is a link between social functioning and employment success has been well-established (Connor et al., EVALUATION OF ADULT VOLUNTEER PROGRAM 3 2019). My site mentor and I want to create resources and goals for social functioning but instead of the vocational aspect, the volunteer and community engagement aspect. My capstone project is E.P.I.C., which stands for empowerment, participation, independence, and community. E.P.I.C. is a program for adults with Down Syndrome, opportunities for socialization and community involvement. To understand the barriers and opportunities in the social life of adults with Down syndrome, Dolva et al. (2019) found it is essential to acknowledge the extent of their experiences with friendship and the characteristics of their social participation patterns. While working and engaging within the community, participants will be able to do so with their friends each week in order to work on socialization at the same time (Deakin et al., 2018). Participants work on vocational, communication, and social skills to boost confidence and increase independence (Mihaila et al., 2020). It is crucial for individuals to work on social skills in this setting. Individuals with Down syndrome exhibited significantly more difficulties in building and utilizing these social skills (Barisnikov & Lejeune, 2018). When individuals with Down syndrome are able to have these improved communication skills, they have better chances of expressing their feelings to avoid emotional challenges as well (Foley et al., 2016). My project will focus on updating the current program. My project aims to bridge the gap between the two programs better through program evaluation. The integration of program evaluation into the occupational therapy process can support program development and sustainability, and promote a solution-focused approach to attaining funding for community-based services (Umeda et al., 2017). I will put together a binder with a similar format for the E.P.I.C. program from GiGi University. The curriculum for E.P.I.C. will involve different resources such as applications, surveys, goals for each individual, and lesson plans based on four areas of communication, social skills/setting, teamwork, and EVALUATION OF ADULT VOLUNTEER PROGRAM 4 collaboration. We would like to share these goals and places with the community, so their volunteering experiences can fit their goals. Background The executive director, my site mentor, and operations manager expressed their need for an improved volunteer program, E.P.I.C., at this location. I am interested in evaluating the E.P.I.C. program to find new ways to improve its success. This increased success will continue to grow individuals with Down Syndrome confidence and independence within the community. Previously, a doctoral capstone student utilized a logic model to effectively evaluate the career program at GiGis Playhouse, GiGi University. I plan to evaluate the volunteer program called E.P.I.C. using a similar framework. The previous doctoral capstone student created a binder with resources to outline coursework for GiGi University. The last student included within her binder a literature review, participant applications, background information about the program, lesson plans, and a timeline for each lesson. For E.P.I.C., I will compile a binder with a literature review, background information about the program, participant applications, current volunteer sites, potential volunteer sites, a list of participant/program goals, and examples of activities that fit under these goals. I will also utilize a logic model created by the Centers for Disease Control and Prevention (CDC) to guide my project further. The purpose of this framework is to summarize the essential elements of program evaluation, provide a framework for conducting effective evaluations, clarify steps in program evaluation, review standards for practical program evaluation, and address misconceptions regarding the purposes and methods of program evaluation (Framework for Program Evaluation - CDC 2017). Being able to apply this EVALUATION OF ADULT VOLUNTEER PROGRAM 5 logic model can lead to improving existing programs. This specific logic model consists of six incremental steps: engage stakeholders, describe the program, focus evaluation design, gather credible evidence, justify conclusions, and ensure the use and sharing of lessons learned. I have completed a thorough literature review for this project, which will set me up for success in program evaluation. I have researched and found many different resources for program evaluation regarding the Down syndrome community. I will also be attending the program each week to work firsthand with each of the individuals and will be able to see precisely how the program runs weekly. In addition to my literature review and participating in the program, I have completed research for models and theoretical frameworks to guide my research and program evaluation. Model: Model of Human Occupation The model I chose for my Doctoral Capstone Experience (DCE) is the Model of Human Occupation (MOHO). I chose this model because I will incorporate social participation into my DCE, which fits my idea for this site and population. The central concept of MOHO is that the person leans towards occupational performance through volition, habituation, and performance capacity (Cole & Tufano, 2020). Social participation and communication fit into volition because the client may need to be motivated by something to participate socially. Habituation is also significant in communication and social involvement because many clients rely on roles and routines for their occupations. Some examples of this during communication are the time, place of interaction, and any positions or jobs included within the social process. Lastly, performance capacity is vital in social participation depending on the clients diagnosis, anatomy, cognition, or motor skills. These aspects, between volition, habituation, and performance capacity, can affect the clients social participation performance. EVALUATION OF ADULT VOLUNTEER PROGRAM 6 Project Design My project consisted of a program evaluation for GiGis Playhouse adult volunteer program called E.P.I.C. After completing the needs assessment, the stakeholders at GiGis Playhouse found it helpful to evaluate their adult volunteer program. This volunteer program has been in place at GiGis for several years and could use updates. My site mentor and I found it would be necessary to evaluate the current program and implement new changes for the success of the adults within the group. We had also discussed the need for more resources for the adult population. There are so many different resources for children with Down syndrome, and that is typically not the case for adults (Popova & Wescott, 2019). . We wanted to continue to provide this resource for the adult participants while making it meaningful to their everyday tasks along the way. The development of this project was guided by the Centers for Disease Control and Prevention (CDC). The CDC has their own theoretical framework for program evaluation that I found to be extremely helpful. Their model includes six connected steps in order to fulfill each step of the program evaluation process (CDC, 2021). The six steps include: engage stakeholders, describe the program, focus the evaluation design, gather credible evidence, justify conclusions, and ensure use and share lessons learned. I completed the first step of engaging with my mentor, who is the executive director, and the operations manager via Zoom and completing the needs assessment. During this step, I explained the purpose of what I could do for their organization and how this would be a collaborative process to determine what their site may need. From this point, we completed brainstorming the program and my actual project. Most of this process included researching for resources, credible evidence, and mapping out the timeline of the overall project. I began to focus on the evaluation design to determine the purpose, usability, EVALUATION OF ADULT VOLUNTEER PROGRAM 7 feasibility, and reality of this evaluation overall and check in with stakeholders for their point of view.(CDC, 2021). I also completed a literature review which was compiled of trustworthy and credible evidence to support this project idea. I decided to conduct a survey I created and sent it out to parents and caregivers to complete. The survey was sent via Google Forms and I sent the study to all eight participants' parents/caregivers, with six parents/caregivers responses and one participants response. The survey consisted of a total of 5 open-ended questions. What are some goals you have for your participant in E.P.I.C.? What improvements or updates would you like to see with E.P.I.C.? What is your participants favorite part of E.P.I.C.? What is your participants least favorite part of E.P.I.C.? What is the main thing you would like for your participant to take away from E.P.I.C.? The parents answers to these questions allowed me to decide what the focus would be for the updated layout of this program. Many parents answered that they would like their participants goals to fall under social skills, communication skills, being part of a team, social cues, independence, and working within the community. After meeting with my site mentor again to go over the results, we decided to have four focus groups for the layout of the program and lesson plans. We chose the four categories: communication skills, social skills or cues, teamwork or collaboration, and healthy relationships or life skills. Deciding which topics were most relevant provided me with the best information for guiding lesson plans. Given the survey responses, five out of the seven answers explained having goals with communication or social skills (71%) (Figure 1). Many of the lesson plans I create EVALUATION OF ADULT VOLUNTEER PROGRAM 8 will focus on resources or games that can help improve participants communication skills and interaction with one another. Two of the seven responses included goals for independence (29%) (Figure 1). These responses showed that it would also be essential to incorporate resources and activities that focus on participants independence. Another 29% of responses indicated that it is vital for participants to know how to work as a team and collaborate with their peers (Figure 1). It was essential to my site mentor and me that this be a theme within the lessons, but it was validating seeing that parents and caregivers also have this goal for the participants. My site mentor and I were mostly interested in parents responses to what updates or changes that they would like to see to the program. This would be another source of vital information to take into consideration when guiding the rest of my project. The program only occurs once a week and only consists of eight participants due to travel purposes. With that, many parents expressed that they would love it if the program could happen more than once a week, and get rid of the application and interview process so more participants can participate. This type of response was present in at least two of the seven responses to this question. Two different responses were asking to have a schedule for each week, so they know what their participant will be doing during the program. A parent expressed that they find it hard to make conversation with their participant after the program when they are also unaware of what occurred during the class. During our meeting to go over the results, a large portion was spent brainstorming on ideas for how to update the class and providing new resources to fulfill the parents expressed needs. The project was carried out by creating a binder for the E.P.I.C. program at GiGis Playhouse. The binder consisted of an explanation of the program, applications to the program, literature review, logic model, resources for individuals, resources for volunteer sites and EVALUATION OF ADULT VOLUNTEER PROGRAM 9 volunteers, goals for the program and individuals, and a list of each volunteer site with examples of possible volunteer activities to reach goals. It will be imperative that each of the resources provided within the binder are visually appealing to the participants. Most individuals with Down syndrome learn most effectively through visuals (Davis et al., 2018). Since the project was based on the parents pre-survey, we wanted to make sure that these wants and needs were being met. My site mentor and I made sure to base all of the resources and lesson plans around skills that parents mentioned they wanted their participants to be working on. The main skills mentioned and included were communication, teamwork, and independence. Many parents expressed a need for a schedule for each week to know what their participant was engaging in each week. We made sure to create a resource that could be completed at the end of each session for parents to go over with their participant (Figure 4). This figure was created to allow participants to be able to discuss what they did each week with their family and friends. We also created a schedule to be handed out to parents that shows where the participants will be volunteering that day and what skills will be focused on during the session. Project Outcomes In order to measure the outcomes of my project and the resources I had created, a postsurvey through Google Forms which was sent out to all eight participants parents or caregivers. Again, seven responded to the post-survey. Parents and caregivers were asked to report their satisfaction on multiple different items. Parents and caregivers were asked to report their satisfaction on a 5-point Likert scale. The answer choices were extremely dissatisfied, dissatisfied, meets expectations, satisfied, and extremely satisfied. The survey consisted of three questions for parents and caregivers to answer. Please rate your satisfaction with your participants communication skills. EVALUATION OF ADULT VOLUNTEER PROGRAM 10 Please rate your satisfaction with your participants teamwork skills. Please rate your satisfaction with overall program content. The results were sent directly to Google Sheets in order to determine means and interpret the data. I interpreted the data using bar graphs based on the percentage of each response. In regards to satisfaction on participants communication skills, 14% reported meeting expectations, 71% reported satisfied, and 14% reported extremely satisfied (Figure 2). In Figure 3, you can see the results to parents satisfaction with teamwork skills. 14% of parents reported it meets expectations, 57% reported to be satisfied, and 29% reported to be extremely satisfied. In Figure 4, it can be shown that 14% of parents report program content meets expectations, 29% report to be satisfied, and 57% are extremely satisfied with program content. The qualitative results showed the majority of parents and caregivers were satisfied with the overall product and how their participants are reaching their communication and team building skills. Finally, I presented my project to my site mentor, program direction, and operations manager on my last week at the site. This presentation was completed virtually through Microsoft Teams. The staff was open to share their thoughts on my new resources and lesson plans that I had created. They were more than happy to have this new material for their program and were open to also sharing how this could extend to new projects in the future as well. Summary The qualitative results showed overall parent and caregiver satisfaction with program content and participants overall communication and team building skills. The new resources and lesson plans provided a new outlook for parents, caregivers, and participants in the updated E.P.I.C. program. The staff also showed great appreciation over the project and reported the benefits of having these resources. The new resources can be continued to share with more EVALUATION OF ADULT VOLUNTEER PROGRAM 11 families and organizations that collaborate with GiGis Playhouse. The resources created can bring awareness to the Down syndrome community. The results also continue to show the importance of providing these occupational based skills for adults with Down syndrome, and how this can increase overall independence. With the addition of new lesson plans and resources that focus on communication skills, interpersonal relationships, team work, and social skills, it allows for participants to build a new sense of confidence and brings comfort to parents and caregivers. Conclusion I believe this project was successful because each individual and family were accepting of my project and were willing to help at any point. The individuals and stakeholders were patient and flexible with me when plans did not go accordingly due to weather or schedule changes. GiGis Playhouse will benefit from my project because it will provide a series of lesson plans and coursework for the participants to have for the next sessions. I have updated this information based on staff opinions and observations, as well as parent and caregiver surveys for the success of the participants. I have provided a plethora of information and resources for future volunteers to utilize when working with the E.P.I.C. group. These resources should in fact lessen the amount of work now needed for the current staff to complete or prepare for sessions. Unfortunately, due to time constraints, I was unable to see these resources being used at GiGis Playhouse. Limitations: Since I will not be on-site when the resources will be in use, there could be a potential for misunderstandings. Potential barriers could be that I do not have full control over what is being utilized and what is not. I will remain in touch with staff through phone and email, but there could be questions and misunderstandings without me being in person each week. EVALUATION OF ADULT VOLUNTEER PROGRAM 12 Another limitation to my project was the weather and schedule changes. This program only occurs once a week so if there were cancellations within volunteers or inclement weather, this would affect the program and their schedule. Overall, the strengths outweigh the few challenges that were experienced during the project. Recommendations: For future projects or capstone students, I think that further research could be done in this area to further examine this kind of program. An example of future research is the program would need to be re-evaluated at least yearly to assess continued usefulness of resources and lesson plans. This would be beneficial to the participants and the site to make sure that they are receiving the best updated care. There is a need to strengthen connections with new volunteer sites and work more closely with these organizations. GiGis Playhouse and most of these organizations have great partnerships, but it would be great to further these relationships and see what can be used to benefit one another. I also think it would be a great idea to engage the parents and caregivers even further. I took the initial step by reaching out to parents and caregivers through surveys, but I think discussions and interviews or even holding support groups could be beneficial as well for a future DCE student at GiGis Playhouse. Implications: Since my project focused on communication skills, social skills, team building, and independence, there is plenty of room for OT involvement. An OT is already on site at GiGis Playhouse for a fitness class, but it would be great to have an OT volunteer for the E.P.I.C. adult program as well. An OT in this setting working with the adults can assist the participants with these skills that would impact their activities of daily living or when volunteering with the site. OTs are also present at this site to answer questions about transitional phases such as starting school, graduating high school, and finding jobs after graduation. There are so many possibilities for an occupational therapist within this kind of organization. EVALUATION OF ADULT VOLUNTEER PROGRAM 13 References About Gigi's Playhouse, Inc.. GiGis Playhouse Down Syndrome Achievement Centers. (n.d.). Retrieved March 11, 2022, from https://gigisplayhouse.org/about-us/ Barisnikov, K., & Lejeune, F. (2018). Social knowledge and social reasoning abilities in a neurotypical population and in children with Down syndrome. PLoS ONE, 13(7). https://doi.org/10.1371/journal.pone.0200932 Centers for Disease Control and Prevention. (2018, December 12). Framework step 2 checklist. Centers for Disease Control and Prevention. Retrieved January 24, 2023, from https://www.cdc.gov/evaluation/steps/step2/index.htm Cole, M. B., & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. SLACK Incorporated. Connor, A., Sung, C., Strain, A., Zeng, S., & Fabrizi, S. (2019). Effects of a vocational socialskills program on psychosocial functioning among young adults with autism. The American Journal of Occupational Therapy, 73(4_Supplement_1). https://doi.org/10.5014/ajot.2019.73s1-po4020 Davis, M. A. C., Spriggs, A., Rodgers, A., & Campbell, J. (2018). The Effects of a PeerDelivered Social Skills Intervention for Adults with Comorbid Down Syndrome and Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 48(6), 18691885. https://doi.org/10.1007/s10803-017-3437-1 Deakin, K., Moore, D. G., & Jahoda, A. (2018). Children and young people with Down syndrome: Their awareness of Down syndrome and developing self perceptions. Journal EVALUATION OF ADULT VOLUNTEER PROGRAM 14 of Applied Research in Intellectual Disabilities, 31(6), 11971208. https://doi.org/10.1111/jar.12494 Dolva, A. S., Kollstad, M., & Kleiven, J. (2019). Friendships and patterns of social leisure participation among Norwegian adolescents with Down Syndrome. Journal of Applied Research in Intellectual Disabilities. https://doi.org/10.1111/jar.12609 Foley, K.-R., Taffe, J., Bourke, J., Einfeld, S. L., Tonge, B. J., Trollor, J., & Leonard, H. (2016). Young People with Intellectual Disability Transitioning to Adulthood: Do Behavior Trajectories Differ in Those with and without Down Syndrome? PLoS ONE, 11(7), 114. https://doi.org/10.1371/journal.pone.0157667 Hardee, J. P., & Fetters, L. (2017). The effect of exercise intervention on daily life activities and social participation in individuals with Down Syndrome: A systematic review. Research in Developmental Disabilities, 62, 81103. https://doi.org/10.1016/j.ridd.2017.01.011 Hewitt, L. E., Hinkle, A. S., & Miccio, A. W. (2005). Intervention to Improve Expressive Grammar For Adults With Down Syndrome. Communication Disorders Quarterly, 26(3), 144155. https://doi.org/10.1177/15257401050260030301 Mai CT C.T. , Isenburg J.L. , Canfield M.A. , Meyer R.E. , Correa A. , Alverson C.J. , et al., National population-based estimates for major birth defects, , Birth Defects Res 111: (18) ((2019) ), 14201435. Mihaila, I., Handen, B. L., Christian, B. T., & Hartley, S. L. (2020). Leisure activity in middleaged adults with Down syndrome: Initiators, social partners, settings and barriers. EVALUATION OF ADULT VOLUNTEER PROGRAM 15 Journal of Applied Research in Intellectual Disabilities, 33(5), 865875. https://doi.org/10.1111/jar.12706 Neil, N., & Jones, E. A. (2018). Communication intervention for individuals with Down syndrome: Systematic review and meta-analysis. Developmental Neurorehabilitatio n, 21(1), 112. https://doi.org/10.1080/17518423.2016.1212947 Popova, E. S., & Wescott, J. J. (2019). Art as occupation: Promoting the occupational therapy role in evaluating community-based programs. SIS Quarterly Practice Connections, 4(1), 57. Thompson, T., Talapatra, D., Hazel, C. E., Coleman, J., & Cutforth, N. (2020). Thriving with Down syndrome: A qualitative multiple case study. Journal of Applied Research in Intellectual Disabilities, 33(6), 13901404. https://doi.org/10.1111/jar.12767 Umeda, C. J., Fogelberg, D. J., Jirikowic, T., Pitonyak, J. S., Mroz, T. M., & Ideishi, R. I. (2017). Expanding the implementation of the Americans with Disabilities Act for populations with intellectual and developmental disabilities: The role of organizationlevel occupational therapy consultation. American Journal of Occupational Therapy, 71, 7104090010p17104090010p6. https://doi.org/10.5014/ajot.2017.714001 EVALUATION OF ADULT VOLUNTEER PROGRAM Figure 1 Participant Goal Survey Figure 2 Satisfaction with Participant Teamwork Skills 16 EVALUATION OF ADULT VOLUNTEER PROGRAM Figure 3 Satisfaction with Participant Communication Skills Figure 4 Satisfaction with Overall Program Content 17 EVALUATION OF ADULT VOLUNTEER PROGRAM 18 Appendix Week DCE Stage (orientation, screening/evaluatio n, implementation, discontinuation, dissemination) 1 Weekly Goal Orientation/Train Complete online ing training modules for site Set up my site email with mentor Objectives Tour of the site Tasks Complete 1/13/23 online trainings Meeting all other staff and Meet members members of the of the site and site to become other staff familiar Create rough draft Explaining to of timeline other staff the goals of my project and what I plan to do while Im here Date complete Introduce myself to families involved with the site Join in on some of the group programs at the site and begin to orient myself with each program Look through different rooms and material closets to view what all is available for use at the site and orient myself to where all materials EVALUATION OF ADULT VOLUNTEER PROGRAM 19 are located for each program EVALUATION OF ADULT VOLUNTEER PROGRAM 2 Screening/Evaluat Finalize literature ion review Gather more knowledge of each program and needs/goals for each Discuss further needs for the site and capstone project Brainstorming goals and needs for project Finalize MOU Write draft for introduction 20 Continue to 1/20/23 research sites website and other organizations around the area to gain more resources Complete introduction draft Mapping out goals and looking at previous projects for resources Looking at MOU and adding information where needed and updating where things have changed from the initial MOU EVALUATION OF ADULT VOLUNTEER PROGRAM 3 Evaluation Begin looking at progression of project Begin draft for background Look at lit review to help when writing draft 21 Rough draft of background section complete Finalizing Researching past progression of capstone project and Continue attending projects to gain brainstorming more of an idea group programs to a better idea of familiarize with program staff and evaluation individuals Finalize some Researching and resources looking for models to add to Found a model my project for and theory to program use with my evaluation project based on program evaluation Continue looking at previous resources and projects to gain more insight on my project Attend volunteer groups Attend volunteer groups 1/27/23 EVALUATION OF ADULT VOLUNTEER PROGRAM 4 Implementation Begin to plan for project implementation Brainstorm all ideas for implementing project and what will be needed 22 Continue to attend group programs to gain more information and insight on the project 2/3/23 Reach out to members at other locations for resources for implementation 5 Implementation Communicating with sites Reaching out to sites available for volunteering to further explain the purpose and objectives of the program so we can alter the volunteer tasks to better fit within the program Creating SMART goals for each session Creating possible SMART goals for either each individual or each program session and sending these to the volunteer sites ahead of time so they have this information Reaching out to 2/10/23 sites Discovering appropriate SMART goals Finding possible resources for each SMART goal EVALUATION OF ADULT VOLUNTEER PROGRAM 6 Implementation Determining progression of program Determining different phases and length of time of program 7 Implementation Researching resources for each goal Continue communicating with staff and other locations on ideas and previous programs 23 Finalize 2/17/23 progression of new framework of program Finalize if multiple phases will be needed Finalizing goals for determining how long the program will need to take place and evaluating if different phases may be needed Utilizing materials from past projects to compare Making sure resources are matching up with SMART goals that were created Printing and 2/24/23 finding resources for program and checking with staff to make sure all are connecting with what we are wanting to do EVALUATION OF ADULT VOLUNTEER PROGRAM 8 Implementation Communicating with volunteer sites Looking into different phases and what is included in each phase to bridge over into other programs better 9 10 Implementation Implementation 24 List of all volunteer sites Finalize list of volunteer sites Phasing out the process of volunteering and how it bridges into the career pathway Breakdown of each phase and adding into resource binder 3/3/23 Examples of activities that can be done at each site to fit with their SMART goals Creating binder of Building binder all current and of resources and previous resources finalizing Create survey to send out to parents/caregivers Asking parents and caregivers questions about the E.P.I.C. program Finalizing binder resources and making copies when needed Sharing final ideas and developing Gathering all resources and phases and creating into binder for new framework 3/10/23 Completing binder of resources 3/17/23 Sharing final ideas with staff Discussing with and participants and participants staff for further feedback and critique Meeting with other members at different locations to EVALUATION OF ADULT VOLUNTEER PROGRAM 25 discuss final ideas as well 11 Discontinuation Prepare for dissemination Making sure project is fully sustainable and ready to continue once capstone ends 12 Discontinuation Preparing for dissemination Finalizing all products of project Getting all resources together and finalized or printed to be viewed for future uses Making sure all binders and programs are Meeting with site set and ready to mentor to plan go through any missing info or Printing out all pieces extra copies of resources Gaining last needed for final minute ideas project from site mentor 3/24/23 3/31/23 EVALUATION OF ADULT VOLUNTEER PROGRAM 26 13 Dissemination Wrap up project on-site Final touches on Final meeting 4/7/23 project, with group resources, and program lesson plans Printing out all resources needed for final project 14 Dissemination Complete final dissemination Complete final dissemination with site Complete final evaluation of site and experience Present project to site virtually with site mentor, program director, and operations manager 4/14/23  ...

... CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 1 Title: The Effects of Caregiver Participation During Therapeutic Riding with Children with Autism Tara Martin May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jenna Trost CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 2 Abstract Objective: There is minimal research on equine programming, where the caregivers participate in the therapeutic program. This study looks at the effects of caregivers participating with individuals with autism in therapeutic horseback riding to focus on communication and teamwork skills to help improve home and community life. Methods: Caregivers completed a pre-survey before implementation. Implementation of communication skills lasted over three weeks. At the end of the three weeks, the researcher and the caregiver completed a post-interview to review the program. Results: Two riders with a primary diagnosis of ASD and their caregivers participated in the project. Two riders and caregivers completed the pre-survey, and two riders and caregivers completed the post-interview. Parents stated they saw minimal improvement in communication skills with the rider during the program. Conclusions: Further research is needed to determine the most effective route for using this type of program. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 3 Introduction Morning Dove Therapeutic Riding is a not-for-profit organization offering equine-assisted services to a wide range of child, adolescent, and adult participants with physical, cognitive, behavioral, and/or emotional disabilities. It is a Premier Accredited member of the Professional Association of Therapeutic Horsemanship (PATH), International. Morning Doves mission is to improve the lives of individuals with disabilities in Central Indiana through equine-assisted therapies and activities (Serving Indianapolis, n.d.). However, therapeutic riding is not considered therapy or covered by insurance. These riders focus on developing proper horsemanship skills, strengthening physical and motor abilities, and encouraging emotional growth and development through a relationship with the horses. Equine programming, where the caregivers participate with the participants with disabilities in therapeutic riding lessons, has had minimal research to determine whether it would benefit the participant or the caregiver. Caregiver participation in therapeutic riding is essential to developing communication and teamwork skills to improve home and community life for individuals with autism. Initially, Morning Dove completed a needs assessment to determine the need for a caregiver participation program. The caregivers complete a pre-survey to determine the need for this program and their goals for the riders with autism. Implementation lasted three weeks, one lesson per week for each rider. A post-interview will determine if the caregivers saw any improvements in communication and teamwork skills after the three weeks conclude. The feedback received from the caregivers will determine if the study supports the claim for caregiver participation in therapeutic riding. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 4 Background Morning Dove assists riders older than four with challenges ranging from emotional trauma, cognitive and developmental challenges, to physical disabilities. Morning Dove has, on average, 65 students in their therapeutic riding program and up to 30 in their EAL programs. Stakeholders that are involved with decision-making include the following: the instructors, board of directors, families, and other partner organizations. Morning Dove is looking to expand its programming to include hippotherapy, music therapy, occupational therapy, and physical therapy. Morning Dove, along with the researcher, conducted a needs assessment prior to arriving at the sight. The needs assessment helped discover Morning Dove's interest in creating a program where caregivers of individuals with ASD participate in therapeutic horseback lessons. This program will aim to work on communication, patience, teamwork, and the goals set during their onboarding session. Goals are set for each participant in order to determine the type of skills that need further development. Morning Dove takes a wide range of populations; however, the most prevalent population is participants with autism spectrum disorder (ASD). Individuals with ASD often experience problems with social interactions and restricted or repetitive behaviors. These individuals also experience different ways of learning, moving, and focusing. Therapeutic riding is an equine-assisted activity to improve the cognitive, physical, emotional, and social skills of individuals with ASD. The articles supporting this study provide information that incorporates horseback riding as an intervention for children with ASD showed improvements in social, cognitive, emotional, and physical skills. In two separate studies, Martin et al. (2020) and CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 5 Roux (2020) evaluated how therapeutic horseback riding improves health for children experiencing disabilities by showing that the riding facilitates the development of a riders self-concept through opportunities for accessible, meaningful participation, a broad range of learning experiences, and can effectively enable skill development in individuals with sensory processing and integration difficulties. Both Gabriels et al. (2015) and Anderson and Meints (2016) found that therapeutic horseback riding for children with ASD significantly improves irritability, hyperactivity, maladaptive behavior traits, social cognition, and social communication. In addition, Kemeny et al. (2022) completed a study to compare therapeutic riding and HeartMath, to test the control on salivary cortisol, stress, social responsiveness, and heart-rate variability. The findings suggest that therapeutic riding is an effective intervention to decrease stress. Palaestra published an article that explored how therapeutic riding combined with cognitive exercises helps children with ASD. This combination can improve children's dexterity, coordination, strength, behavior, and academic performance (Therapeutic Horseback, 2020). Horseback riding also assists with muscle development, physical balance, flexibility, and endurance, per Keel Anderson et al. (2019). Parents of children with ASD commonly report experiencing higher levels of stress in comparison to parents of children with other neurodevelopmental disorders or children who are typically developing (Olson et al., 2022). Caregivers who experience burnout may show signs of exhaustion, withdrawal from others, emotional instability, or inability to concentrate (Caring for the caregiver, 2021). During their study to examine child clinical features that predict high levels of caregiver strain, Bradshaw et al. (2021) CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 6 determined that the strongest child predictors were disruptive behavior, autism severity, oppositional behavior, and hyperactivity. Improving the specific communication and teamwork skills of individuals with ASD can decrease caregiver stress, as demonstrated in the Thi Lan Anh Mai & Nujjaree Chaimongko study. In the Thi Lan Anh Mai & Nujjaree Chaimongko study, the researchers evaluated the effectiveness of intervention programs to improve the health conditions of children with ASD (2022). The researchers determined that participants in the intervention program had a significantly higher quality of life for the families and significantly lower caregiver burden than those in the control group (Thi Lan Anh Mai & Nujjaree Chaimongko, 2022). In addition, the participation of a childs caregiver in the intervention program may help improve the socialization and communication skills of the child with ASD. Although studies show the benefits of caregiver participation, there is limited research to base an opinion on caregivers participating in therapeutic riding. Eickmeier et al. (2022) focused on the principle that patients and caregivers are key partners in the intervention process. Caregivers are more than service users but rather partners in developing, implementing, and evaluating the effects of the programs. Park et al. (2020), Chung and Meadan (2021), and Brown and Woods (2016) all aimed to investigate the effects of caregiver involvement in early intervention programs. Each study confirmed a positive effect on targeted communication and teamwork skills developed when caregivers participated as partners in the intervention process. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 7 Theory/FOR/Model The model selected to guide the project is the Kawa Model. This river metaphor best demonstrates the relationship between the variables of occupation in Japanese life and the process of occupational therapy intervention for the Kawa Model (Cole & Tufano, 2008). The metaphor communicates the inseparable nature of people from their collective social groups and the inseparable quality of occupations from their natural and spiritual contexts. Occupational challenges occur when internal or external barriers interfere with the group's work and prevent the river of life from flowing freely (Cole & Tufano, 2008). The program at Morning Dove will allow the caregiver and the patient to work on communication, teamwork, and patience. The goal will be to work together to increase the flow of life within the home and community, allow inclusion among the family members, and maintain a sense of harmony with one another. Applied Behavior is the frame of reference (FOR) that will help guide the project. Applied Behavior FOR facilitates desired behaviors through defined goals and working toward them using skill instruction, modeling, coaching, and behavioral reinforcement (Cole & Tufano, 2008). This FOR has a focus on observational learning, which teaches occupational skills or strategies through demonstrations. This FOR was used by providing examples from other groups, instructors, and the researcher to reinforce patients on working with the caregiver to demonstrate ways to work together to clean, care for, mount, and communicate with the horse. The goal will be to remove cues and triggers that cause certain behaviors and interactions between the patient and the caregiver and find new ways to create adaptive behaviors that help build teamwork and communication. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 8 Project Design After discussing the needs assessment with Morning Doves leadership team, there was an interest in developing and trialing a new program allowing caregivers to participate in therapeutic riding lessons alongside individuals with ASD. Morning Dove and the researcher determined that the targeted skills include communication, teamwork, and patience between the caregiver and the rider. An initial email was sent to the caregivers of the riders with a primary diagnosis of ASD to provide information to the caregiver of the project and to receive approval for the rider and caregiver to participate in the study. After the researcher received consent, the caregivers received a pre-survey regarding communication skills, riders goals, parents goals, and caregiver burnout. A post-interview was conducted at the end of the study to determine if the caregiver thought the program helped with communication, teamwork, and patience between the rider and the caregiver. Four caregivers completed the pre-survey, and two riders with a primary diagnosis of ASD and their caregivers participated in the study. The two riders and caregivers completed the post-interview. Implementation Caregivers of riders with a primary diagnosis of ASD received a survey electronically a week before the therapeutic riding lessons began. The caregivers completed the pre-survey regarding the information on communication skills, caregiver burnout, and the progression of the rider's goals. During the three weeks of therapeutic riding lessons, the caregivers and the riders completed activities including grooming, mounting, and walking the horse. The activities also worked on balancing, crossing midline, communication, and teamwork skills. At the end of the three weeks, a post- CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 9 interview was conducted to determine if the sessions helped improve the rider and caregivers communication and teamwork skills. Some challenges during the study included a change in staffing a month before grounded therapy sessions began. The prior staffing did not leave behind any support to assist the new staff in preparing the grounded and therapeutic riding sessions. Other challenges included a lack of caregiver participation, higher functioning riders with autism, and a crowded arena during riding lessons when caregivers were involved. Many caregivers stated their reason for not wanting to participate was that the riding lessons for the riders were their time away from the caregiver. In a crowded arena, adding the caregiver was challenging when considering the number of individuals involved during the riding lessons, such as the single instructor, a horse leader, and at least one side walker for all three participants. The crowdedness could cause the horse to spook during the lessons and make it challenging to communicate due to the rider listening to the instructor, the caregiver, the horse leader, and the side walker. This created an overwhelming environment for the rider. Outcomes The caregivers of riders with a primary diagnosis of ASD received a pre-survey if they consented to participate in the study. The survey questions aimed towards receiving demographic information, asking how satisfied caregivers are with the communication skills between adults and the child, how satisfied the caregivers are with a support system, and how satisfied they were with the progress of the goals set during the onboarding. See Table A within Appendix A for pre-survey responses from the four caregivers. Overall, caregivers felt satisfied with their support system and their CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 10 communication skills with family members. Two out of the four caregivers listed communication or social interaction as the primary symptoms and goals set by parents to target during lessons, which supports the need for this type of programming. Implementation of the program lasted for three weeks. Week one consisted of observing the riders with their caregivers, the horses, the instructor, and the volunteers. Components the researcher was looking for were how riders responded to requests for tasks, if the riders expressed any unwanted behaviors to non-preferred tasks, and how the riders communicated needs to others. Weeks two and three involved working with the riders and caregivers in the riding lessons. Caregivers would repeat the instructions of the activities from the instructor to the rider for them to complete. Due to the crowded arena and the challenges for the riders to listen to the caregiver and the instructor, the researcher adapted the program to where the researcher became the side walker and worked with the rider on communication skills. The researcher then reported what worked best and what the rider struggled with after each week's lesson ended. Skills the researcher worked on were nonverbal communication, such as signs for calm body, help, stop, and go, as well as working on eye contact. Other skills related to communication were prompting the rider to repeat expectations required of the rider while on the horse, using kind words and not hurtful words, and appropriately expressing the feelings they may be experiencing when completing non-preferred activities. At the end of week threes lessons, a post-interview occurred with the caregiver and riders to determine if they felt any improvement in communication skills, what they felt the program could use more improvement on and any feedback for the research and CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 11 the program. Due to the challenges experienced throughout the project, caregivers stated they saw minimal improvement in communication skills with the rider during the program. Caregivers and the researcher believed that having more time for implementation and a calmer and more secluded environment may benefit and show more improvements for the program. Summary Equine programming, where the caregivers participate with the participants in lessons, has minimal research to determine if it would benefit the participant and the caregiver. Morning Dove Therapeutic Riding showed interest in creating a program where caregivers can participate in therapeutic riding lessons alongside the riders to work on skills such as communication, teamwork, and patience. A wide range of studies supports the effectiveness of therapeutic riding for individuals with ASD for social communication, meaningful participation in activities, strengthening, balance, and coordination. Past research also supports the benefits of caregiver participation in the intervention process showing positive effects on targeted communication skills. Creating a program that brings these interventions together can create a new intervention program and provide benefits for the caregiver and the individual with ASD. There were no significant findings found during the study. Caregivers stated they saw minimal improvement in communication skills with the rider during the program. The researcher felt they needed more time to adapt the communication skills necessary to help the caregiver and rider. Parents and the researcher felt it was challenging to communicate with the rider. The rider must listen to the instructor, horse leader, and side walkers instructions. Adding in the caregiver made it overwhelming for the rider CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 12 because the caregiver had to repeat all the instructions from the instructor during lessons. Other improvements to the program would be a longer duration to implement and study the program, a more stable environment, and a more extensive dataset. Conclusions Therapeutic riding has shown significant benefits for riders with ASD. It has shown improvements in confidence, social skills, strength, and independence. Although there were no significant findings from this study, a program that involves the caregivers and the riders together can be beneficial. There is a need for further trial and research for this type of program. Instead of using this program during therapeutic riding lessons, further research should consider a grounded program when fewer people are involved (no horse leader or side walker). The caregivers and riders work on their communication skills while completing grooming, bathing, tacking, feeding, and barn work. As the program becomes more structured, this programming can expand to other populations, such as other diagnoses and the geriatric population. Therapeutic riding can be a recommendation to parents or therapists interested in looking for a different approach to specific goals and interventions. As clinicians, we should consider the caregiver in our interventions home programming to help them feel confident using the skills in therapy at home and in the community. This can lead to a decrease in caregiver burnout and an increase in caregiver involvement, which will also show increased progress through goals for the participants. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 13 References Anderson, S., & Meints, K. (2016). Brief Report: The Effects of Equine-Assisted Activities on the Social Functioning in Children and Adolescents with Autism Spectrum Disorder. In Journal of Autism & Developmental Disorders (Vol. 46, Issue 10, pp. 33443352). https://doi.org/10.1007/s10803016-2869-3 Bradshaw, J., Gillespie, S., McCracken, C., King, B. H., McCracken, J. T., Johnson, C. R., Lecavalier, L., Smith, T., Swiezy, N., Bearss, K., Sikich, L., Donnelly, C., Hollander, E., McDougle, C. J., & Scahill, L. (2021). Predictors of Caregiver Strain for Parents of Children with Autism Spectrum Disorder. Journal of Autism & Developmental Disorders, 51(9), 30393049. https://doi.org/10.1007/s10803020-04625-x Brown, J. A., & Woods, J. J. (2016). Parent-Implemented Communication Intervention. Topics in Early Childhood Special Education, 36(2), 115124. https://doi.org/10.1177/0271121416628200 Caring for the caregiver: How to avoid caregiver burnout -. The Autism Therapy Group - ABA Therapy - Independence Together. (2021, June 4). Retrieved January 20, 2023, from https://atgtogether.com/caring-for-the-caregiver-how-to-avoidcaregiver-burnout/ Centers for Disease Control and Prevention. (2022, March 28). Signs and symptoms of autism spectrum disorders. Centers for Disease Control and Prevention. Retrieved January 19, 2023, from https://www.cdc.gov/ncbddd/autism/signs.html Chung, M. Y., & Meadan, H. (2021). Caregiver Involvement in Early Intervention CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 14 Services: Service Providers Perspectives. Inclusion, 9(1), 3145. https://doi.org/10.1352/2326-6988-9.1.31 Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Eickmeier, T., Mills, N., & Belanger, A. (2022). Families as partners in care: A novel model of family engagement in childrens rehabilitation and developmental services. International\Journal of Integrated Care (IJIC), 22, 12. https://doi.org/10.5334/ijic.ICIC22082 Gabriels, R. L., Pan, Z., Dechant, B., Agnew, J. A., Brim, N., & Mesibov, G. (2015). Randomized Controlled Trial of Therapeutic Horseback Riding in Children and Adolescents With Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(7), 541549. https://doi.org/10.1016/j.jaac.2015.04.007 Keel Anderson, S., Loy, D. P., Janke, M. C., & Watts, C. E. (2019). The Effects of Therapeutic Horseback Riding on Balance. Annual in Therapeutic Recreation, 26, 307321. https://doi.org/10.18666/TRJ-2019-V53-I4-9773 Kemeny, B., Burk, S., Hutchins, D., & Gramlich, C. (2022). Therapeutic Riding or Mindfulness: Comparative Effectiveness of Two Recreational Therapy Interventions for Adolescents with Autism. Journal of Autism & Developmental Disorders, 52(6), 24382462. https://doi.org/10.1007/s10803-021-05136-z Martin, R. A., Graham, F. P., Levack, W. M., Taylor, W. J., & Surgenor, L. J. (2020). CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 15 Exploring how therapeutic horse riding improves health outcomes using a realist framework. British Journal of Occupational Therapy, 83(2), 129139. https://doi.org/10.1177/0308022619865496 Olson, L., Chen, B., Ibarra, C., Wang, T., Mash, L., Linke, A., Kinnear, M., & Fishman, I. (2022). Externalizing Behaviors are Associated with Increased Parenting Stress in Caregivers of Young Children with Autism. Journal of Autism & Developmental Disorders, 52(3), 975986. https://doi.org/10.1007/s10803-02104995-w Park, H. I., Park, H. Y., Yoo, E., & Han, A. (2020). Impact of Family-Centered Early Intervention in Infants with Autism Spectrum Disorder: A Single-Subject Design. Occupational Therapy International, 17. https://doi.org/10.1155/2020/1427169 Roux, C. (2020). Horse Riding: Its Influences on Sensory Processing and Relevance to Occupational Therapy. New Zealand Journal of Occupational Therapy, 67(3), 9 14. Serving Indianapolis through Equine Assisted Services. Morning Dove Therapeutic Riding. (n.d.). Retrieved March 11, 2022, from https://morningdovetrc.org/ Therapeutic Horseback Riding Combined with Cognitive Exercises can Help Children with ADHD and Autism Spectrum Disorders. (2020). Palaestra, 34(2), 55. Thi Lan Anh Mai, & Nujjaree Chaimongko. (2022). Effectiveness of a Family Management Intervention Program among Families of Children with Autism: A Randomized Controlled Trial. Pacific Rim International Journal of Nursing Research, 26(1), 6376. CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 16 Appendix Table 1. Pre-Survey Responses from Caregivers Pre-Survey Responses from Caregivers Question Percentage Childs Current Age 50% responded 6 years old 25% responded 16 years old 25% responded 17 years old From your perspective, which of the following statements best describes your child's level of autism? 75% responded high functioning autism 25% responded moderate functioning autism My family members help the children learn to be independent 50% responded with satisfied 50% responded with very satisfied My family has the support we need to relieve stress 50% responded with satisfied 25% responded with very satisfied 25% responded with neither My family members teach the children how to get along with others 50% responded with satisfied 50% responded with very satisfied My family can communicate needs and wants to other family members effectively 50% responded with very satisfied 25% responded with satisfied 25% responded with neither My family members support each other to accomplish goals 50% responded with satisfied 50% responded with very satisfied Which of the following symptoms does your child's goals relate to? (Therapeutic riding goals) 25% responded Neurological 25% responded Social, Communication, Stereotypical, Neurological, and Allergic 25% responded Social Interaction 25% responded Stereotypical behaviors and restrictive interests How much have the targeted symptoms improved following treatment/therapy? 50% responded moderate level of improvement 25% responded a minimal level of improvement 25% responded a high level of improvement How much have the targeted symptoms worsened following treatment/therapy? 100% responded with a minimal level of worsening of symptoms What goals do you have for your child that you want to help improve? 75% responded with some form of improving communication verbally and nonverbally, improving eye contact, and improving independence CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 17 Table 2. Doctoral Capstone Weekly Timeline Doctoral Capstone Weekly Timeline Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation Weekly Goal Objectives 1) Complete orientation by the middle of the week. Meet with site mentor and other site personnel. Tasks Meet all staff on site. Complete paperwork for the site. Screening/evaluation 2) Review and modify needs assessment by the end of the week. Finalize review of Needs Assessment. Review past Needs Assessments and determine if any changes or new questions will benefit. Date complete 01.09.2023 01.09.2023 01.12.2023 Meet with new ED for answers as well as site mentor. 3) Create a draft of pre-, mid-, and post-survey for the program by the end of the week. Establish ways to measure project outcomes. Create a Google Forum for all surveys to be emailed out to parents to complete when necessary. 01.13.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 2 Screening/evaluation 1) Complete literature search by the middle of the week. 2) Begin writing Intro Draft and complete by the end of the week. 3 Screening/evaluation 1) Begin writing Background Draft and complete by the end of the week. 2) Attend a Training class by the end of the week. Establish outcome assessment. Write the introduction of the site, introduce the project, and overview of paper. 18 Finalize MOU 01.11.2023 Review outcome assessment with site mentor and faculty mentor. 01.11.2023 Complete and finish write-up to turn into BrightSpace. Write any relevant and specific info of populations, review needs assessment, problems of work. Complete and finish write-up to turn into BrightSpace. Side walker training to learn walker skills for sessions. Attend the training with site mentor over weekend for experience and new learning. 01.12.2023 01.23.2023 02.02.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 19 4 Implementation 1) Design and Implementation Draft and complete by end of the week. Write how and why I developed the project, and how I carried out the project. Complete and finish write-up to turn into BrightSpace. 02.15.2023 5 Implementation 1) Have presurvey for participants be complete by the middle of the week. Send presurveys to help understand the needs and wants from participants about the project. Email out survey to participants to complete a week prior session beginning. 02.15.2023 6 Implementation 1) Barn Buddies sessions begin and implementing program by end of the week. Begin focusing on goals for programs and outcomes wanted for the program. Complete grounded therapy sessions MondayThursday that include working towards at least one goals. 02.15.2023 2) Evaluate the program on Friday. Determine if goals and outcomes are working and if any changes will be needed. What worked well, what didnt. What was the response from the participants and site mentor? 02.17.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 7 Implementation 1) Continue implementing the program into sessions by the end of the week. 2) Evaluate the program on Friday. 8 Implementation 1) Continue implementing the program into sessions by the end of the week. 2) Evaluate the program on Friday. Begin focusing on goals for programs and outcomes wanted for the program. Complete grounded therapy sessions MondayThursday that include working towards at least one goal. Determine if goals and outcomes are working and if any changes will be needed. What worked well, what didnt. Begin focusing on goals for programs and outcomes wanted for the program. Complete grounded therapy sessions MondayThursday that include working towards at least one goal. Determine if goals and outcomes are working and if any changes will be needed. What worked well, what didnt. 20 02.22.2023 02.24.2023 What was the response from the participants and site mentor? What was the response from the participants and site mentor? 03.01.2023 03.03.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 9 Implementation 21 Spring outdoor sessions begin 1) Begin implementing the program into sessions by the end of the week by observing riders during the lessons. 2) Evaluate the program on Friday. 3) Begin writeup of Outcomes Draft and complete it by the end of the week. Begin focusing on goals for programs and outcomes wanted for the program. Determine if goals and outcomes are working and if any changes will be needed. Write evaluation plan and report all valid assessments and run stats. Complete grounded therapy sessions Monday-Friday that include working towards at least one goal. 03.06.2023 What worked well, what didnt. 03.09.2023 What was the response from the participants and site mentor? Complete and finish write-up to turn into BrightSpace. 03.10.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 10 Implementation 1) Continue implementing the program into sessions by the end of the week. 2) Evaluate the program on Friday. 11 Implementation Begin focusing on goals for programs and outcomes wanted for the program. Determine if goals and outcomes are working and if any changes will be needed. 22 Complete grounded therapy sessions Monday-Friday that include working towards at least one goal. 03.13.2023 What worked well, what didnt. 03.17.2023 What was the response from the participants and site mentor? 3) Begin writeup of Dissemination Plan and complete by the end of the week. Determine what is being disseminated, the end users, partners, evaluation, and work plan. Complete and finish write-up to turn into BrightSpace. 01.11.2023 1) Have postinterview with the caregivers completed by the end of the week. Determine the benefits of the project from the participants to see if this type of program is worth keeping. Complete analyzing and formatting the interviews for organization. 03.24.2023 CAREGIVER PARTICIPATION IN THERAPEUTIC RIDING 23 12 Implementation 1) Complete analyzing data by the end of the week. Finalize data Determine if the program showed an increase in skills for participants. 03.31.2023 13 Discontinuation 1) Begin writing Abstract, Summary, and Conclusion Draft and complete by the end of the week. Write how intro, background, and project all relate together and restate important results. Complete and finish the writeup to turn into BrightSpace. 04.07.2023 14 Dissemination 1) Begin writing the Scholarly report and complete it by the end of the week. Bringing the entire project together. Review drafts and fix any changes made by the coordinator or self. 04.10.2023 Create an outline of the scholarly report. Complete and finalize writeup of scholarly report. Create a PPT with notes. 04.12.2023 04.20.2023 04.23.2023  ...

... 1 Hippotherapy Specific Outcome Resources to Improve Reimbursement Rates Kyli Luna May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Kaylin Shiver, MS, OTR, BCP, CAS 2 Abstract Childrens TherAplay is the largest pediatric rehabilitative medical facility exclusively providing hippotherapy in the country. The needs assessment identified a need for hippotherapy resources to increase insurance reimbursement rates. The Hippotherapy Assessment and Evaluation Tool (HEAT) was trialed, implemented, and taught to therapists at the facility as well as creating a packet of information about why hippotherapy matters. Five patients were chosen using purposeful sampling to include a variety of diagnosis and ages. These patients were tested at the beginning and end of an eight-week period using the HEAT. There were significant improvements in the total HEAT scores with all patients. An educational presentation was provided to therapists to introduce the HEAT, provide details on efficiency, and receive feedback/concerns. Completing this assessment helped identify new deficits to target with patients and identify potential need for other services. Staff members were excited to utilize the HEAT as well the informative packet. 3 Introduction In 2001, Childrens TherAplay Foundation, a non-for-profit organization, became the first and only therapy center in Indiana to provide hippotherapy (HPOT). Occupational therapists (OTs), physical therapists (PTs), and speech-language pathologists (SLPs) utilize equine movements as a treatment to provide motor and sensory input for children of varying diagnosis helping patients reach their functional goals. It has now grown to be the largest pediatric rehabilitative medical facility exclusively providing hippotherapy in the country. The chosen project at Children's TherAplay will focus on incorporating and developing effective assessment strategies for a non-standardized outcome measure in the clinic called the Hippotherapy Evaluation and Assessment Tool (HEAT), which has never been utilized by the clinic. Insurance companies all over the nation are vulnerable to reimbursing hippotherapy services due to the lack of scientific research and data showing the impact hippotherapy has on children amongst a variety of disabilities (Stolz et. al., 2022). Utilizing a hippotherapy specific outcome measure to measure progress using hippotherapy as a treatment tool will plan to help insurance companies see a direct measurement of progress utilizing hippotherapy for treatment (Stolz et. al., 2022). Therapists will be provided with educational materials on how to utilize the HEAT as well as raw data on patients who were assessed using this tool. Alongside of this research, a visual informative will be created that will be used to advocate and educate third party payers as well as caregivers on the various components of hippotherapy. This project will be guided by theories and models that best suit the needs of the targeted populations as well as supporting the need for insurance reimbursement for hippotherapy services. Data will be analyzed through raw data reporting outcomes and discussing the importance of outcomes leading to future implications for utilizing HPOT in practice. 4 Background Hippotherapy is a treatment tool that has been established since the 1960s and is utilized by occupational therapy, physical therapy, and speech therapy (Leidig, 2018; Koca & Ataseven, 2015). The natural movement of the horse provides varied motor and sensory input that can be translated in the use of everyday activities. There are centers all over the world that are using hippotherapy as a treatment tool with research showing improvements with children of varying diagnosis including Autism Spectrum Disorder, Cerebral Palsy, etc. (Peters et. al., 2022; Champagne et. al., 2017). Childrens TherAplay Foundations mission is to provide children with disabilities a foundation for developing life skills through innovative therapies, including physical, occupational, and speech therapies using a horse as a treatment tool, in a safe and caring environment (Childrens TherAplay Foundation, Inc., 2022). They believe that bringing together different experiences, beliefs, and cultures allows us to collectively and more effectively serve our constituents, our community, and our world (Childrens TherAplay Foundation, Inc., 2022). Their core values include support, inclusiveness, excellence, community, education, and empowerment. Childrens TherAplay serves children of all disabilities and conditions including ASD, Downs Syndrome, Cerebral Palsy, ADD, SCI, TBI, and many more. Children usually participate in a 20-minute horse riding session and then continue the rest of the treatment in the clinic. This facility follows best practice statements presented by the American Hippotherapy Association including; children must be in the age range of 18 months to 12.5 years and must weigh no more than 80-100 lbs. due to ensuring safety for the patients, therapists, and horses; must be willing to wear safety protection when on the horse and be able to maintain adequate 5 head control; and there are only to be three horses at a time on the floor and each horse must be assisted with a therapist, a side walker, and most importantly a horse handler (AHA, 2021). All children and family have access to hippotherapy services if they meet the criteria and have a referral from a physician. They accept all insurance providers including third party payors. Hippotherapy is currently covered under Medicaid but there are some third-party providers that will not cover hippotherapy services. or require patients and therapists to jump through many hoops as reported by the billing coordinator and lead therapists at Children's TherAplay. One of the biggest challenges that needs to be addressed in the hippotherapy world are insurance barriers (Pham & Bitonte, 2016). Insurance companies all over the nation are vulnerable to reimbursing hippotherapy services due to the lack of scientific research and data showing the impact hippotherapy has on children amongst a variety of disabilities (Stolz et. al., 2022). The therapists at Childrens Theraplay are asking for resources to send to insurance as a means of advocating for their patients and increasing insurance reimbursement rates. Reimbursement rates can also likely increase with the use of direct related outcome measures measuring progress using a specific intervention (Stolz et. al., 2022), which is where the implementation of the HEAT at the clinic will come into play. After reviewing the literature, it was found that this is very common for hippotherapy services not being covered under insurance even though there is literature showing how beneficial hippotherapy is to children and even adults with disabilities (Ballard et. al., 2020). Hippotherapy has been shown to increase improvements in communication, interpersonal relationships, and mobility (Potvin-Blanger et. al., 2022). At Children's Theraplay Foundation, children of many diagnoses are treated, some including complex medical conditions. In an article addressing children with high medical complexities, caregivers reported that it is difficult to get 6 the coverage they need without putting up a fight due to the patients requiring a lot of maintenance work whereas insurance wants to see continuous intensive progress (Foster et. al., 2021). This is especially noted with private paying insurers as this is an issue in many aspects of healthcare, noted with children receiving less referrals for specialty care if they have private insurance compared to public insurance (Skinner & Mayer, 2007). Private insurances bring about the most barriers at Childrens Theraplay requiring frequent prior authorizations and increased appeals for services impacting delayed services or decreasing reimbursement rates as reported by the billing coordinator and lead therapist. The therapists at the clinic are open and excited about incorporating a new tool demonstrating direct progress utilizing hippotherapy. There is currently no research showing other clinics incorporating the HEAT at their clinic or the impact it has had, however there are quality thesis studies that confirm statistical reliability and validity (Abrams et al., 2019; Barnette et. al., 2018) as well as showing statistically significant relationships with the Pediatric Evaluation of Disability Inventory (PEDI) and the Gross Motor Function Measure (GMFM) (Austin et. al., 2013; Snyder et al., 2012). The HEAT looks at a variety of domains including static posture, dynamic motor behavior, sensory processing, and psychosocial/behavior. Various studies demonstrate improvements in similar characteristics noted within the HEAT including increased social skills, mobility, gross motor function, and increasing motivation (Potvin-Belanger et. al., 2021; Grockien et. al., 2018). The goal at Childrens Theraplay is to provide a new assessment tool and a new resource for therapists to have in their toolbox so that they will have numerical data showing progress of patients utilizing equine movements. This work is different from a more systemic approach because it allows for a short-term solution while a bigger plan for policy change is in the works. 7 Theories The Person-Environment-Occupation (PEO) occupation-based model and the Lifespan/Development frame of reference (FOR) has been chosen as a best fit to guide this project. These two theories fit together as the PEO model looks at how the person, occupation, and environment come together to create an optimal fit for occupational performance for the client over the lifespan and throughout the lifespan we need to be able to understand the mastery of skill is corresponding with the age of the person (Cole & Tufano, 2008). Hippotherapy is appreciated by parents (persons) in that it encompasses physical and psychosocial benefits that impact the social environment and occupations and have noticed changes in their children (persons) after various hippotherapy sessions as seen in various research studies including neuromotor function, life habits, mobility, social skills, and interpersonal relationships (occupations) (Potvin-Belanger, et. al., 2021; Moriello, et. al., 2020; Anderson, et. al., 2019). The environment is practicing occupations on the horse or in the barn and being able to translate them over to the clinic, the home, and the community. Children with ASD showed increased participation with activities of daily living (ADLs) after participating in a variety of equine-assisted activities including grooming, feeding, and communicating with the horses demonstrating mastery skills across context (Borgi, et. Al., 2016). As children develop, they begin to reach new skills of mastery and its important to know how to utilize hippotherapy throughout those different stages of development for each child. It is important to see how patients and their families benefit from hippotherapy and how it helps them progress throughout their developmental stages. Bringing together data and use of the PEO and Lifespan/Developmental FOR will help guide research in order to increase rates for reimbursement through third party payers. 8 Project Design and Implementation While exploring the literature, looking for ways to help improve insurance reimbursement rates, a research article on the HEAT came up in the search. Showing direct quantitative objective measurements directly related to hippotherapy services has been reported to portray progress to third party payers increasing chances for reimbursement (Stolz et. al., 2022). This was the only hippotherapy specific outcome that appeared in a deep dive literature search. As stated above, the HEAT has also been confirmed to show statistical reliability and validity. It is a free convenient assessment tool based on observations and can be used to measure progress over short periods of time. A few articles completed hippotherapy interventions over an eight-week or eight session time spans with success which is why progress was measured with the HEAT over an eight-week period equaling eight total sessions (Glen S. Cotton, 2021; Gabrielle Moriello, 2020). Five patients were chosen using purposive sampling in order to assess and treat a variety of ages and diagnosis; refer to Table 1. Descriptive Patient Data. Interventions were tailored to each individual based on their first assessment with the HEAT. Different diagnosis and medical complexities were tested in order to be able to use the info as a demonstration for all therapists to be able to learn about the HEAT and how it can be utilized across a variety of patients. Using a generalizable collection of data, the HEAT will be presented to the therapists at the clinic using personal experience to help further educate them on the tool. During free time throughout the 8-week testing period, an informative packet was created for HPOT incorporating ways of measuring it utilizing the HEAT. This packet was developed to meet the eye of third-party payers, so it was filled with research, guidelines, supporters, and 9 ways of measuring HPOT. This packet was then shared with leaders and coordinators at Childrens TherAplay. Please refer to Appendix A: DCE Weekly Planning Guide to see a weekby-week schedule on my project design and implementation. There were many varying challenges and successes to implementing this new assessment tool Before implementing this tool, communication was made with barn staff to inform them on the plan utilizing the HEAT and making sure it was safe for the horses. One big challenge with administering this assessment was having to adapt on spot based on the behaviors of the horse. It was also crucial that the assessment was looked over and you had a very well understanding of the tool as it is difficult to manipulate paper items while your patient is riding the horse. However, patients interacted well with the assessment and administration of the tool was able to be easily adapted to maximize performance. Project Outcomes The HEAT was found to be a free, convenient assessment tool that was confirmed to be reliable and valid. Across an eight-week span, significant changes were noted in the static posture domain, dynamic motor behavior domain, and the total score overall. However, there was not significant changes noted in the sensory processing domain and psychosocial/behavioral domain as scores either decreased or remained stagnant; refer to Table 2. Pair Samples Test for HEAT Outcomes; Figure 1. HEAT Domain Outcomes Pre vs Post Hippotherapy Interventions. These outcomes were shared with therapist via PowerPoint along with how to be effective with administration utilizing the horses at their facility. Therapists reported concerns for utilizing this assessment including it not being standardized, being able to know if PTs and OTs are scoring domains correctly, discriminating between vision deficits and attention regulation, and appropriateness depending on cognitive functioning for certain patients. Overall, we were able to 10 see increased total scores for all our patients across an eight-week period. It also demonstrated the thought process for our patients who scored higher and close to reaching max scores if they are still appropriate for HPOT services. With this assessment new deficits were able to be on the horse that were not usually easily looked over. It also identified a need for possible referrals for other services including speech or physical therapy. The informative packet on HPOT was shared with the billing coordinator as she would be a main user of the packet to use for caregivers and third-party payers; refer to: https://www.canva.com/design/DAFbIxo4DPc/ZRA_UMMnxXbiPEIzt4QuAg/view?utm _content=DAFbIxo4DPc&utm_campaign=designshare&utm_medium=link&utm_source =publishsharelink As she read through it, she verbally stated I was able to learn more about what and how hippotherapy was used and how it was measured, this will be really helpful for me. The lead therapist also loved the packet and believed it would be a great visual overall for Childrens TherAplay Foundation. Summary Children's TherAplay has been battling the need for hippotherapy specific resources in order to inform third party payers and community members who are not familiar with hippotherapy treatment and process. These resources plan to decrease insurance challenges for reimbursing services. A way of tackling this challenge was trialing, implementing, and teaching HEAT that is not being utilized within the facility as well as creating a hippotherapy specific informative that can be used to inform community members and third-party payers. It was found that the HEAT did well at measuring outcomes, and we were able to see noticeable improvements over an eight-week period. Although not significant in all domains of 11 the HEAT, hippotherapy has been shown to show improvements in motor function across a variety of diagnosis and ages. While completing these assessments we were able to identify challenges from certain horse personalities to finding motivating techniques to complete bilateral integration techniques. These challenges and methods of assessing to increase efficiency and patient outcomes were shared with the therapists in the clinic. Majority of therapists were excited to start integrating this assessment within their practice and increased understanding was demonstrated by people who were not as familiar with the hippotherapy process. Conclusion During the time spent at Childrens Theraplay, new skills were obtained by being able to analyze, put together educational resources, and teach professionals the importance of hippotherapy and why it is important to use a hippotherapy specific assessment tool. Hippotherapy was shown to be an effective intervention treatment in order to reach functional goals as demonstrated through improved HEAT scores. Childrens TherAplay will benefit from this project as it will continue to challenge their clinical skills with a new assessment as well as provide additional objective data to third party payers directly related to the hippotherapy treatment they provide. They will also benefit from long term use of an updated wide-spanned informative addressing the varying aspects of hippotherapy, its benefits, how it is used, how its measured, and who supports it. Future implications consist of advocating and encouraging use of the HEAT with new therapists starting at Childrens Theraplay Foundation as well as beginning to advocate to other facilities on the importance of utilizing this tool within their practice. The therapy professions utilizing hippotherapy should continue to thrive at finding new methods of advocating and expanding the knowledge and resources of hippotherapy in order to continue increasing 12 insurance reimbursement rates. Using these tools can help therapists pinpoint specific interventions utilizing equine movements in order to create more challenge for higher functioning patients. 13 References Abrams, B., Black, K., Buttler, C., & Long, T. ( 2019). Interrater Reliability of the Hippotherapy Evaluation and Assessment Tool (HEAT) Between Students and Clinicians [Masters Thesis, Brenau University]. Accessed at ://heatassessment.com/research/ American Hippotherapy Association. (2021). American Hippotherapy Association, Inc. Statements of Best Practice for the Use of Hippotherapy by Occupational Therapy, Physical Therapy, and Speech-Language Pathology. American Hippotherapy Association, Inc. Accessed at americanhippotherapyassociation.org Anderson, S. K., Loy, D. P., Janke, M. C., & Watts, C. E. (2019). The Effect of Therapeutic Horseback Riding on Balance. Therapeutic Recreation Journal, 53(4), 307-321. https://doi.org/10.18666/TRJ-2019-V53-14-9773 Austin, A., Bridges, K., Pledger, D., & Truitt, L. (2013) Establishing Concurrent Validity of the Hippotherapy Evaluation and Assessment Tool [Masters Thesis, Brenau University]. Assessed at https://heatassessment.com/research/ Ballard, I., Vincent, A., & Collins, C. (2020). Equine Facilitated Psychotherapy with Young People: Why Insurance Coverage Matters. Child and Adolescent Social Work Journal, 37, 657-663. https://doi.org/10.1007/s10560-020-00712-1 Barnette, S., Cager, K., Kern, K., & Payne, L. (2018). Inter-rater Reliability of the Hippotherapy Evaluation and Assessment Tool (HEAT) [Masters Thesis, Brenau University]. Accessed at https://heatassessment.com/research/ 14 Borgi, M., Loliva, D., Cerino, S., Chiarotti, F., Venerosi, A., Bramini, M., Nonnis, E., Marcelli, M., Vinti, C., De Santis, C., Bisacco, F., Fagerlie, M., Frascarelli, M., & Cirulli, F. (2016). Effectiveness of a Standardized Equine-Assisted Therapy Program for Children with Autism Spectrum Disorder. Journal of Autism & Developmental Disorders, 46, 1-9. DOI: 10.1007/s10803-015-2530-6 Champagne, D., Corriveau, H., & Dugas, C. (2017). Effect of Hippotherapy on Motor Proficiency and Function in Children with Cerebral Palsy Who Walk. Physical & Occupational Therapy, 37(1), 51-63. DOI: 10.3109/01942638.2015.1129386 Childrens TherAplay Foundation. (2022). Childrens TherAplay Foundation, Inc. About Us (childrenstheraplay.org) Cole, M & Tufano, R. (2008). Applied Theories in Occupational Therapy: A Practical Approach. SLACK Incorporated, p. 127 & 209. Glen, C. S. (2021). Effect of Hippotherapy on Sesnory Integration Among Children with Autism Spectrum Disorder: A Pilot Study. American Journal of occupational Therapy 75(2) DOI: 10.5014/ajot.2021.75S2-RP368 Grockien, A., Dovidatien, G., Kerizien, S., & Stankeviius, R. (2018). Influence on Functional Mobility and Motivation of Hippotherapy for People with Special Needs. Veterinarija ir Zootechnika, 76(98), 29-32. ISSN 1392-2130 Foster, C., Fuentes, M., Wadlington, L., Jacob-File, E., Desai, A., Simon, T., & MangioneSmith, R. (2021). Caregiver and provider experiences of physical, occupational, and speech therapy for children with medical complexity. Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach Throughout the Lifespan 14:505516. DOI:10.3233/PRM-190647 15 Koca, T. T. & Ataseven, H. (2015). What is hippotherapy? The indications and effectiveness of hippotherapy. Northern Clinics of Instanbul, 2(3) 247-252. DOI:10.14744/nci.2016.71601 Leidig, M. (2018). An Examination of Hippotherapy as a Tool to Deliver Physical, Occupational, and Speech Therapy. WWU Honors Program Senior Projects. 101. https://cedar.wwu.edu/wwu_honors/101 Moriello, G., Terpstra, M. E., & Earl, J. (2020). Outcomes Following Physical Therapy Incorporating on Neuromotor Function and Bladder Control in Children With Down Syndrome: A Case Series. Physical & Occupational Therapy in Pediatrics, 40(3), 247260. https://doi.org/10.1080/01942638.2019.1615601 Peters, C., Wood, W., Hepburn, S., & Moody E. (2022). Preliminary Effect of Occupational Therapy in an Equine Environment for Youth with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders 52:4114-4128 https://doi.org/10.1007/s10803-02105278-0 Pham, C., & Bitonte, R. (2016). Hippotherapy: Remuneration issues impair the offering of this therapeutic strategy at Southern California rehabilitation centers. Neuro Rehabilitation, 38, 411-417. DOI:10.3233/NRE-161332 Potvin-Blanger, A., Freeman, A., & Vincent Claude. (2021). Hippotherapy and life habits with children with motor deficit and neurodevelopmental impairment: A pilot survey of parents. Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach Throughout the Lifespan, 14, 41-49. DOI: 10.3233/PRM-190641 16 Potvin-Blanger, A., Vincent, C., Freeman, A., & Flamand, V.H. (2022) Impact of Hippotherapy on the Life Habits of Children with Disabilities: A Systematic Review. Disability and Rehabilitation, 44:26, 8161-8175, DOI: 10.1080/09638288.2021.2012847 Skinner, A. & Mayer, L. (2007). Effects of insurance status on childrens access to specialty care: a systematic review of the literature. BMC Health Services Research, 7:194 doi:10.1186/1472-6963-7-194 Snyder, J., Smith, D., Mapp., K. & Wade, K. (20120) establishing Concurrent validity of the Hippotherapy Evaluation and Assessment Tool [Masters Thesis, Brenau University]. Access at https://heatassessment.com/research/ Stolz, I, Anneken, V., & Frobse, I. (2022). Measuring Equine-Assisted Therapy: Validation and Confirmatory factor of an ICF-Based Standardized Assessment-Tool. International Journal of Environmental Research and Public Health, 19, 2738. https://doi.org/10.3390/ijerph19052738 17 Table 1 Descriptive Patient Data Diagnosis Age Duchenne Muscular Dystrophy 5 Down Syndrome 8 Autism Spectrum Disorder 3 Congenital Malformation of Corpus Callosum 4 Right Hemiparesis due to Acquired TBI 10 18 Table 2 Pair Samples Test for HEAT Outcomes Paired Samples Test Paired Differences t Sig. (2df tailed) Std. Error Mean 95% Confidence Interval of the Difference .80000 Lower .57884 Upper 5.02116 3.500 4 .025 Pair PostDynamicMotorBehaviorDomain 5.20000 2 PreDynamicMotorBehaviorDomain 3.70135 1.65529 .60417 9.79583 3.141 4 .035 Pair PostSensoryProcessingDomain 3 PreSensoryProcessingDomain 1.60000 1.34164 .60000 -.06587 3.26587 2.667 4 .056 .00000 1.87083 .83666 2.32294 4 1.000 Mean Pair PostStaticPostureDomain 1 PreStaticPostureDomain Pair PostPsychosocialBehavioralDomain 4 - PrePsychosocialBehavioralDomain Pair PostTotalScore - PreTotalScore 5 2.80000 9.60000 Std. Deviation 1.78885 7.60263 3.40000 2.32294 .000 .16009 19.03991 2.824 4 .048 19 Figure 1 HEAT Domain Outcomes Pre vs Post Hippotherapy Interventions Heat Total Score/100 HEAT Domain Outcomes Pre vs Post Hippotherapy Interverntions 100 90 80 70 60 50 40 30 20 10 0 Pre Sensory Post Sensory Pre Psychosocial/ Post Psychosocial/ Pre Total Scores Pre Static Posture Post Static Posture Pre Dynamic Motor Post Dynamic Domain Behavior Domain Motor Behavior Processing Domain Processing Domain Behavioral Domain Behavioral Domain Domain Post Total Scores Heat Domains Pre vs Post Duchenne Muscular Dystrophy Down Syndrome Autism Spectrum Disorder Congenital Malformation of Corpus Callosum TBI- R. Hemi 20 Appendix 1 DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Orientation Become oriented with site Review needs assessment Objectives Meet staff and patients Observe hippotherapy sessions Update needs assessment and continue to ask questions 2 Screening/Evaluation Complete new Literature Search Begin writing Introduction Rough Draft Introduced to EMR system (Practice Perfect) Finalize MOU Continuing observing patients Read through literature articles about hippotherapy Tasks Fill out onboarding paperwork Schedule 1:1 meetings with Billing Coordinator and Director of Therapy Services Date complete 1.9.2023 1.12.2023 1.12.2023 (updated 2.8.2023 due to slight project revamp) Create Weekly Timeline Meet with 1.13.2023 Billing Coordinator to begin understanding 1.18.2023 insurance process Meet with Begin to think Director of Therapy about 5 patients to Services treat and implement the Create HEAT on surveys for therapist and parents about insurance barriers 1.24.2023 1.19.2023 21 3 Screening/Evaluation Finish Introduction Rough Draft Begin writing Background Draft Begin thinking about outcome assessment 4 Screening/Evaluation Finalize project plan Complete Background Rough Draft Begin learning about different insurance requirements for hippotherapy Determine outcome measure for project Continue observing hippotherapy sessions Gather all HEAT materials Schedule 1:1 meeting with barn manager about HEAT implementati on Continue reading articles and Chart review understanding patients insurance process Complete training Review and module for gather a deep the HEAT understanding of the HEAT Send out surveys to therapists and parents Review the HEAT with site mentor Identify 5 patients to complete the HEAT on Update barn on HEAT implementati on and what to expect Meet with barn manager 1.17.2023 1.26.2023 1.19.2023 Not complete d due to revamp of project (not directly insuranc e focused) 2.2.2023 2.1.2023 Meet with site mentor 2.2.2023 Print out needed materials to complete the HEAT on 5 patients Create HEAT administratio n binder Begin creating HEAT educational resources 2.7.2023 2.1.2023 2.2.2023 22 5 Implementation Administer the HEAT on 5 patients Complete Project Design and Implementati on Rough Draft Complete 5 treatment sessions with documentatio n Met with capstone coordinator to address project revamp and redirect focus on implementing and educating therapist on HEAT, will also make a packet of resources for billing coordinator to inform insurance companies Communicate with horse handlers on new assessment Begin creating an outline for package of resources Create excel spreadsheet with patient scores from the HEAT 2.20.2023 finished Finish and receive updates on documenting hippotherapy sessions 2.9.2023 Update Weekly Timeline 2.6.2023 2.7.2023started 2.8.2023 23 6 Implementation Begin gathering resources for insurance advocacy Complete 5 treatment sessions 7 Implementation Complete 5 treatment session Complete 2 pages of package of resources Complete midterm evaluation 8 Implementation Reflect on HEAT administratio n, what can be better, what went well? Continue working on HEAT PowerPoint slides Document treatment sessions Identify 5 resources to send package of resources to Complete 5 treatment sessions Attend Capitol Hill Day February 22nd Document treatment sessions Complete 2 pages of package of resources Continuing reading articles about project Make edits to introduction Make edits to background draft Make edits to project design and implementati on Begin putting together scholarly report draft 2.14.2023 2.15.2023 2.16.2023 2.20.2023 2.23.2023 Meet with site mentor Make edits to already completed package of resources 2.28.2023 3.2.2023 Meet with site mentor to share already 2.27.2023 developed 3.3.2023 resource pages Continuing searching for resources to share resources with 24 9 Implementation Complete 5 reassessments with the HEAT Complete 2 pages of package of resources 10 Implementation Complete 5 treatment sessions Complete 2 pages of package of resources Begin working on Project Outcomes Draft Document treatment sessions Continuing finding articles about project Turn in Project Outcomes Draft Begin working on Disseminatio n Plan Document treatment sessions 11 Implementation Complete 5 treatment sessions Complete 2 pages of package of resources Continuing finding articles about project Turn in Disseminatio n Plan Begin working on abstract Document treatment sessions Continuing reading Read new articles Make edits to package of resource pages 3.8.2023 3.10.2023 3.9.2023 Meet with barn staff on HEAT thoughts Read new articles Make edits to package of resource pages 3.14.2023 3.16.2023 3.17.2023 Continue asking barn staff about HEAT thoughts Read new articles 3.20.2023 3.24.2023 Make edits to package of resources 3.20.2023 3.24.2023 25 12 Implementation Complete 5 treatment sessions Finalize package of resources 13 Discontinuation Complete 5 final HEAT reassessments Finalize HEAT PowerPoint with educational materials articles about project Document treatment sessions Continuing reading articles about project Complete 5 treatment sessions with documentatio n Make final edits on package of resources Continue working on abstract, conclusion, and summary 14 Dissemination Complete Final Evaluation Disseminate HEAT outcomes and educational resource to therapist Receive feedback and thoughts on HEAT from therapists Find more resources for package of resources Make final edits to package of resources 3.27.2023 3.30.2023 3.31.2023 Begin sending out package of resources Identify 4.3.2023 appropriate time to meet 4.3.2023 with therapists Identify appropriate times to meet with Billing Coordinator and Director of Therapy Services 4.6.2023 Create PDF and make sure it is added to SDrive Meet with site 4.13.2023 mentor 4.11.2023 Meet with faculty 4.11.2023 mentor Document satisfaction Gather all and likelihood final of utilizing resources for the HEAT for 4.13.2023 26 Disseminate assessment easy access package of tool use by the resources to therapists Complete Billing Coordinator final scholarly Say final report and Director goodbyes of Therapy Services Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... 1 The Relationship Between Functional Performance Outcomes, Rehabilitation Intensity, and the Potential Effect of PDPM on Skilled Nursing Facilities By Christine Kroll, Tara Martin, Brenna Menke, Anne Mari West, Faith Wilkins, Madison Woo School of Occupational Therapy, University of Indianapolis, Indianapolis, United States 2 The Relationship Between Functional Performance Outcomes, Rehabilitation Intensity, and the Potential Effect of PDPM on Skilled Nursing Facilities Abstract Objective: This study utilized Section GGs functional performance measures to evaluate correlations between rehab intensity, patient self-care, and mobility outcomes to ensure patients are receiving sufficient amounts of therapy in postacute care settings. Methods: SPSS Statistics 27.0 was used to conduct a secondary analysis of a medical data set collected from 93 skilled nursing facilities in the midwest region (N = 1352). Results: The study identified relationships between insurance type, length of treatment, and diagnostic category in a SNF based on Medicare beneficiaries. There was a significant positive relationship between insurance and length of treatment, where beneficiaries with Medicare were found to have longer stays (avg. days 31) than those with Medicare Advantage Plans (avg. days 17). A limited positive correlation was found between length of stay and functional outcomes measured in self-care and mobility items (p = 0.01). Conclusions: The shift from volume to value-based reimbursement for rehabilitation services in PAC settings created questions surrounding the relationship between the amount of therapy provided and patient functional outcomes. Functional outcomes were found to be higher in Medicare beneficiaries as measured by standardized Section GG measurements in PAC when their insurance coverage allowed for longer stays versus Medicare Advantage Plans. Keywords: section GG; occupational therapy; medicare 3 The Relationship Between Functional Performance Outcomes, Rehabilitation Intensity, and the Potential Effect of PDPM on Skilled Nursing Facilities Within the past decade, policymakers created an initiative known as the Triple Aim to evaluate current healthcare practices and optimize three critical components of the United States healthcare system: improve the quality of health services provided, improve the health and wellness of the United States population, and decrease the cost of healthcare (Berwick et al., 2008; Sandhu et al., 2018). Medicare is a federal health insurance program in the United States for people ages 65 and over, regardless of income, medical history, or health status (Centers of Medicare and Medicaid Services, 2019b). Currently, Medicare plays a critical role in providing health and financial security to 50 million people (Centers of Medicare and Medicaid Services, 2019a). Medicare insures various medical services, including Part A services that cover inpatient hospital stays, skilled nursing facility (SNF) stays, home health visits, and hospice care. Over the past decade, healthcare costs covered by Medicare grew by 34.3% and rose an additional 3.2% between 2018 and 2019 (U. S. Census Bureau, 2020). This increase in healthcare costs covered by Medicare is partly due to the 65+ population utilizing more services (Cubanski et al., 2019). Medicare Advantage Plans (MGA) were first introduced in 2003 in response to a need for additional coverage for Medicare beneficiaries, specifically regarding prescription drug coverage (Jacobson, 2015). Advantage plans are healthcare insurance coverage plans facilitated through government-contracted private companies that provide a continuum of coverage options with lower out-of-pocket costs for beneficiaries with various medical needs compared to traditional medicare plans. Between 2008 and 2018, the number of beneficiaries enrolled in an MGA plan extended from 22% to 34% (Cubanski et al., 2019). Following these policy changes, the number of beneficiaries choosing private plans grew partly to lower out-of-pocket costs (Jacobson, 4 2015). However, these out-of-pocket costs are variable between private companies and private insurers contracted through Medicare and must follow the rules set by Medicare to ensure reimbursement of services covered through MGA (Medicare, 2022). Since 2000, the passing of the Affordable Care Act (ACA), 24 U.S.C. 157 (2010) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, 24 U.S.C. 1395 (2014) included mandates and significant changes to reduce the cost of services, improve the quality of care for Medicare Part A recipients, and implement the Triple Aim initiative (Sandhu et al., 2018). Based on these mandates, the Center for Medicare and Medicaid Services (CMS) transitioned in October 2019 from a volume to a value-based system called a Patient-Driven Payment Model (PDPM) that focuses on patient characteristics and the quality of healthcare service, replacing the former system based on the amount of services provided. The PDPM changed reimbursement methods by creating a standardized number of therapy minutes per diagnosis, a change that was meant to deter SNF rehabilitation services from inappropriately administering costly therapy minutes. CMS initiated the shift in payment models in anticipation that it would reduce the rate of readmissions and improve the health of Medicare beneficiaries (Kroll & Fisher, 2019). Additionally, this change in reimbursement may influence treatment plan decisions for patients and impact reimbursement for therapy services related to patient outcome measurements from standardized data collection across post-acute care (PAC) settings (Sandhu et al., 2018). Currently, there is no standardized amount of therapy per day in rehabilitation services in Skilled Nursing Facilities (Jette et al., 2005). Identifying a method to quantify rehabilitation intensity can help refine the value of therapy services for Medicare beneficiaries and improve the value-based care payment model. 5 Within each PAC setting, functional outcomes were measured using individual assessment tools. However, the assessments did not include the same standardized items across settings. The development of a new tool in PAC was the precursor to change in reimbursement allowing for the feasibility of implementation across settings and comparing functional outcomes (Deutsch et al., 2022). The CMS created and implemented the Continuity Assessment Record and Evaluation (CARE) tool (Sandhu et al., 2018) which collects standardized data regarding the functional status of Medicare beneficiaries on admission to a PAC facility. Section GG is an excerpt from the CARE tool consisting of self-care and mobility scales assessed at admission and discharge and is now the assessment of function tool used across PAC settings (Sandhu et al., 2018). The creation of Section GG eliminated a barrier for researchers to determine meaningful comparisons of functional outcomes; before the CARE tool, relationships between functional outcomes and rehabilitation intensity could not be explored (Kroll & Fisher, 2019). For clinicians to use Section GG scales, self-care and mobility, independently from the CARE tool, a team of expert personnel in their respective fields tested individual items within the CARE tool to confirm the validity and reliability of the measures across various PAC settings (Gage et al., 2012). These pilot tests revealed that individual items within the CARE tool showed high interrater reliability between healthcare professionals and demonstrated face validity compared to assessment tools testing similar items (Gage et al., 2012). In a study by Cogan et al. (2020), researchers found that functional outcomes from mobility and self-care scales of the Functional Independence Measure (FIM) had a positive correlation with length of stay (LOS) and rate of recovery (Cogan et al., 2020). Similarly, we want to utilize Section GGs functional performance measures to evaluate correlations between 6 rehab intensity and patient self-care and mobility outcomes. The items from Section GG aid in determining the quality measures of rehabilitation services provided regarding the new PDPM reimbursement model for SNFs and other PAC facilities. Similar to previous studies, we will be defining rehabilitation intensity calculated by dividing the total time spent in rehabilitation treatment by the length of stay [RI=Time (min)/LOT(min)] (Jette et al., 2005; Mallinson et al., 2014). Understanding this relationship may facilitate an agreement between medical professionals and Medicare policymakers on evidence-based practice decisions that best support patients in PAC settings. Methods Study Design This study was a secondary analysis of a medical data set collected from a therapy company that provides care in skilled nursing facilities. Medical system data was retrieved from 93 SNFs located in two midwestern states in the United States. The data analyzed was for one fiscal year from October 1st, 2020, to September 31st, 2021. Demographic and health information was collected for a total of 1352 participants in addition to the functional measures assessed through Section GG as part of the Minimum Data Set (MDS) for Medicare programs (Centers of Medicare and Medicaid Services, 2019a). Data was pulled from 2020 to 2021 to include patients seen under the external circumstances of COVID-19- and one-year postimplementation of the Medicare Patient-Driven Payment Model (PDPM). The current study is considered exempt from review by the University of Indianapolis institutional review board as the medical data set has been deidentified and poses less than minimal risk to participants. This report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline (Elm et al., 2008). 7 Inclusion Criteria Participants were included based on the following inclusion criteria: 1) admission to a skilled nursing facility following a hospital stay, 2) age 65 years and older, 3) received rehabilitation services, 4) primary payer source documented as Medicare Part A or Medicare Advantage, 5) diagnosed with a medically complex (multiple/complex morbidities) or orthopedic conditions (hip or other), 6) discharged to the community, and 7) had complete admission and discharge records. Demographic information collected included sex and age. Since not all Medicare Beneficiaries are over the age of 65, those under the age of 65 were excluded to reduce the risk of bias due to age stratification. Any erroneous data from the data set, such as data outside reporting parameters, were also excluded. Clean and Excluded Data Data extracted from the medical data set from 93 SNFs was organized by the researchers based on if the participant had completed both the mobility and self-care sections, just the mobility section, or just the self-care section of the Section GG tool. Therapy Measures and Functional Outcomes The primary outcomes assessed were the Section GG scores included in the Minimum Data Set (MDS), the length of treatment, and the amount of therapy (i.e., Occupational and Physical) provided during the SNF stay. Occupational therapists scored participants on self-care items while the physical therapists scored the mobility items. Within three days of admission and by the last three days prior to discharge, the scores were recorded and identified as pre-and postrehabilitative scores. The scores represent a continuum of dependence with self-care and mobility tasks where a score of one is the max dependency needed to complete the task and a score of six for complete independence. Additional scores include a 07 (refusal), 09 (not 8 applicable), 10 (not attempted due to environmental limitation), and 88 (not attempted due to medical condition/safety), which were not included in the analysis. Statistical Analysis Data analyses of the medical data set were conducted using SPSS Statistics 27.0 (SPSS Statistics, 2020). Descriptive statistics were analyzed for all variables (Table 1). The length of treatment variable was positively skewed to the right, so a log-10 transformation was completed. Linear regressions for PTLOT and OTLOT based on (a) RI and insurance, and (b) RI and dxcat. Linear regressions were also run for the average change in SC and average change in MO based on (a) dxcat & LOT, (b) dxcat & time; (c) dxcat, insurance, and RI, (d) dxcat, insurance, beginning SC/MO, and LOT; and (e) dxcat, insurance, beginning SC/MO, and time. Two-tailed T-tests were conducted to evaluate the means of individual items in the Section GG MO and SC sections to determine if there were relationships between the variables. Results The data consisted of participants classified by outcome groups: participants with MO and SC data (n=824), participants with just SC data (n=322), and participants with just MO data (n=383). The researchers excluded participants based on their age (below 65 or above 120), any erroneous information (scores higher than 6), and unidentified or missing insurance information. A total of (n=177) participants were excluded (68 participants after no insurance, 33 participants after erroneous data, and 76 participants after age), leaving 1352 participants remaining. Insurance Out of the 1352 participants, 63.6% of the participants had Medicare while 36.4% of the participants had Medicare Advantage. Of the Medicare participants, 64% had a diagnosis of medically complex, 16% had ortho-hip, and 20% had ortho-other. Of the Medicare Advantage 9 participants, 61% had a diagnosis of medically complex, 18% had ortho-hip, and 21% had orthoother. Results found that people with MCA tend to have longer stays and had higher improvements in self-care and mobility scores than people with MGA (see Figures 1 and 2). The type of insurance the participant had was significant to the LOT, which then led to a significance in the time. Participants with MCA had a longer LOT and had an increase in time compared to participants with MGA. Diagnostic Categories We compared the links between (PT/OT)Time, insurance, diagnostic category, and (PT/OT)LOT. Results showed that the relationship between insurance and PT LOT is strongest for patients with medically complex diagnoses. On the opposite end, the relationship between insurance and PTLOT is weakest when looking at patients with the diagnosis of ortho-other. The same results were found when comparing the relationship between insurance and (PT/OT)Time. When analyzing the relationship between insurance type and (PT/OT)LOT, the relationship was strongest for patients with medically complex diagnoses and similar for both ortho diagnosis categories. Rehab Intensity Due to (PT/OT)LOT and (PT/OT)Time having the same relationship within diagnoses and with insurance, we looked at the relationship between LOT, time, and RI. In this test, we saw that (PT/OT)Time and (PT/OT)LOT are strongly correlated. Patients with MCA had an average of 42 mins/session, while patients with MGA had an average of 44 mins/session. Results indicate that RI decreases with an increase in LOT for both PT/OT and that MGA patients had much less variability and shorter stays. Patients with MCA had an average LOT of 27 days, while patients with MGA had an average LOT of 16 days. 10 Predicting LOT Regressions were run to predict how long a person will be allowed to remain in therapy (PT or OT LOT) as a function of their insurance and RI. For both PT and OT, results showed that patients were significantly likely to have less rehab intensity the longer they are in rehab and that they were significantly likely to have more time in rehab if they have MCA rather than MGA insurance. To predict how long a person will be allowed to remain in therapy (PT or OT LOT) as a function of their diagnosis and rehab intensity, results showed that patients were significantly likely to have less rehab intensity the longer they are in rehab. They were significantly likely to have more time in rehab if they have a diagnosis of Ortho-Hip rather than Medically complex, and Ortho-Other had a marginally significant likelihood of more time in rehab than did Medically complex. Predicting Functional Outcomes Since the RI is too small for meaningful linear regression analysis, 2-tailed T-tests were conducted to evaluate the means of various individual items in the Section GG MO and SC sections to determine if there is a relationship between the variables. Table 2 demonstrates a broad correlation between Section GG MO items, change in status and the treatment provided. For Table 3, overall, we found that 2-tailed T-tests demonstrated correlations (p=.01) between Section GG MO and SC items based on the treatment provided as measured by length of stay in rehabilitation (LOT) and the time (minutes provided) and number of therapy sessions provided. However, one item in MO (Sit < >Ly) and two items in SC (Eat and TH) correlated with RI at a higher level (p=0.05), refer to Tables 2 and 3. 11 Discussion This study evaluated correlations between rehab intensity, patient self-care, and mobility outcomes as measured using Section GGs functional performance tool. While the researchers predicted there would be a significant relationship between RI and LOT using the calculation RI=Time (min)/LOT(min), this yielded a numerical value too small to derive significant correlations above the p=.01 level. Previous studies using this RI calculation found significant correlations (Jette et al., 2004, 2005; OBrien & Zhang, 2018; Prusynski et al., 2021). However, these were performed under the RUG system, where the present study is amongst the first to measure RI under the PDPM payment model (Kroll & Fisher, 2019). Under the RUG system, SNFs were incentivized to provide higher amounts of therapy for the greatest financial return from reimbursement (Prusynski et al., 2021). When CMS enforced the new PDPM payment model, these incentives were reduced, creating an overall reduction in the amount of rehabilitation provided to beneficiaries (Chen et al., 2021). For example, researchers in Cogan et al. (2021) found that patients grouped in high and medium levels of therapy received 130 minutes or more per day. Whereas, this study found average therapy minutes per treatment at 82.5 minutes, for both MCA and MGA. Evaluating the effect of reduced therapy minutes on patient outcomes is important to ensure that an overcorrection in costeffective healthcare practices does not exist. While this study aimed to find evidentiary support for the effect RI has on patient outcomes under the PDPM payment model, researchers determined that a different calculation is necessary to determine RI correlations. However, the researchers found that LOT and Time may be better predictors of improvement, with findings that show a significant relationship between 12 LOT, the type of insurance covering Medicare beneficiaries SNF stay, medical conditions of Medicare beneficiaries, and their functional outcomes. In this study, patients who experienced the most improvement from admission to discharge had a medically complex diagnosis; this positive relationship applies to both OT and PT LOT. Ortho-hip and ortho-other diagnoses also showed functional increases, however the correlation between these outcomes and LOT were weaker in comparison to medically complex patients. These results provide a unique insight to the type of Medicare beneficiary that benefits most from longer lengths of stay. Past studies have evaluated the relationships between the amount of therapy received and functional improvements through readmission rates and functional outcomes, reporting results that are different than those discovered in the present study (Jette et al., 2005; Chen et al., 2012). First, Jette et al. (2005) researchers found that rehabilitation intensity at higher dosages contributed increased functional independence and minimized need for longer length of stay. It is important to recognize that the changes in policy from a fee-for-service to a PDPM model affects the therapy dosage that Medicare beneficiaries receive. Reimbursement changes affect providers and how they choose to manage therapy services and may lead to changes in the length of stay; in this case, the length of stay beneficiaries receive becomes increasingly vital to support improved functional outcomes. Researchers in Chen et al. (2021) using a Skilled Nursing Facility Utilization and Payment Public Use File which provided information on Medicare beneficiaries stays in the year 2016 under the FFS payment model found a positive relationship between higher amounts of rehabilitation administered and rates of readmission. Chen et al. (2021) found that some SNFs provided more therapy related; however, this resulted in individuals who received more therapy 13 and a longer LOS yet yielded higher rates of readmission and associated costs of care. These findings suggest two important concepts. One, under the previous payment model, therapists may have been able to supply excess amounts of therapy without regard to patient outcomes. Second, in conjunction with the present study findings, the differences of severity in patient conditions impacts how much time with therapy is necessary to maximize patient outcomes, and should be considered in regards to healthcare policy to support patients who would benefit from more therapy. In light of recent trends which show an exponential number of traditional Medicare (MCA) beneficiaries are opting for Medicare Advantage (MGA) plans, it is important to evaluate how these changes in coverage affect treatment outcomes (Damico et al., 2022). This study identified significant relationships between traditional Medicare (MCA) and Medicare Advantage (MGA) plans and length of a Medicare part A stay in a SNF (LOT), which were also evaluated in terms of patients' diagnostic category (Ortho-hip, Ortho-other, and Medically Complex). The LOT was found to have a significant relationship with insurance, where beneficiaries with traditional Medicare plans were found to have longer stays compared to those with Medicare Advantage. Before healthcare reform, reimbursement incentivized PAC companies under the FFS reimbursement model to maximize rehab minutes and beneficiary length of stay regardless of frailty, medical necessity, or insurance type (Angelelli et al., 2000). Under the new PDPM, researchers in this study found that regardless of insurance type, the average therapy minutes were similar between disciplines but was significantly less than the time provided under the FFS model (82.5 minutes v. 130 minutes). In contrast, there was more variability in length of stay coverage regardless of diagnosis category where MGA patients had shorter stays in an SNF due 14 to the cuts in rehab reimbursement compared to MCA beneficiaries. Specifically, patients with MCA had on average longer stays (27 days v. 16 days), which were positively correlated with better functional outcomes. This suggests that some insurance types support appropriate amounts of medically necessary services, which are correlated with longer stays, and thus show better functional outcomes. However, if beneficiaries with a higher frailty status are prematurely discharged due to lack of insurance coverage, the length of treatment may not be enough to address their functional deficits, resulting in lower functional outcomes . Transitioning to the PDPM greatly influenced the amount of therapy patients are able to receive and how long they are able to receive therapy services. While it is important to minimize excessive therapy dosage, policymakers should be aware of the effect that changes in policy have on the functional outcomes of beneficiaries. This study provides insight to how functional outcomes as measured by Section GG are impacted by payment model shifts. Length of treatment was found to be positively significant when correlated with functional outcomes, which demonstrates the importance of finding a balance between safeguarding therapy resources that maximize beneficiaries functional outcomes while encouraging facilities to make treatment decisions that are cost-effective. Future Research Future researchers should consider how the different insurance plans and LOT have the potential to affect the amount of readmissions to acute and post-acute care facilities following discharge from a post-acute care setting. Other researchers could also investigate the functional outcomes of patients once discharged to the community and if their length of stay provided by insurances in a PAC impacted the success patients had in the community, including readmission rates to hospitals (within 30 days of hospital and SNF stay). Due to limited time and resources, 15 our study did not delve into the possible impact COVID-19 had on functional outcomes, admission to post-acute care settings, and length of stay. Future research can focus on the effect COVID-19 had in post-acute care settings. In addition, further research should be conducted with a national dataset to add clarity to the relationship of the functional outcome measures to the amount of therapy provided with more diagnostic groups and diversified demographic populations. Study Limitations There are several study limitations that should be acknowledged. In this study, we focused the analysis only on Medicare beneficiaries aged 65 years and older. Due to this, findings can not be generalized to patients younger than the age of 65 years who receive therapy services in post-acute care. It is also unknown if the therapy sessions were group or individual sessions or what type of treatment interventions the patients received that could be associated with better mobility or self-care patient outcomes. Additionally, our data only included the diagnostic categories of medically complex, ortho-hip, and ortho-other. There may have been other conditions the patients had that could have influenced therapy minutes or length of treatment. Conclusions Implementation from a volume to value-based payment model for health care services has not considered the relationship between the amount of therapy provided to patients needed for functional outcomes. The findings of this study suggest that Medicare beneficiaries show better functional outcomes as measured by standardized Section GG measurements in PAC when their insurance coverage allows for longer stays. Insurance that allows for variability in length of stay is more supportive of improvement in functional outcomes compared to insurance options 16 that limit occupational and physical therapy minutes in an SNF. If patients are discharged too early, they may not receive the volume of rehabilitation services needed to maximize functional performance outcomes, which could lead to hospital readmissions. The implications of these findings on payment model changes suggest potential hindrance of functional outcomes, posing a risk to insurance companies and PAC facilities in the form of costly rates of readmission. Data Availability Statement Data is available from the corresponding author. Funding This work was supported by the University of Indianapolis InQuery Collaborative Grant [Funding Agency] under Grant #995038. Disclosure The authors report that there are no competing interests to declare. 17 References Affordable Care Act, 42 U.S.C. 157 et seq. (2010) Angelelli, J. J., Wilber, K. H., & Myrtle, R. (2000). A Comparison of Skilled Nursing Facility Rehabilitation Treatment and Outcomes Under Medicare Managed Care and Medicare Fee-for-Service Reimbursement. The Gerontologist, 40(6), 646653. https://doi.org/10.1093/geront/40.6.646 Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs, 27(3), 759769. ProQuest Public Health. Centers of Medicare and Medicaid Services. (2019a). Five-Star Quality Rating System | CMS. https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/fsqrs Centers of Medicare and Medicaid Services. (2019b). Fact Sheet: MDS Changes. Chen, A., Unruh, M. A., Hye-Young Jung, & Jung, H.-Y. (2021). Do Skilled Nursing Facilities That Provide More Rehabilitation Therapy Have Lower Rehospitalization Rates? American Journal of Medical Quality, 36(5), 304310. CINAHL Plus with Full Text. https://doi.org/10.1097/01.JMQ.0000735444.48095.74 Cogan, A. M., Weaver, J. A., McHarg, M., Leland, N. E., Davidson, L., & Mallinson, T. (2020). Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery. JAMA Network Open, 3(1), e1919672. https://doi.org/10.1001/jamanetworkopen.2019.19672 Cubanski, J., Neuman, T., & Freed, M. (2019, August 20). The Facts on Medicare Spending and Financing. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/thefacts-on-medicare-spending-and-financing/ 18 Damico, A., Freed, M., Fuglesten Biniek, J., & Neuman, T. (2022, August 25). Medicare Advantage in 2022: Enrollment Update and Key Trends. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-enrollmentupdate-and-key-trends/ Deutsch, A., Palmer, L., McMullen, T., Le, T., Toth, M., Marino, M., Vaughan, M., Schwartz, C., & Edwards, A. (2022). A Postacute Care Function Process Quality Measure for the Collection of Standardized Self-Care and Mobility Data: Development, Implementation, and Quality Measure Scores. Archives of Physical Medicine & Rehabilitation, 103(6), 10611069. CINAHL Plus with Full Text. https://doi.org/10.1016/j.apmr.2022.01.148 Elm, E. von, Altman, D. G., Egger, M., Pocock, S. J., Gtzsche, P. C., & Vandenbroucke, J. P. (2008). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Journal of Clinical Epidemiology, 61(4), 344349. https://doi.org/10.1016/j.jclinepi.2007.11.008 Gage, B., Smith, L., Ross, J., Coots, L., Kline, T., Shamsuddin, K., Reilly, K., Abbate, J. H., Gage-Croll, Z., Deutsch, A., & Mallinson, T. (2012). The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on Reliability Testing, Volume 2 of 3. 189. Improving Post-Acute Care Transformation Act, 24 U.S.C. 1395 et seq. (2014) Jacobson, G. (2015). The Emerging Role of Private Plans in Medicare. Journal of the American Society on Aging, 39(2), 7884. Jette, D. U., Warren, R. L., & Wirtalla, C. (2004). Rehabilitation in skilled nursing facilities: Effect of nursing staff level and therapy intensity on outcomes. American Journal of Physical Medicine & Rehabilitation, 83(9), 704712. Jette, D. U., Warren, R. L., & Wirtalla, C. (2005). The relation between therapy intensity and 19 outcomes of rehabilitation in skilled nursing facilities. Archives of Physical Medicine and Rehabilitation, 86(3), 373379. https://doi.org/10.1016/j.apmr.2004.10.018 Kroll, C., & Fisher, T. (2019). The congressional mandate: Standardised post-acute care quality measures. International Journal of Therapy and Rehabilitation, 26(8), 110. https://doi.org/10.12968/ijtr.2019.0028 Medicare. (2022). How do Medicare Advantage Plans work? Medicare.Gov. https://www.medicare.gov/sign-upchange-plans/types-of-medicare-healthplans/medicare-advantage-plans/how-do-medicare-advantage-plans-work OBrien, S. R., & Zhang, N. (2018). Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions | Elsevier Enhanced Reader. Archives Of Physical Medicine And Rehabilitation, 99, 107115. https://doi.org/10.1016/j.apmr.2017.07.012 Prusynski, R. A., Gustavson, A. M., Shrivastav, S. R., & Mroz, T. M. (2021). Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review. Physical Therapy, 101(3), pzaa230. https://doi.org/10.1093/ptj/pzaa230 Sandhu, S., Furniss, J., & Metzler, C. (2018). Using the New Postacute Care Quality Measures to Demonstrate the Value of Occupational Therapy. American Journal of Occupational Therapy, 72(2), 7202090010p1. https://doi.org/10.5014/ajot.2018.722002 SPSS Statistics (27.0). (2020). [Windows]. IBM Corporation. U. S. Census Bureau. (2020, June 25). 65 and older populations grows rapidly as baby boomers age. U. S. Census Bureau. https://www.census.gov/newsroom/press-releases/2020/65older-population-grows.html 20 21 Table 1. Variable List Variable Labels Variable Abbreviations Medicare MCA Medicare Advantage Plans MGA Physical Therapy Length of Treatment PTLOT Occupational Therapy Length of Treatment OTLOT Physical Therapy Time in Minutes PTTime Occupational Therapy Time in Minutes OTTime Rehab Intensity RI Diagnostic Category dxcat Self-care score improvements SC Mobility score improvements MO 22 Figure 1. Scatter Plot of SC Impr., OTLOT, and Insurance Figure 2. Scatter Plot of MO Impr., PTLOT, and Insurance 23 Table 2. 2-Tailed T-Tests for MO Improvement Note: Refer to Table 4 for Mobility Section GG Items Table 3. 2-Tailed T-Tests for SC Improvement 24 Note: Refer to Table 5 for Self-Care Section GG Items 25 Table 4 Mobility Section GG Items Mobility Section GG Abbreviations Mobility Section GG Description 1 step (curb) 1 step Ability to go up and down a curb/step 12 steps 12 step Ability to go up and down 12 steps with/without railing 4 steps 4 step Ability to go up and down 4 steps with/without railing Car transfer Car T/F Ability to transfer in and out of car on passenger side Chair/bed-to-chair transfer Ch < > Bd T/F Ability to transfer to and from a bed to a chair Lying to sitting on side of bed Ly > EOB Ability to move from lying on back to sitting edge of bed with feet on floor and no back support Picking up object PU Obj. Ability to bend from standing to pick up small object off floor Roll left and right Roll L< >R Ability to roll from lying on back to left and right and return to back Sit to lying Sit < >Ly Ability to move from sitting edge of bed to lying flat on bed Sit to stand Sit < >Std Ability to stand from sitting in bed/chair Toilet Transfer TO T/F Ability to get on/off toilet/commode Walk 10 feet Amb 10 Ability to walk 10 feet in a room Walk 150 feet Amb 150 Ability to walk 150 feet in a room Walk 150 feet with two turns Amb 150 +2 Ability to walk 150 feet with two turns Walk 10 feet on uneven surfaces Amb 10 US Ability to walk 10 feet on uneven or sloping surfaces 26 Wheel 150 feet W/C 150 Ability to wheel 150 feet in a room Wheel 50 feet with two turns W/C 50 +2 Ability to wheel 50 feet with two turns Table 5 Self-Care Section GG Items Self-Care Section GG Abbreviations Self-Care Section GG Description Eating Eat Ability to use suitable utensils, bring food to mouth, and swallow food presented Lower Body Dressing LBD Ability to dress/undress below the waist including fasteners Oral Hygiene OH Ability to use suitable items to clean teeth/dentures Putting on/taking off footwear Footwear Ability to take on/off appropriate footwear, socks, or shoes Shower/bathe self Bathe Ability to bathe self in shower/tub including washing, rinsing, and drying Toileting hygiene TH Maintain hygiene and manage clothes before/after using toilet/commode Upper body dressing UBD Ability to dress/undress above the waist including fasteners  ...

... ACCEPTANCE TOWARDS THERAPY SERVICES Improving Independent Living Residents Acceptance Towards Skilled Therapy Services Tyler Kramer-Stephens May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Lori Breeden, EdD, OTR 1 ACCEPTANCE TOWARDS THERAPY SERVICES Abstract The purpose of this doctoral capstone project was to understand why independent living (IL) residents presented with decreased acceptance of skilled therapy services and to implement mechanisms to improve their adherence towards a skilled therapy program at Compass Park. Independent living residents demonstrated a decreased acceptance towards skilled therapy services secondary to a lack of understanding on what skilled therapy involves, which increased their risk of debility and hospitalizations. The program consisted of educational seminars and therapeutic wellness activities in order to increase the IL residents understanding of what a skilled therapy program involves. The IL residents presented with an increase in their readiness to initiate a skilled therapy program for prevention and improvement in their self-perceived global mental health. The program was sustained at Compass Park through the social services team administering educational videos about skilled therapy services for IL residents to view before beginning a skilled therapy program. 2 ACCEPTANCE TOWARDS THERAPY SERVICES 3 Nettie Ransford, late Indiana Secretary for the Order of the Eastern Star, had the idea for Compass Park in the late 19th century, which was to establish a community for the children and widows of Freemasons who have passed away. With the support of the masonic organization, Compass Park became a well-known masonic orphanage and womens shelter in 1903 (Compass Park, 2020). As time progressed, the stakeholders of the organization altered their mission in order to serve the general older adult population. This shift allowed individuals who are not associated with the Masons to purchase dwellings at Compass Park. Compass Park is a large campus that includes independent living apartments and villas, assisted living facility, memory care units, and a rapid recovery skilled nursing facility. The stakeholders of Compass Park contract therapists from Healthcare Therapy Services, Inc. to treat individuals in their skilled nursing facility and provide outpatient therapy to residents living in the assisted and independent living facilities. Independent living residents presented with a decreased acceptance towards participating in a skilled therapy program secondary to a lack of understanding, decreased self-efficacy, and fear of inability to age in place. The skilled therapy and social services team reported that IL residents experience falls and hospitalizations secondary to a lack of acceptance and adherence towards a skilled therapy program for prevention. I focused on delivering educational seminars, followed by common therapeutic activities, in order to assess alterations in IL residents readiness to change and patientreported wellness. In order to ensure sustainability of the program (DeIuliis & Bednarski, 2020), I created educational videos on the topics covered in the seminars for the social services and skilled therapy team to provide to IL residents during their transitions in care. ACCEPTANCE TOWARDS THERAPY SERVICES 4 Background The population I served were individuals who are 55-years-old and greater who reside in the independent living facility at Compass Park, Indiana Masonic Home. Independent living residents may reside in dwellings that are apartments, which are interconnected with the main building, or they may reside in their own single-level villas. Due to the fact that IL residents are able to function and complete pertinent occupations independently, they may not currently require skilled therapy services. Known challenges have been identified by Compass Park stakeholders in regard to IL residents during my needs assessment of the organization. First, the most recent challenge was that IL residents presented with decreased physical health due to a lack of wellness activities being implemented at Compass Park since the beginning of the COVID-19 pandemic for infection control. A second challenge that Compass Park stakeholders reported was that IL residents are likely to refuse therapeutic services and choose to prematurely discontinue services. Katie Grissom, Director of Operations for Healthcare Therapy Services, reported that residents are initially hesitant to participate in a skilled therapy program secondary to decreased selfefficacy, fear that they will have to move from their dwellings, and a decreased understanding of what a skilled therapy program involves or the benefits of engaging in a skilled therapy program (Kramer-Stephens & Grissom, 2022). After discussion with an IL social services team member, it was apparent that a lack of education before and during the transition period of care is a primary reason why IL residents refuse to initiate a rehab program. After interviewing the IL residents, it became apparent that many are relatively unaware of what a skilled therapy program involves, the importance of ACCEPTANCE TOWARDS THERAPY SERVICES 5 engaging in one, or how engaging in a skilled therapy program can improve their ability to age in place for a longer period of time. My on-site mentor and additional members from the skilled therapy team agree that administering educational seminars and educating the IL activity director on wellness activities will certainly be beneficial for the IL residents. The IL social services team reported that it would be beneficial to have access to the educational videos in order for them to distribute them to IL residents who may be apprehensive of a skilled therapy program in the future. Educating to IL residents that participation in a skilled therapy program, which provides preventative (Elliot & Leland, 2018) and health promotion (Berger et al., 2018) interventions will increase their ability to age in place may improve their acceptance of a skilled therapy program. Furthermore, providing education to residents on the importance of participation in a skilled therapy program is an effective method to improve adherence towards the program (McLean et al., 2010). The researchers results inform the program in that providing structured and purposeful educational seminars will improve acceptance and adherence towards skilled therapy programs provided by Compass Park. I will also be educating participants on what will likely be involved in their therapeutic program so they will know what to expect prior to initiation. Meade et al. (2019) found that social, personal, and environmental supports were important in improving adherence towards a skilled therapy program. Educating participants on support systems offered through a skilled therapy program at Compass Park may improve their readiness to accept an advised skilled therapy program. Li et al. (2014) found that poor transitions in care negatively affected patient perceptions regarding the next step in their care, such as a skilled therapy program. A lack of education and support systems before and during ACCEPTANCE TOWARDS THERAPY SERVICES transition periods of care worsened patients medical and functional outcomes (Li et al., 2014). Advocating for IL residents to involve their support systems during a transition period may increase the likelihood that IL residents initiate engagement in a prescribed skilled therapy program. Providing educational videos to the IL social services team to administer to IL residents before their transition of care may improve their acceptance towards accepting skilled therapy services. Shared decision-making positively impacted health outcomes of individuals in the clinical setting (Lgar et al., 2018). Educating to IL residents on their role of goal-setting, activity tolerance, and the Just-Right-Challenge in a skilled therapy program may increase their acceptance of skilled therapy services, while improving their therapeutic outcomes (Moore & Kaplan, 2018). Skilled therapy practitioners have consistently utilized shared decision-making in practice, whether consciously or not (Duncan, 2022). The IL residents understanding of this core therapeutic practice may increase their acceptance of a skilled therapy program as residents will have an increased sense of locus of control (Marton et al., 2020). This program is different from those in the literature because it applies to the specific population of older adults residing in an IL facility, and addresses a previously determined gap in communication regarding services. Much of the literature addressed improving adherence with a skilled therapy program in acute care or outpatient settings, but there is a lack of literature that addresses acceptance towards participation in a prevention-based therapy program among residents in an independent living facility. Through analysis of my needs assessment and the literature, designing this educational program will be important to 6 ACCEPTANCE TOWARDS THERAPY SERVICES 7 encourage the IL residents to participate in a skilled therapy program when applicable to sustain their ability to age in place. Theoretical Framework I utilized the Readiness to Change model to guide the programs design, implementation, and evaluation. The Readiness to Change model was originally utilized to improve patient adherence with prescribed medications, but has been adapted to improve adherence with healthy lifestyle changes (Stonerock & Blumenthal, 2017). The Readiness to Change model was an applicable model to guide the program because it directly assesses behaviors for adherence. The model indicates that there are five stages of behavioral change for adherence; they are precontemplation, contemplation, preparation, action, and maintenance. I have adapted the Readiness to Change assessment tool to fit the needs of the program. The IL residents presented in the pre-contemplation phase, which indicated that education on the risks versus benefits of participation in a skilled therapy program is best practice for improving behavioral change (American Society on Aging, 2006). The cognitive behavioral frame of reference guided the program because the approach is used to alter individuals dysfunctional perceptions (Cole & Tufano, 2008), in which I implement strategies to increase the IL residents acceptance towards engagement in a skilled therapy program. The goal of the program was to increase acceptance of skilled therapy services so residents may have improved occupational performance and ability to age in place. The Readiness to Change model when combined with the cognitive behavioral approach were beneficial to guide the program. ACCEPTANCE TOWARDS THERAPY SERVICES 8 Program Development & Implementation I developed the program to improve acceptance and adherence towards the skilled therapy services offered at Compass Park amongst the IL residents. The literature indicated that educating individuals on the importance of purposeful engagement in skilled therapy services improved their adherence towards a skilled therapy program (McLean et al., 2010), while also improving their outcomes in regard to occupational performance in older adult populations (De Coninck et al., 2017; Nielsen, 2022; Turcotte et al., 2018). The IL residents presented in the precontemplation phase of behavioral change from the Readiness to Change model, which means that education on skilled therapy is indicated to increase acceptance (American Society on Aging, 2006). I implemented six educational seminars focusing on an introduction to therapy and its benefits, as well as common therapy interventions one might expect. The educational seminars were paired with hands-on wellness activities so the IL residents may integrate common therapy interventions into their lives. These interventions included fall prevention, seated exercise and tissue lengthening program, mindfulness, energy conservation, and pain management. I utilized two outcome measures to assess the progress of the participants and impact of the educational seminars and wellness activities. The first outcome measure was a survey based on the Readiness to Change model to determine which phase of behavioral change the participants presented in prior to the implementation of the program (Katz et al., 2019). As my project was intended to improve acceptance towards a skilled therapy program, understanding how initially willing the participants were to participate was important in how I design and implement the program. The second outcome measure I utilized was the Patient Reported Outcomes Information System (PROMIS) tool (Gruber-Baldini et al., 2017). This outcome ACCEPTANCE TOWARDS THERAPY SERVICES 9 measure was important for the program because I was able to assess the participants selfperceptions on their current global health status (Gruber-Baldini et al., 2017), which indicated whether the participants would be willing to participate in a skilled therapy program to improve their self-perceived deficits. The PROMIS tool also allowed participants to organize their thoughts prior to reporting their concerns to the IL social services team when indicating their request for skilled therapy services. A pertinent challenge during the implementation of the program was participant drop-out secondary to uninterest. When I encountered this challenge, I utilized cognitive behavioral approaches to challenge the participants absolutist thought patterns (Cole & Tufano, 2020). For instance, a common reason that participants did not wish to participate was due to believing they will never need therapy. I successfully altered the perceptions of three individuals by challenging these absolute statements. The second challenge was decreased patient participation in the program secondary to residents forgetting that the program events were being held at a particular day and time. To address this challenge, I implemented further marketing towards the program by advertising on hallway monitors and calling participants the morning of the program events in order to provide a reminder. Program Outcomes I analyzed the data from the PROMIS tool and Readiness to Change survey before and after the implementation of the program. I analyzed the change in responses for the PROMIS tool in order to understand the effect that the program had on IL residents self-perceptions for global health. I also analyzed the change in responses for the Readiness to Change survey to understand the effect that the program had on improving the IL residents understanding of a therapy program. The Readiness to Change survey also allowed for me to assess the change in ACCEPTANCE TOWARDS THERAPY SERVICES 10 the residents acceptance of skilled therapy services offered at Compass Park. The difference in responses for the PROMIS tool and Readiness to Change survey and were captured as independent means. A two-tailed paired sample t-test was completed in Microsoft Excel to determine the significance of change in the participants responses for my Readiness to Change survey and the PROMIS tool (Gupta et al., 2019). The educational seminars, in conjunction with wellness activities, were indicated to be statistically significant in improving the participants acceptance towards a skilled therapy program and their perceptions of their own global health. One can infer from Table 1 in Appendix A that the participants reported they had an improved understanding of what a skilled therapy program involves and increased willingness to participate in a skilled therapy program. Table 1 also indicates that the participants reported a decreased sense of worry that they will have to move from their dwellings after participation in a skilled therapy program and belief that a skilled therapy program is too intensive. Based on the responses from the post-survey based on Readiness to Change, the participants have progressed to the contemplation or preparation phase (Katz et al., 2019). The responses from interviews and the pre-survey indicated that residents were in the pre-contemplation stage (Katz et al., 2019). One can infer from Table 2 in Appendix B that the participants have improved self-perceptions of their global mental health. The IL residents reported that they have previously experienced debility and deficits in their occupational engagement secondary to a variety of reasons. After the IL residents learned and obtained first-hand experience about what a skilled therapy program involves, the IL residents who have voiced these concerns reported that they will be contacting the IL social services team in order to hopefully receive a skilled therapy consultation. ACCEPTANCE TOWARDS THERAPY SERVICES 11 Summary & Conclusion In summation, IL residents initially exhibited decreased acceptance towards initiating a skilled therapy program and that residents who have initiated a skilled therapy program demonstrate poor adherence. The rapid recovery unit and long-term care facility have had an influx of admissions from residents who were residing in the IL facility secondary to decreased initiation of preventative measures. The program was designed and implemented to provide IL residents with educational seminars and wellness activities in order to improve their understanding of what skilled therapy has to offer and how it improves aging in place via prevention-based therapy. Based on the results from the needs assessment, IL residents exhibited decreased acceptance towards skilled therapy services secondary to the following: poor self-efficacy, fear of inability to age in place, and a misunderstanding of what skilled therapy is (Compass Park, 2020). Aligned with face-to-face in-service events for the IL residents, I have also created condensed educational videos for sustainability of the program. The social services team have adopted the use of these educational videos and will present the educational videos to IL residents before or during their transition in care for the IL residents to have an improved understanding of skilled therapy services. Many of the residents reported increased positivity during their day when they were able to gather for the weekly educational seminars and wellness activities. My findings indicated an improvement in the participants self-perceived global mental health as presented by the results gathered from the PROMIS tool. Post measurement data from the Readiness to Change survey indicated that IL residents improved in their understanding of what a skilled therapy program involves and acceptance of initiating a skilled therapy program. IL residents had a paradigm shift ACCEPTANCE TOWARDS THERAPY SERVICES 12 from believing skilled therapy services are not warranted to contemplating or preparing to seek assistance from the social services team to begin an individualized skilled therapy journey. In conclusion, through data analysis and conversation with the residents and team members at Compass Park, I have accomplished much with the implementation of the program. The data indicated that the IL residents have shifted their perspective of skilled therapy and are more apt towards beginning a skilled therapy program. Independent Living residents have reported increased acceptance towards initiating a skilled therapy program; some participants have even reached out to IL social services in order to receive a physician consultation for skilled therapy orders. I assured sustainability of the program by creating a webpage titled, What is Therapy at Compass Park?. During the dissemination of my findings and implications of the program to the social services and nursing team members for the IL facility, I have provided methods to continue with use of the webpage. The social services team members will direct new residents to the webpage in order to learn about what skilled therapy services Compass Park has to offer. Additionally, the social services team may have the current residents review this webpage in order to improve their understanding of what to expect before beginning their skilled therapy journey. My findings were beneficial for the profession of occupational therapy because they indicate that providing in-service events for IL residents have improve their readiness to change and adhere to a skilled therapy program. The IL residents shift in their readiness to change, from pre-contemplation to contemplation or preparation, indicated an improvement in the residents desire to initiate and adhere to a skilled therapy program. ACCEPTANCE TOWARDS THERAPY SERVICES 13 References American Society on Aging and American Society of Consultant Pharmacists Foundation. (2006). Facilitating behavior change - adult meducation. Retrieved April 21, 2023, from http://adultmeducation.com/downloads/Adult_Med_Facilitating.pdf Berger, S., Escher, A., Mengle, E., & Sullivan, N. (2018). Effectiveness of health promotion, management, and maintenance interventions within the scope of occupational therapy for community-dwelling older adults: A systematic review. The American Journal of Occupational Therapy, 72(4). https://doi.org/10.5014/ajot.2018.030346 Cole, M. B., & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. SLACK Incorporated. Compass Park. (2020, June 19). Retrieved March 11, 2022, from http://www.compasspark.org/ De Coninck, L., Bekkering, G. E., Bouckaert, L., Declercq, A., Graff, M. J., & Aertgeerts, B. (2017). Home- and community-based occupational therapy improves functioning in frail older people: A systematic review. Journal of the American Geriatrics Society, 65(8), 18631869. https://doi.org/10.1111/jgs.14889 DeIuliis, E. D., & Bednarski, J. A. (2020). The entry level Occupational Therapy Doctorate Capstone: A Framework for the experience and project. SLACK Incorporated. Duncan, E. (2022). Shared Decision-Making Skills in Practice. In Skills for practice in occupational therapy. Elsevier. ACCEPTANCE TOWARDS THERAPY SERVICES 14 Elliott, S., & Leland, N. E. (2018). Occupational therapy fall prevention interventions for community-dwelling older adults: A systematic review. The American Journal of Occupational Therapy, 72(4). https://doi.org/10.5014/ajot.2018.030494 Gruber-Baldini, A. L., Velozo, C., Romero, S., & Shulman, L. M. (2017). Validation of the Promis measures of self-efficacy for managing chronic conditions. Quality of Life Research, 26(7), 19151924. https://doi.org/10.1007/s11136-017-1527-3 Gupta, A., Mishra, P., Pandey, C. M., Singh, U., Sahu, C., & Keshri, A. (2019). Descriptive statistics and normality tests for statistical data. Annals of Cardiac Anaesthesia, 22(1), 67. https://doi.org/10.4103/aca.aca_157_18 Katz, L., Patterson, L., & Zacharias, R. (2019). Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change. Canadian Journal of Pain, 3(1), 7078. https://doi.org/10.1080/24740527.2019.1582296 Kramer-Stephens, T., & Grissom, K. (2022, March 2). Needs Assessment. personal. Lgar, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuchko, J., Graham, I. D., Lyddiatt, A., Politi, M. C., Thomson, R., Elwyn, G., & Donner-Banzhoff, N. (2018). Interventions for increasing the use of shared decision making by Healthcare Professionals. Cochrane Database of Systematic Reviews, 2018(7). https://doi.org/10.1002/14651858.cd006732.pub4 ACCEPTANCE TOWARDS THERAPY SERVICES 15 Li, J., Young, R., & Williams, M. V. (2014). Optimizing transitions of care to reduce rehospitalizations. Cleveland Clinic Journal of Medicine, 81(5), 312320. https://doi.org/10.3949/ccjm.81a.13106 Marton, G., Pizzoli, S. F., Vergani, L., Mazzocco, K., Monzani, D., Bailo, L., Pancani, L., & Pravettoni, G. (2020). Patients health locus of control and preferences about the role that they want to play in the medical decision-making process. Psychology, Health & Medicine, 26(2), 260266. https://doi.org/10.1080/13548506.2020.1748211 McLean, S. M., Burton, M., Bradley, L., & Littlewood, C. (2010). Interventions for enhancing adherence with physiotherapy: A systematic review. Manual Therapy, 15(6), 514521. https://doi.org/10.1016/j.math.2010.05.012 Meade, L. B., Bearne, L. M., & Godfrey, E. L. (2019). Its important to buy in to the new lifestyle: barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain. Disability and Rehabilitation, 43(4), 468478. https://doi.org/10.1080/09638288.2019.1629700 Moore, C. L., & Kaplan, S. L. (2018). A framework and resources for shared decision making: Opportunities for improved physical therapy outcomes. Physical Therapy, 98(12), 1022 1036. https://doi.org/10.1093/ptj/pzy095 Nielsen, T. L., Holst-Stensborg, H. W., & Nielsen, L. M. (2022). Strengthening problem-solving skills through occupational therapy to improve older adults occupational performance - A systematic review. Scandinavian Journal of Occupational Therapy, 30(1), 113. https://doi.org/10.1080/11038128.2022.2112281 ACCEPTANCE TOWARDS THERAPY SERVICES Stonerock, G. L., & Blumenthal, J. A. (2017). Role of counseling to promote adherence in Healthy Lifestyle Medicine: Strategies to improve exercise adherence and enhance physical activity. Progress in Cardiovascular Diseases, 59(5), 455462. https://doi.org/10.1016/j.pcad.2016.09.003 Turcotte, P.-L., Carrier, A., Roy, V., & Levasseur, M. (2018). Occupational therapists' contributions to fostering older adults' social participation: A scoping review. British Journal of Occupational Therapy, 81(8), 427449. https://doi.org/10.1177/0308022617752067 16 ACCEPTANCE TOWARDS THERAPY SERVICES 17 Appendix A Table 1 Analysis of Participants Readiness to Change for a Therapy Program Statement Provided I understand what a therapy program involves. I am willing to participate in a therapy program, if needed. I am worried that I will have to permanently move from my home if I participate in a therapy program. Presurvey Mean Post-survey Mean Pre-survey Standard Deviation Post-survey Standard Deviation p 2.25 1.625 0.707106781 0.51754917 0.049173714 2.25 1.625 0.707106781 0.51754917 0.011201433 3.625 4.5 0.916125381 0.534522484 0.02093757 I believe a therapy program is too 3.625 4.625 0.51754917 0.51754917 intensive for me. Note. The table indicates the participants agreement with each statement provided. 0.00724699 Numerical mean values that are closer to one indicate more agreement and numerical mean values that are closer to five indicate less agreement with the statements provided. *Bolded items are statistically significant, p < 0.05 ACCEPTANCE TOWARDS THERAPY SERVICES 18 Appendix B Table 2 Analysis of Participants Self Perceived Global Health Domain of PROMIS tool Pre- Global Physical Health Mean Standard Deviation 13 2 p 0.079602012 Post- Global Physical Health 13.75 2.314550249 Pre- Global Mental Health 14.75 2.764571783 0.049867231 Post- Global 15.75 3.105295017 Mental Health Note. A numerical mean value closer to 20 represents greater self-perceived global mental and physical health. *Bold items are statistically significant, p < 0.05 ACCEPTANCE TOWARDS THERAPY SERVICES 19 Appendix C Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage Weekly Goal Orientation Complete orientation Meet with stakeholders Complete onsite needs assessment Complete timeline for DCE 2 Orientation Screening / Evaluation Update needs assessment Begin predata collection and interviewing of residents for program Complete update literature search Objectives Tasks Meet with site mentor, key stakeholders, IL residents to introduce myself and why I am on site to implement my program Set up meetings with aforementioned individuals Determine outcome measure to utilize and implement for IL residents Write background and introduction draft Determine marketing mechanisms for program Date complete Jan 13 Finalize MoU Complete necessary paperwork for orientation Implement flyers door-todoor for marketing of program Jan 20 ACCEPTANCE TOWARDS THERAPY SERVICES 20 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 3 4 DCE Stage Weekly Goal Screening / Evaluation Finish predata collection and interviewing of residents for program Implementation Implement first education seminar and wellness activity Objectives Finalize goals for DCE Finalize recruitment of participants for program 30 min seminar on intro to therapy 30 min wellness activity of common ther acts Goal of half of participants to attend Tasks Finish background and introduction drafts Date complete Jan 27 Provide reminder pamphlets for my first inservice the following week Complete background draft Review topics to be covered and wellness activities with on-site mentor Complete project design and implementation draft Feb 3 ACCEPTANCE TOWARDS THERAPY SERVICES 21 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 5 DCE Stage Weekly Goal Implementation Implement second education seminar and wellness activity Record self for educational videos for sustainability, focusing on first weeks topic 6 Implementation Implement third education seminar and wellness activity Record self for educational videos for sustainability, focusing on second weeks topic Objectives 30 min seminar on benefits of therapy 30 min wellness activity of seated AROM Tasks Review topics to be covered and wellness activities with on-site mentor Date complete Feb 10 Midterm evaluation Goal of half of participants to attend 30 min seminar on fall prevention 30 min wellness activity of seated tai chi Goal of half of participants to attend Review topics to be covered and wellness activities with on-site mentor Feb 24 ACCEPTANCE TOWARDS THERAPY SERVICES 22 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 7 DCE Stage Weekly Goal Implementation Implement fourth education seminar and wellness activity Record self for educational videos for sustainability, focusing on third weeks topic 8 Implementation Objectives Tasks 30 min seminar on pain management Review topics to be covered and wellness activities with on-site mentor Review topics to be covered and wellness activities with on-site mentor 30 min wellness activity of seated tissue lengthening Date complete Mar 3 Goal of half of participants to attend Implement fifth education seminar and wellness activity 30 min seminar on energy conservation and mindfulness Record self for educational videos for sustainability, focusing on fourth weeks topic 30 min wellness activity of guided breathing and mindfulness Goal of half of participants to attend Review topics to be covered and wellness activities with on-site mentor Project outcomes draft due (post-pone until Mar 24 as I am behind on post-data collection) Mar 10 ACCEPTANCE TOWARDS THERAPY SERVICES 23 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 9 10 DCE Stage Weekly Goal Implementation Implement sixth education seminar and wellness activity 30 min seminar on improving positive outlook on life Record self for educational videos for sustainability, focusing on fifth weeks topic 30 min wellness activity of gratitude journaling Record self for educational videos for sustainability, focusing on sixth weeks topic Begin edits of educational videos, including visual cues, quality of video, and adding subtitles for educational video one through three Implementation Complete edits for educational videos and finalize for upload to webpage Objectives Tasks Review topics to be covered and wellness activities with on-site mentor Date complete Mar 17 Dissemination plan due Goal of half of participants to attend Consult with on-site mentor on additional criteria to add to videos Mar 24 ACCEPTANCE TOWARDS THERAPY SERVICES 24 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage Weekly Goal 11 Implementation Complete edits for educational videos and finalize for upload to webpage Begin edits of educational videos, including visual cues, quality of video, and adding subtitles for educational video four through six Consult with on-site mentor on additional criteria to add to videos 12 Discontinuation Upload videos to webpage and finalize aesthetics of webpage to prepare for dissemination Edit webpage for easy access and navigation for IL residents Draft due for abstract, summary and conclusion Prepare PP for dissemination next week Objectives Tasks Edit PP for dissemination presentation Consult with on-site mentor on webpage criteria Date complete Mar 31 Apr 7 ACCEPTANCE TOWARDS THERAPY SERVICES 25 Table 3 Doctoral Capstone Experience and Project Weekly Planning Guide Week 13 DCE Stage Weekly Goal Dissemination Disseminate to social services and nursing Objectives Tasks Prepare dissemination presentation to Therapy staff Edit PP and consult with on-site mentor for additional criteria to add to PP. Ensure social services and nursing team understand purpose of translation tool 14 Dissemination Disseminate to therapy team Ensure therapy team understands purpose of translation tool Consult with on-site mentor on additional criteria for dissemination presentation for therapy team . Date complete Apr 14 Apr 21  ...

... Pre- and Postnatal Education and Care for Young and Expecting Mothers: An Occupational Therapy Case Report Angela L. Kilbride May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Alissia Garabrant, OTD, MS, OTR Paige McIntire, OTD, OTR, TBRI Practitioner Pre- and Postnatal Education and Care for Young and Expecting Mothers: An Occupational Therapy Case Report PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS TABLE OF CONTENTS ABSTRACT....................................................................................................................... 2 I. INTRODUCTION................................................................................................. 3 II. BACKGROUND................................................................................................... 4 III. THEORY............................................................................................................... 6 IV. PROJECT DESIGN & IMPLEMENTATION...................................................... 7 V. OUTCOMES......................................................................................................... 9 VI. SUMMARY......................................................................................................... 12 VII. CONCLUSION................................................................................................... 13 REFERENCES................................................................................................................ 15 TABLES.......................................................................................................................... 18 APPENDIX..................................................................................................................... 22 1 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 2 ABSTRACT Introduction: Occupational therapists (OTs) utilize a holistic approach with individuals receiving services through considering risk factors and addressing areas of development, physicality, and mental health. One unique setting OTs are not frequently seen in are Juvenile Justice Systems and addressing maternal care. At the Dickinson Juvenile Justice Center, there is a need for female education in pre- and postnatal care. Project Purpose: To provide educational resources for expecting and new mothers on pre- and postnatal self-care for mothers, fetal and infant development, development of sensory processing skills, and forming healthy/strong attachment styles to mitigate possible risk factors associated with birth. Case Description: The participant in this single case report is a female within the juvenile justice system expecting her first child. She voluntarily agreed to evidence-based education sessions in juvenile probation for 5 weeks with pre- and post-surveys. She reported to be 21 weeks pregnant with the desire to stay sober and out of the system in the future. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 3 INTRODUCTION Johnson County Juvenile Detention, JCJD, located just south of Indianapolis has a population of both males and females ages 12-18, but typically males. The detention system is created to fit males, limiting the resources available to females, specifically for juvenile expecting mothers. Occupational Therapy education creates a role within this setting to benefit their life skills and healthy coping mechanisms, as well as education and resources available to residents in the system. The aim of the capstone project at Johnson County Juvenile Community Corrections is to complete a single-participant case study to promote pre- and postnatal education and self-care for young and expecting mothers. The project will provide evidence-based education and material to the participant that encourages healthy development in the infant/baby and promotes healing and healthy lifestyle choices for mothers post pregnancy. I will assess the knowledge of the participants prior to education to understand her level of knowledge, access to resources, and areas of concern relating to the pregnancy. This aids in understanding the level of prior knowledge and education that she has going into her pregnancy, and specifically what is a necessity to address. This will help in understanding what areas are lacking in this area, and what supports are necessary for access to resources and overall healthy development with her child. Occupational Therapists are educated and trained on developmental milestones, teaching life skills, and introducing compensatory strategies for those skills when dealing with a variety of patients, in this case, young and expecting mothers. There is limited research and exposure to occupational therapy in the juvenile justice system for expecting mothers, as well as, decreased resources for this population. The purpose of this project is to provide educational resources for expecting and new mothers on pre- and postnatal self-care for mothers, fetal and infant PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 4 development, development of sensory processing skills, and forming healthy/strong attachment styles to mitigate possible risk factors associated with birth. Following the evidence-based education, I will assess the knowledge of the participant and receive feedback over the resources shared to educate young and expecting mothers. BACKGROUND The Johnson County Juvenile Detention (JCJD) is located in Franklin, Indiana, with the ability to reach up to 48 individuals at a time (County Office, 2022). The JCJD serves youth from various counties across the state of Indiana. These individuals consist of over 24% of the Johnson County population (U.S. Census Bureau: Johnson County, Indiana, 2021). The Johnson County Community Juvenile Justice System reaches juveniles that are at a heightened risk for occupational deprivation, social injustice, and mental health deficits (Edgemon et al., 2020; Young et al., 2018). The residents within the juvenile justice system can range from six to eighteen years of age. This facility works to rehabilitate the residents by improving both behavioral, emotional, and occupational skills. In addition, the occupational therapist on site emphasized the importance of encouraging the residents to take responsibility for their lives and build their life skills and independence to become successful members in their community. During the needs assessment, the site noted the need for maternal education for females pregnant in the juvenile justice system. This need was made even more apparent when at the site as a juvenile was in that position with limited education and resources available. Currently, within the juvenile justice system, there are challenges involving the behaviors, victim-blaming, and social demands of this population. The term juvenile justice system includes juvenile detention, probation, and youth correctional facilities (Javdani, 2019; Underwood & Washington, 2016). This, in combination with additional resources, can benefit PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 5 the community and the individuals to decrease the challenges faced by these individuals and the consequential actions (Mulvey & Iselin, 2008). At JCJD, the occupational therapist focuses on advocating the needs of the residents to improve the services provided, regulating emotions in the moment (pre-/post-court, etc.), and educating on coping mechanisms for life skills. Occupational Therapy in Juvenile Justice Occupational therapists take all impacting aspects in the individuals life, including environmental and personal factors, to better understand where the individual is mentally and physically. Furthermore, OT takes a holistic approach, taking into consideration risk factors along the lines of development, physicality, and mental health of the individual receiving the services (American Occupational Therapy Services, 2021; Picotin et al., 2021). Occupational therapists can be seen as social change agents due to their role and ability to impact population health and occupational justice in the individuals they reach through holistic and evidence-based practice (Picotin et al., 2021, p. 231). This can be done by addressing the individual's needs while encouraging and advocating for those needs. As occupational therapists, we can positively impact change and increase the resources individuals have for themselves (Picotin et al., 2021). The drive for evidence-based practice within all areas of occupational therapy has also shown to have an important impact on the interventions provided in the juvenile justice system. These interventions include cognitive-behavioral therapy, structured interventions, family-based interventions, and behavioral expectation training (Amani et al., 2018; Johnson-Kwochka et al., 2020). Expecting Mothers in Juvenile Justice The Coalition for Juvenile Justice reported in 2019 that There are no concrete or current nationwide figures on the number of pregnant youths who are justice-involved. However, there is PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 6 clear evidence that the rates of teenage pregnancy among incarcerated youths are significantly higher than those of the general population. A 2004 Juvenile Facilities Census found that 2.1% of girls in juvenile justice facilities are pregnant at any given time (Ades, 2019). With the limited numbers, come decreased resources for the expecting mothers in juvenile justice. Occupational Therapy, with assistance from the Person-Environment-Occupational model, allows these areas to be addressed, advocacy for the case study participant, and education on preand postnatal strategies for lifestyle improvements during pregnancy. Project Purpose The purpose of this project is to provide educational resources for expecting and new mothers on pre- and postnatal self-care for mothers, fetal and infant development, development of sensory processing skills, and forming healthy/strong attachment styles to mitigate possible risk factors associated with birth. Through a single-participant case study, As the individuals within the juvenile justice system are a vulnerable and at-risk group of individuals, it is important to address all areas limiting their abilities to withstand on their own and in the community (Zajac et al., 2016). When you add in the component of a juvenile being an expecting mother, more complications arise in limitation of educational resources in and outside of the juvenile detention. THEORY The model and frame of reference that will aid in the project approach are PersonEnvironment-Occupation (PEO) model, the lifespan and the developmental frames of reference. Aspects of the model and frames of reference will assist throughout the project to better understand the life experiences and knowledge of the participant, and assist in selecting education provided. The PEO model emphasizes the interaction and relationship between the three components. This model will aid in better understanding the impact of the different areas PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 7 on the individuals life and how the new role of being a mother will affect it. There is an additional emphasis on collaborating with the individual to establish client-centered goals for therapeutic success through a top-down approach. This will allow the educational sessions to be shaped to best meet the needs of the case study participant (Cole & Tufano, 2008). The lifespan and developmental frame of reference can be used by occupational therapists to guide reasoning, set goals for different times in life, and provide meaning to lifes occupations. The overall goal with the use of lifespan and developmental frame of reference, from the occupational therapy perspective, is to assist the participant in healthy lifestyle changes and to gain knowledge to promote the growth of her baby, during and after pregnancy. Aspects of the model and frame of reference will assist throughout the project to better understand the mothers knowledge and education received prior to and during pregnancy. In addition, it will increase resources available to females that are pregnant within the juvenile justice system, as they are so limited (Barnert et al., 2020). Dickinson Juvenile Community Correction will have additional resources for their residents and juveniles on probation, and for future connections. PROJECT DESIGN & IMPLEMENTATION This project was conducted as both the juvenile justice system and maternal health are emerging areas relative to occupational therapy. There are various topics occupational therapists can address within these practice areas, but many are not due to the lack of research and OT exposure in the settings. The intent of this project is to provide evidence-based education and resources to the Dickinson Juvenile Community Corrections to use in future collaborations with hospitals in how OTs can use a holistic approach for advocacy and evidence-based education. This can in turn mitigate possible risk factors associated with birth. The ultimate goal was to PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 8 avoid early trauma for the child to decrease the likelihood of children engaging in risky behaviors that may lead them into contact with the juvenile justice system. The project was a single-participant case study performed at Dickinson Juvenile Community Corrections in juvenile probation. The participant, at 21 weeks pregnant, voluntarily agreed to participating in a pre- and post-survey, as well as the educational sessions. For the educational portion, six presentations were created for five educational sessions with the case study participant. Within the first session, the participant completed a pre-survey (Appendix A) and the Adverse Childhood Experiences (ACEs) Assessment. The ACEs Assessment was completed to understand the participants childhood experiences that will play into how to cope with stress and to understand her risk of high stress, or toxic stress. The pre-survey gathered demographic information on the participant and her level of knowledge prior to education. Evidence-based education included presentations on fetal development, prenatal education and self-care, building healthy attachment with your fetus/baby, sensory processing and toys, infant development and developmental milestones, and postnatal education and self-care. Education included factual information, educational videos and flyers, one book, and worksheets/handouts. I provided her with the educational material to best benefit her and the life of her unborn child. This information was provided to bridge the gap for her as a mother and give community resources to best fit their needs. With the fifth session, the participant completed a voluntary post-survey (Appendix B) to best understand the knowledge gained by the participant and gain feedback from her, to compare to the knowledge pre-survey. This provides insight into what areas are still lacking, and what supports are necessary for these specific populations, expecting mothers and expecting mothers in juvenile justice. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 9 Challenges when implementing this project presented with communication barriers, time constraint, and overall limitation in research on pregnancy within the juvenile justice system. Communication to create the collaboration was one of the most important things especially when it comes to developing it in a timely manner, staying positive, following-up, and being consistent with information provided. Once the participant voiced a desire to participate in the education, communication became easier. However, with the fifth educational session, the participant did cancel three times, setting the project back two weeks. We were able to meet over the phone, go over the final education portion and complete the post-survey with minimal complications. One of the main successes during project implementation was the participant engagement and willingness to participate in the education. She had a strong desire to provide a healthy, good life for her unborn child, driving the motivation for the educational material. In addition, another huge success was meeting the needs of the participant on an educational level, and creating the education in a way that is easy to understand. Participant Educational Sessions The participant received one-on-one educational sessions with Paige McIntire, OT at Dickinson Juvenile Community Corrections, supervising and incase assistance was necessary. There were six presentations for the five participant sessions. The six presentations were on fetal development, prenatal education and self-care, building healthy and strong attachment with fetus/baby, sensory processing and toys for babies, infant development and developmental milestones, and, lastly, postnatal education and self-care with a mental health component. The participant asked for additional information regarding breast pumping and feeding a newborn, Sudden Infant Death syndrome (SIDs) and safe sleeping, perineal tearing, car seats, medical terminology, and birth plans. It was noted that at the beginning of each session, the participant PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 10 updated on her current state, any struggles, and any existing or new questions that had come up. Sessions lasted between 90 to 120 minutes at a time with the participant verbalizing a good attitude towards the material at the end of each session. OUTCOMES The participant completed the ACEs Assessment in the first educational session. Results from this assessment demonstrated an increased risk of toxic stress for the participant due to her childhood experiences. This, in turn, emphasizes the need for coping strategies in times of stress, specifically while transitioning into motherhood. In the pre-survey, the participants reported little to no knowledge in five areas including types of attachment, meeting sensory needs, possible risk factors impacting the fetus, How to balance your time between yourself (self-care) and your child, and infant development (Table 2). The participant rated her knowledge as high for one statement: Ability to define substances that can put your child at risk, during and post-pregnancy. This is the area in which she does receive education due to being in the juvenile justice system. She reported a moderately high level of knowledge in two areas including building a strong attachment with the baby and identifying what to do if your baby isn't meeting developmental milestones. The participant exhibited increased knowledge in all areas addressed on the post survey following education except for one (Table 2). The one statement she did not increase knowledge in was: how to build a strong attachment with baby. However, the participant did not lose knowledge, but was able to maintain her level of knowledge in this area rating it a four of five on the likert scale, indicating a moderately high level of knowledge. With that, the participant indicated a high level of knowledge in seven of thirteen categories. The educational material and PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 11 resources for this doctoral capstone project presented an overall improvement in her knowledge in twelve of thirteen areas relating to pre- and postnatal care for mother and baby. Anticipated outcomes of this case study doctoral capstone project were increased knowledge on pre- and postnatal self-care, fetus and infant development, strategies to promote babys sensory needs, and strategies for forming healthy attachment with baby. The project was successful in meeting the anticipated outcomes. In addition, I was able to work with the participant to educate on how to advocate for self and navigate through the healthcare system. A medical terminology document was created for increased understanding of information the participant received from doctors. Within the first session, we were able to assist the participant in navigating access to health insurance and acquiring a new birth certificate to then move forward to receive additional proof of identification. Educational Website In addition, a website including all evidence-based educational materials and the five presentations was created for future use and to help educate young mothers in the juvenile system. SUMMARY Juvenile, expecting mothers in the juvenile system have limited resources and support for increased success after the baby is born. In addition, they may not be provided with the life skills following time in detention to meet the daily needs of themselves and their new child. A review of literature showed limitations in the education and research provided to this population; however, there is also a limitation in the amount of research being done on this population. With assistance from an occupational therapist, expecting mothers can better understand how to navigate the pre- and postnatal stages of pregnancy and understand how to navigate the medical PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 12 world while advocating for themselves. A single-case, qualitative study was conducted to provide evidence-based educational material and resources to this population, and for young and expecting mothers. Educational material included fetal development, prenatal education and self-care, forming healthy/strong attachment style with baby, infant development and education on care for newborns, sensory development and processing skills, and postnatal education and self-care. Dickinson Juvenile Community Correction has additional resources for their residents and juveniles on probation, but also as a resource for future connections or collaborations to improve overall understanding and life skills during and after pregnancy. Occupational therapists can assist in advocating, educating, and creating compensatory strategies to benefit the expecting mother, with the ultimate goal to decrease likelihood of children engaging in risky behaviors that may lead them into contact with the juvenile justice system. CONCLUSION A single-case, qualitative study was conducted with one participant through probation at the Dickinson Juvenile Justice Center. The participant completed five evidence-based educational sessions with completion of pre- and post-surveys to determine growth in knowledge. The findings support the need for educational material and resources to support this population and, more generally, expecting mothers of all ages. The participant identified several benefits from these experiences, specifically education of advocacy in the medical world, fetal development education, and the variety of resources provided for further education. The development of evidence-based education and resources for this population supports the need for occupational therapy life skills and increase in research in this population. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 13 The OT at Dickinson Juvenile Justice Center manages a variety of different programs while also seeing residents in detention. With my assistance, this education was able to be completed thoroughly which may not have been possible in a short period of time. As the outcomes demonstrated its effectiveness through the post-survey, the OT is able to continue to use the education as needed and share it as a resource to others in the community. Current research related to juvenile justice and occupational therapy is currently limited with minimal resources to benefit the residents and those on probation. Occupational therapy allows for work to be done to improve their overall lifestyle through exposure to right from wrong, education on life skills, communicating needs, and behavioral and emotional regulation. This case study doctoral capstone project demonstrates the need for further research in this area, as well as in maternal health or pre- and postnatal care in the justice system. It provides additional evidence-based education and research in occupational therapy, juvenile justice, and pre- and postnatal care. The qualitative outcomes demonstrate a growth in knowledge following the educational material as it relates to pre- and postnatal education and care in young and expecting mothers. In addition, future use was made easily accessible through the educational website. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 14 REFERENCES Ades, Z. (2019). Addressing the needs of pregnant youths. Coalition for Juvenile Justice. Retrieved January 23, 2023, from https://www.juvjustice.org/blog/1144 Amani, B., Millburn, N. G., Lopez, A., Young-Brinn, A., Castro, L., Lee, A., & Bath, E. (2018). Families and the juvenile justice system: Considerations for family-based interventions. Fam Community Health, 41(1):55-63. http://doi.org/10.1097/FCH.0000000000000172 Barnert, E., Sun, A., Abrams, L. S., & Chung, P. J. (2020). Reproductive Health Needs of Recently Incarcerated Youth During Community Reentry: A Systematic Review. BMJ Sexual & Reproductive Health 46(3): 161171. doi:10.1136/bmjsrh-2019-200386. Burger, M., Hoosain, M., Einspieler, C., Unger, M., & Niehaus, D. (2020). Maternal perinatal mental health and infant and toddler neurodevelopment - Evidence from low and middle-income countries. A systematic review. Journal of Affective Disorders, 268, 158-172. doi: 10.1016/j.jad.2020.03.023. Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., Herrlich, A. (2014). Major Survey Findings of Listening to Mothers (SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women's Childbearing Experiences. Journal of Perinatal Education, 23(1): 9-16. doi: 10.1891/1058-1243.23.1.9. Edgemon, A. K., Rapp, J. T., Brogan, K. M., Richling, S. M., Hamrick, S. A., Peters, R. J., & ORourke, S. A. (2020). Behavioral skills training to increase interview skills of adolescent males in a juvenile residential treatment facility. Journal of Applied Behavior Analysis, 53(4), 2303-2318. https://doi.org/10.1002/jaba.707 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 15 Javdani S. (2019). Critical issues for youth involved in the juvenile justice system: Innovations in prevention, intervention, and policy. Journal of Prevention & Intervention in the Community, 47(2), 6775. https://doi.org/10.1080/10852352.2019.1575564 Johnson County Juvenile Detention Center - Franklin, IN. County Office. (2022). Retrieved March 30, 2022, from https://www.countyoffice.org/johnson-county-juvenile-detention-center-franklin-in-e94/ Johnson-Kwochka, A., Dir, A., Salyers, M. P., & Aalsma, M. C. (2020). Organizational structure, climate, and collaboration between juvenile justice and community mental health centers: implications for evidence-based practice implementation for adolescent substance use disorder treatment. BMC health services research, 20(1), 929. https://doi.org/10.1186/s12913-020-05777-3 Lederman, R. & Weis, K. (2009). Psychosocial adaptation in pregnancy: Seven dimensions of maternal development (3rd ed.). New York: Springer Pub. Co. Mulvey, E. P. & Iselin, A-M. R. (2008). Improving Professional Judgements of Risk and Amendability in Juvenile Justice. Future Child, 18(2), 35-57. http://doi.org/10.1353/foc.0.0012 Picotin, J., Beaudoin, M., Hlie, S., Martin, A. ., & Carrier, A. (2021). Occupational Therapists as Social Change Agents: Exploring Factors that Influence Their Actions. Canadian Journal of Occupational Therapy, 88(3), 231243. https://doi.org/10.1177/00084174211022891 Sakala, C., Declercq, E. R., Turon, J. M., & Corry, M. P. (2018, September). Listening to mothers reports and Surveys: A population-based survey of womens childbearing experiences. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 16 National Partnership for Women & Families. Retrieved February 13, 2023, from https://www.nationalpartnership.org/our-work/health/maternity/listening-to-mothers.html State of California Department of Health Care Services. (2021, May 13). Learn about screening. ACEs Aware. Retrieved February 20, 2023, from https://www.acesaware.org/learn-about-screening/ Simkin, P., Whalley, J., Keppler, A., Durham, J., & Bolding, A. (2018). Pregnancy, childbirth, and the newborn: The complete guide (5th ed.). Hachette Books. Underwood, L. A., & Washington, A. (2016). Mental Illness and Juvenile Offenders. International Journal of Environmental Research and Public Health, 13(2), 228. https://doi.org/10.3390/ijerph13020228 U.S. Census Bureau: Johnson County, Indiana. (2021, July 1). Retrieved March 30, 2022, from https://www.census.gov/quickfacts/fact/table/johnsoncountyindiana/PST045221 Visger, Joan M., "Predictors Of Psychosocial Adaptation To Pregnancy Among Urban African-American Primiparas" (2013). Wayne State University Dissertations. Paper 712. Young, S., Greer, B., & Church, R. (2017). Juvenile delinquency, welfare, justice and therapeutic interventions: a global perspective. BJPsych Bulletin, 41(1), 2129. https://doi.org/10.1192/pb.bp.115.052274 Zajac, K., Sheidow, A. J., & Davis, M. (2015). Juvenile Justice, Mental Health, and the Transition to Adulthood: A Review of Service System Involvement and Unmet Needs in the U.S. Children and Youth Services Review, 56, 139148. https://doi.org/10.1016/j.childyouth.2015.07.01 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS TABLES Table 1 Pre-survey Demographic and Subjective Data Subjective Questions Participant Response Level of education Enrolled in 12th grade, completed 11th Describe the setting you will be raising your child A clean good home What does your support system look like? I have a good support system Are you in school or working? If yes to either, where? yes both I graduate June right before I have him What experience, if any, do you have raising kids or I help my bestfriends mom with her as a caregiver? kids all the time What parts of raising and caring for a baby are you comfortable with? Anything What worries you or makes you feel uncomfortable when it comes to raising your baby? not feeding him enough or on time Previous history with any health concerns or diagnoses, mental and physical? Nothing *** Preferred method/location of birth? (hospital/home - midwife/doctor) Natural at st. francis Have you been pregnant before? no Currently, what are your biggest areas of concern? how I will feel after I have him 17 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS What resources or educational information have you been provided, if any? Angela and Paige What information or resources have you been able to access on your own, if any? what to expect app 18 Note. The participant reported no previous diagnoses of mental health conditions, but was further educated and noted a history of anxiety and depression. PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 19 Table 2 Pre- and Post-survey Participant Responses Pre-Education Response Knowledge Questions Post-Education Reponse How to build a strong attachment with baby 4 4 How to identify the different types of attachment 1 4 How to meet you childs sensory needs 1 5 How sensory needs impact the development of your child 3 4 How to describe the development of a fetus 3 5 Ability to identify possible risk factors impacting the fetus 1 4 5 5 2 3 Ability to identify 3 or more pre- or postnatal self-care tasks 2 5 How to balance your time between yourself (self-care) and 1 5 How to describe the development of an infant 1 4 Ability to identify developmental milestones to look for 2 5 (before giving birth) Ability to define substances that can put your child at risk, during and post-pregnancy Ability to identify postpartum mental health complications your child PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Ability to identify what to do if your baby isn't meeting developmental milestones 4 20 5 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 21 Appendix A Participant Pre-Survey Questions Project Purpose: to provide educational resources for expecting and new mothers on pre- and postnatal self-care for mothers, development of sensory processing skills, forming healthy/strong attachment styles, and mitigating possible risk factors associated with birth. Educational Topics Development of fetus pre- and postnatal self-care for mothers development of sensory processing skills forming healthy/strong attachment styles mitigating (reducing) possible risk factors associated with birth In addition to this pre-survey, you will also be completing the Adverse Childhood Experience (ACEs) Assessment. Learning about You: Demographic & Subjective Information What is your age? (Short Answer) Level of Education: What grade are you in or what grade did you complete last? (Short Answer) Describe the setting that you will be raising your child in. (Short Answer) What does your support system look like? What kind of help do you expect after having the baby? (Long Answer) Are you still in school or working? If yes to either, where? (Long Answer) PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS What experience, if any, do you have raising kids or as a caregiver? (Long Answer) What parts of raising and caring for a baby are you comfortable with? (Long Answer) What worries you or makes you feel uncomfortable when it comes to raising your baby? (Long Answer) Previous diagnosis with any health concerns or diagnoses, mental or physical? (Long Answer) Current Pregnancy Number of weeks pregnant? (Short Answer) Preferred method/location of birth? (hospital/home - midwife/doctor) (Long Answer) Have you been pregnant before? o Yes o No If yes to above question, describe your previous pregnancy experience(s) (pre/during/post) (Long Answer) Currently, what are your biggest areas of concern in terms of your pregnancy? (Long Answer) What resources or educational information have you been provided, if any? (Long Answer) 22 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS What information or resources have you been able to access on your own, if any? (Long Answer) Pre-Knowledge Instructions: Rate your knowledge on a scale 1-5 1 = little to no knowledge (uncomfortable with the topic) 5 = high level of knowledge (very comfortable with the topic) How to build a strong attachment with baby o1 o2 o3 o4o5 How to identify the different types of attachment o1 o2 o3 o4o5 How to meet your childs sensory needs? o1 o2 o3 o4o5 How sensory needs impact the development of your child o1 o2 o3 o4o5 How to describe the development of a fetus o1 o2 o3 o4o5 Ability to identify possible risk factors impacting the fetus (before giving birth) o1 o2 o3 o4o5 Ability to define substances that can put your child at risk, during and post-pregnancy o1 o2 o3 o4o5 Ability to identify postpartum mental health complications o1 o2 o3 o4o5 Ability to identify 3 or more pre- or postnatal self-care tasks o1 o2 o3 o4o5 How to balance your time between yourself (self-care) and your child? o1 o2 o3 o4o5 How to describe the development of an infant o1 o2 o3 o4o5 Ability to identify developmental milestones to look for 23 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 24 o1 o2 o3 o4o5 Ability to identify what to do if your baby isnt meeting developmental milestones o1 o2 o3 o4o5 References Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., Herrlich, A. (2014). Major Survey Findings of Listening to Mothers (SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women's Childbearing Experiences. Journal of Perinatal Education, 23(1): 9-16. doi: 10.1891/1058-1243.23.1.9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894594/ Lederman, R. & Weis, K. (2009). Psychosocial adaptation in pregnancy: Seven dimensions of maternal development (3rd ed.). New York: Springer Pub. Co. Retrieved from: https://nursing-and-health-professions.uiw.edu/_docs/moms/psychosocial-adaptation-to-pr egnancy-third-edition.pdf Sakala, C., Declercq, E. R., Turon, J. M., & Corry, M. P. (2018, September). Listening to mothers reports and Surveys: A population-based survey of womens childbearing experiences. National Partnership for Women & Families. Retrieved from: https://www.nationalpartnership.org/our-work/health/maternity/listening-to-mothers.html PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 25 Appendix B Participant Post-Survey Questions Project Purpose: to provide educational resources for expecting and new mothers on pre- and postnatal self-care for mothers, development of sensory processing skills, forming healthy/strong attachment styles, and mitigating possible risk factors associated with birth. Educational Topics Development of fetus pre- and postnatal self-care for mothers development of sensory processing skills forming healthy/strong attachment styles mitigating (reducing) possible risk factors associated with birth In addition to this pre-survey, you will also be completing the Adverse Childhood Experience (ACEs) Assessment. Your Educational Experience Overall, how do you feel about the education you received? (Long Answer) Education Feedback How do you feel about going into your pregnancy, becoming a mother? (Long Answer) Are you feeling prepared, or more prepared after the educational sessions? (Long Answer) What most benefited you? (Long Answer) What could have been done differently? (Long Answer) Currently, what are your biggest areas of concern? Did you receive information on this topic? PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS (Long Answer) What areas do you feel you need more information in? (Long Answer) Post-Knowledge Instructions: Rate your knowledge on a scale 1-5 1 = little to no knowledge (uncomfortable with the topic) 5 = high level of knowledge (very comfortable with the topic) How to build a strong attachment with baby o1 o2 o3 o4o5 How to identify the different types of attachment o1 o2 o3 o4o5 How to meet your childs sensory needs? o1 o2 o3 o4o5 How sensory needs impact the development of your child o1 o2 o3 o4o5 How to describe the development of a fetus o1 o2 o3 o4o5 Ability to identify possible risk factors impacting the fetus (before giving birth) o1 o2 o3 o4o5 Ability to define substances that can put your child at risk, during and post-pregnancy o1 o2 o3 o4o5 Ability to identify postpartum mental health complications o1 o2 o3 o4o5 Ability to identify 3 or more pre- or postnatal self-care tasks o1 o2 o3 o4o5 How to balance your time between yourself (self-care) and your child? o1 o2 o3 o4o5 26 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 27 How to describe the development of an infant o1 o2 o3 o4o5 Ability to identify developmental milestones to look for o1 o2 o3 o4o5 Ability to identify what to do if your baby isnt meeting developmental milestones o1 o2 o3 o4o5 References Declercq, E.R., Sakala, C., Corry, M.P., Applebaum, S., Herrlich, A. (2014). Major Survey Findings of Listening to Mothers (SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women's Childbearing Experiences. Journal of Perinatal Education, 23(1): 9-16. doi: 10.1891/1058-1243.23.1.9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894594/ Lederman, R. & Weis, K. (2009). Psychosocial adaptation in pregnancy: Seven dimensions of maternal development (3rd ed.). New York: Springer Pub. Co. Retrieved from: https://nursing-and-health-professions.uiw.edu/_docs/moms/psychosocial-adaptation-to-pr egnancy-third-edition.pdf Sakala, C., Declercq, E. R., Turon, J. M., & Corry, M. P. (2018, September). Listening to mothers reports and Surveys: A population-based survey of womens childbearing experiences. National Partnership for Women & Families. Retrieved from: https://www.nationalpartnership.org/our-work/health/maternity/listening-to-mothers.html PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Appendix C Session 1 Worksheet: Highlighting important areas of fetal development 28 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Appendix D Session 2 Worksheet: Prenatal Self-care Goals 29 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Appendix E Session 3 Worksheet: Strategy worksheet for pre- and postnatal attachment 30 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Appendix F Pregnancy Dos and Donts 31 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 32 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 33 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 34 Appendix G Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage Weekly Goal Objectives Tasks Date complete 1/13 1 Orientation Get accustomed to the site, meet employees, and communicate project plan 1. observe OT work in juvenile justice 2. observe nurture group 3. get familiar with staff and site 1. Familiarize self with resident and their current situation 2. create plan with Paige for week 2 and project planning 3. Orient self to THRIVE AA program for juveniles 2 Orientation determine new plan for capstone due to changes from site 1. Project plan for school system 2. Make changes to MOU 1. Continue research for changes to project 2. changes to MOU - new draft 3. attend court sessions 4. project meeting with director of community corrections 5. Begin THRIVE AA program for 12 weeks with juveniles in probation 1/19 3 Screening/ Evaluation Draft new MOU 1. Project Development for Preand Post-natal care collaboration with hospitals 2. Complete introduction due 1/23 3. Reaching out for collaborations with Hospitals in Johnson County 1. New project development plan written 2. Continue research on previous studies done 3. Create write up message about project for hospital 4. Write Introduction for Scholarly Report 01/26 4 Screening/ Evaluation Finalize Project Plan 1. Continue building rapport with residents and employees at site 2. Edit Literature Review for Background 1. Edits to Literature Review 02/03 for Introduction and Background 2. Write and submit background due 01/30 3. Reaching out for collaborations with Johnson Memorial Hospital (call, PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 35 email, and in-person visit no response) 5 Screening/ Evaluation Finalize new MOU for case study over Pre- and Postnatal Education 1. New project plan for educational sessions with case study participant 2. Finalize mini MOU 3. Re-work 1. Continuous communication with Alissa and Christine for mini MOU - finalize to be sent 2. Rewrite Intro and background drafts 3. Complete Project Design and Implementation Draft for submission on 02/06 02/10 6 Screening/ Evaluation Educational Session Planning 1. Thorough plan for educational sessions organized into 5-6 categories 2. Continue building rapport with residents and employees at site, and in THRIVE 3. Develop pre-survey 1. Send mini MOU on 02/14 for signatures via email 2. Written out plan for educational components 3. Begin research for educational material and resources for single-participant case study 4. Research for pre-survey and begin draft 5. Develop presentation and worksheets for first educational session with participant 02/17 7 Implementati on Implement Pre- and Postnatal education sessions with case study participant 1. Provide education to participant on fetal development, risk factors, and highlights of development 2. Build rapport and trust with participant for increased success 1. Finalize pre-survey and schedule time with participant 2. Administer pre-survey and ACEs assessment to participant 3. Present first educational material with presentation, videos, and handouts 5. Create five week plan with participant 6. Create presentation for session 2 02/24 8 Implementati on Implement Pre- and Postnatal education sessions with case study participant 1. Provide education to participant on prenatal education and self-care 1. Provide educational presentation, videos, handouts and worksheets over topic 03/03 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 36 2. Continue working alongside other employees in detention, building rapport, and participating in additional programming 2. Additional education on prenatal mental health 3. Create presentation for session 3 9 Implementati on Implement Pre- and Postnatal education sessions with case study participant 1. Provide education to participant on forming healthy/secure attachment with fetus/baby 2. Continue working alongside other employees in detention, building rapport, and participating in additional programming 1. Provide educational presentation, videos, handouts and worksheets over topic 2. Create presentation for Session 4 and add developmental milestones 03/10 10 Implementati on Implement Pre- and Postnatal education sessions with case study participant 1. Provide education to participant on infant development and developmental milestones 2. Continue working alongside other employees in detention, building rapport, and participating in additional programming 1. Provide educational presentation, videos, handouts and worksheets over topic 2. write and submit outcomes draft (not all outcomes completed) initial findings and anticipated outcomes 3. Create presentation for session 5 4. Draft post-survey and check with Paige for approval 03/17 11 Implementati on Implement Pre- and Postnatal education sessions with case study participant 1. educational session on sensory processing and baby sensory needs 2. Continue working alongside other employees in 1. Provide educational presentation, videos, handouts and worksheets over topic 2. Provide list of toys by age and month correlating with 03/24 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS Implement Pre- and Postnatal education sessions with case study participant 37 detention, building rapport, and participating in additional programming sensory needs and overall development 3. Create dissemination plan and submit on 03/20 1. provide educational session to participant -canceled 2. Continue working alongside other employees in detention, building rapport, and participating in additional programming 1. Develop website for educational material to be housed with presentations included (for future site use) - resource 2. Planning detention nurture group and conduct with two groups 3. Create presentation for session 5 12 Implementati on 13 Discontinuatio Complete final n education session and begin reviewing qualitative data 1. Create Dissemination Presentation and plan for time to present 2. Post-survey completion by participant 1. Create presentation for 04/07 dissemination of findings, educational material, and website for future use 4. Decide who to be involved in dissemination send invite 2. Begin writing abstract for scholarly report 3. Call participant for final educational session and post-survey due to 1.5 weeks of cancellations - able to complete 4. Review and analyze qualitative data - edit outcomes draft 14 Dissemination 1. Present DCE project to site mentor, judge, director of community corrections, state prosecutor, probation director, and more 1. Prepare and practice for presentation on final day 2. Discuss future use of website as a resource 3. Disseminate to site on 04/14 4. Inform of county resource guide completed in addition Dissemination Presentation to Site 03/31 04/14 PRE- AND POSTNATAL EDUCATION FOR YOUNG & EXPECTING MOTHERS 38 for resident/juvenile use (shelters and food resources) 5. Write and submit Abstract, Summary and Conclusion due 04/10 Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... 1 Professional Development Among Young Adult Refugees to Decrease Occupational Deprivation Sierra Kern May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Kristina Watkins, OTD, MOT, OTR 2 Abstract Many refugees face occupational deprivation during their transition to and living in new countries (Huot et al., 2021; McCarthy, 2020). Rapid employment is essential to becoming independent, which is why young adult refugees often have to accept the first job they are offered due to language barriers and a lack of meaningful opportunities (Ingvarsson et al., 2016). This report serves to share the experience of creating, implementing, and evaluating a professional development program among five young adult refugees in hopes to build foundational, transferable skills and confidence required to establish and maintain meaningful employment. All five participants improved their scores on both the confidence survey and knowledge check, indicating that this program is effective in improving appropriate workplace skills and confidence to utilize in their new country. Keywords: occupational therapy, refugees, resettlement, occupational deprivation, professional development, confidence 3 Professional Development Among Young Adult Refugees to Decrease Occupational Deprivation Introduction Refugees are individuals who have fled their home country due to war, violence, or persecution of race, religion, social group, or political opinion (United Nations Refugee Agency, 2019). Refugees are a vulnerable population and have the right to assistance when transitioning to a permanent country of residence. Catholic Charities of Indianapolis (CCI) is one local non-profit that provides assistance within Refugee and Immigrant Services (RIS) in Indianapolis, Indiana. Their vision is Providing Help. Creating Hope. Serving All. (Bethuram, 2021, p. 1). RIS has served over 20,000 refugees, immigrants, humanitarian parolees, special immigrant visa holders, and more since 1975 (Archdiocese of Indianapolis, n.d.). Over 1,300 refugees and immigrants were served in 2020-2021, a significant decline compared to the 2,750 refugees that were resettled in 2019-2020, due to the COVID-19 pandemic and the political administration (Bethruam, 2021). Currently, RIS serves a majority of Burmese, Congolese, and Afghan refugees. RIS provides crisis relief services including, but not limited to, housing assistance, employment assistance, cultural orientation, English language assistance, and aid for the application and utilization of social services. Legal services are also provided for refugees and immigrants within the office. Help for refugees is provided from the point of arrival in the United States up to 90 days for cultural assimilation unless a client is enrolled in Match Grant. However, RIS provides employment services for up to five years. Many first jobs in the United States are not dream jobs for refugees considering the language barriers and the need for rapid employment in order to become self-sufficient. This means many refugees experience occupational deprivation with employment and face mental health struggles such as indecision and anxiety (Huot et al., 2021). A professional development 4 mentorship program with adolescent and young adult refugees was created, implemented, and evaluated to address these deficits The purpose of this paper is to share the experience of the professional development program among refugees in an effort to decrease occupational deprivation. Background Refugees Face Occupational Deprivation and Injustice Many refugees or immigrants face some form of occupational deprivation (Cipriani et al, 2021; Huot et al; 2021; Ingvarsson et al., 2016; McCarthy et al, 2020). Research indicates that one barrier to occupational engagement includes the provision of meaningful activities to participate in (Trimboli & Taylor, 2016). Oftentimes, refugees and immigrants are given activities to complete, but participants do not view them as meaningful, which decreases overall participation rates (Darawsheh, 2019). Likewise, when refugees transition to the United States, rapid employment is essential to become self-sufficient (Cultural Orientation Resources Exchange [CORE], n.d.) but many refugees are required to accept work that is not meaningful. Many times, immigrants or refugees face unemployment during their resettlement period of 90 days and beyond, impacting both mental health and financial health (Trimboli & Taylor, 2016). Obtaining and maintaining a job not only allows for financial independence but also provides an opportunity for refugees to socialize, become proficient in the host countrys language, and improve self-confidence (Trimboli & Taylor, 2016). However, language barriers, long waiting times for appropriate paperwork, and lack of meaningful opportunities pose challenges for refugees (Ingvarsson et al., 2016). Skills obtained and degrees earned in countries of origin may become irrelevant once a refugee transitions to a permanent country of residence due to different curricular requirements (Darawsheh, 2019). Some refugees also face 5 discrimination with working conditions where refugees report feeling trapped without opportunities (Darawsheh, 2019, p. 6). Minimal research has been published analyzing the occupational performance of refugees who have arrived in their permanent countries of residence. Al Hwayan (2020) published a study that investigated the relationship between anxiety and the ability to make professional decisions. Results indicated moderate levels of anxiety amongst the Syrian refugees in Jordan. Occupational therapists interviewed two refugees after they transitioned to the United States and found they struggled with occupational deprivation, belonging, and adaptation (McCarthy et al., 2020). The same study also determined that identity issues and culture shock influenced refugees self-perception (McCarthy et al., 2020). Changes in or termination of occupations, including employment, influenced struggles surrounding adaptation (McCarthy et al., 2020). There is limited research available on occupational therapy interventions interacting with or supporting the overall well-being of refugees, and even less research specific to job attainment (Trimboli & Taylor, 2016). Occupational therapists can play an essential role in addressing many problems refugees face (Darawsheh, 2019) including the cultivation of social occupation, physical spaces for the community, and social networks (Huot et al., 2021). One weakness of current interventions is a lack of cultural context consideration and there is a call to action to tailor interventions for each participant (Trimboli & Taylor, 2016). Needs Assessment and Doctoral Capstone Project Refugees and immigrants face vocational challenges, unemployment, and a lack of meaningful engagement which contribute to occupational deprivation (Trimboli & Taylor, 2016). Deciding ones professional trajectory can be stressful for anyone. However, refugees under severe stress from transitioning to a new country may face even higher levels of anxiety and indecisiveness (Al Hwayan, 2019). 6 Through needs assessment interviews with many staff members at CCI, it was discovered that adolescent and young adult refugees face major challenges in obtaining meaningful jobs. There is currently limited bandwidth available to dedicate to this population as CCI is an extremely small office with limited funding. The current job employment team assists with rapid employment, but many jobs offered are not skilled, meaningful, or even close to dream jobs. The project goals are to clarify participants interests, improve job readiness skills, and discuss stress management techniques. Worry and anxiety levels are high in the adolescent population since they are experiencing life and personal transitions (Kulcsar et al., 2020). Adolescents can experience career indecisiveness, which is a chronic struggle, or career indecision, which is more of an acute difficulty (Kulcsar et al., 2020). Refugees and immigrants most likely face career indecision due to their challenging transition to the United States. Kulscar et al. (2020) found that adolescents struggles include a lack of readiness, lack of information, and inconsistent information. Young adult refugees may face similar struggles due to different cultural contexts and the need to acclimate to their new country of residence. However, positive coping strategies to manage anxiety have been found to increase career satisfaction (Miles et al., 2018). Gee et al. (2021) found significant improvements in college and career readiness after interventions surrounding self-awareness, interpersonal skills, coping skills, goal setting, and option exploration were implemented among underserved adolescents. One study implemented a career development program that improved participants self-efficacy, career adaptability, and job clarity (Yoon et al., 2019). Interestingly, the provision of this program was found to increase refugees sense of hope, self-reflection, and adaptation (Yoon et al., 2019). Each aforementioned component was included in the 6-week professional development program. 7 Theory The Model of Human Occupation (MOHO) and the Social Cognitive Theory (SCT) will guide the development and implementation of my project. The MOHO states that people are open systems that constantly change based on their environment, volition, habituation, and performance capacity. Refugees have experienced many changes in the environment, and their occupational capacity and skills are influenced by new settings. According to the SCT, observational learning and vicarious reinforcement indicate that learning occurs when one is exposed to the stimulus through modeling (Brown et al., 2011) in the environment. These aspects were addressed through program implementation covering relevant professional skills. It is essential to build self-efficacy to positively influence ones reciprocal determinism, which considers personal, social, and behavioral factors to make a change. Internal motivation and confidence, along with environmental context, are driving factors of change for both the SCT and MOHO (Kielhofner, 2009 & Brown et al., 2011). One goal of this project was to improve refugees self-efficacy and allow for the presentation and application of knowledge gained through related activities. Changes in participants perceived confidence and familiarity with professional development skills were targeted through MOHO principles of volition, habituation, and performance capacity (Cole & Tufano, 2020). After completing the program, participants could articulate their interests, values, and personal causation via resumes or job interviews. Performance capacity and occupational skills will be assessed through the pre-and post-knowledge checks. Project Design and Implementation A six-week professional development program was created after the needs assessment revealed a gap in meaningful employment services for young adult refugees (Al Hwayan, 2020; 8 Gee et al., 2021). Current literature advocates for individual or small group programs to provide a more personalized, culturally sensitive experience (Trimboli & Taylor, 2016; Kulscar et al., 2020). Therefore, five clients were recruited via convenience sampling to participate in a one-to-one or a two-to-one program format as a pilot program for RIS. The recruited participants are currently assimilating to U.S. culture and most are working jobs with nontraditional hours. Therefore, the program was developed to be implemented once weekly for six weeks to fit within participants busy schedules. Additionally, programs were designed to be implemented in the clients home or at a nearby church within walking distance for convenience given most participants do not have transportation. One outcome measure to measure confidence in professional development included a pre/post-survey to complete on the first and last week of program implementation. A knowledge check was also administered on week one and again on week six to measure knowledge gained from the program. The six-week program encompasses a multitude of pertinent skills needed to establish employment (Kiteki, 2021 & Bartel, 2018), including, but not limited to confidence, goal setting, organization, communication, time management, adaptability, integrity, problem-solving, professionalism, emotional regulation, and stress management. Strengths-based interviewing, responding, and questioning (Crawford & Turpin, 2018) were utilized throughout implementation in order to increase participants confidence and identify personal strengths and environmental resources. Each week, clients participated in an interactive presentation and completed a related activity to the topic(s) of the week. The presentation included relevant vocabulary and descriptions of each skill along with advice on how to improve each skill. The related activities expanded upon this advice and provided an opportunity to apply knowledge gained from the 9 presentation. Participants were allowed to keep printed materials as a resource and were provided with notebooks and pencils for taking notes. Some challenges for program implementation included time constraints and language barriers. As previously stated, many refugee participants worked non-traditional hours. Because of this, they often had other necessary appointments or responsibilities during the scheduled program time and would have to reschedule. Additionally, many cultures outside of the U.S. perceive time and punctuality differently. Constant communication was necessary with participants to ensure they would attend the session as scheduled. Language barriers also proved to be another barrier in the program. While most participants had a good foundational understanding of English, larger or uncommon vocabulary words and acronyms required the use of translation services such as Google Translate. The program was originally planned to be completed in person over a six-week period, but the delivery of the program required tailoring for some groups. One group completed two sessions via Zoom and one group completed one session on Zoom due to scheduling conflicts and convenience. Although these aspects posed challenges to implementation, all participants completed the program in addition to the confidence and knowledge post-surveys. Project Outcomes Outcome Measures Three different assessments were used to evaluate the results of the professional development program: a confidence survey, a knowledge check, and a semi-structured interview. A pre-and post-confidence survey aimed to measure the change in confidence levels regarding professional development skills. The confidence survey included 26 questions on a 4-point Likert scale (ranging from 1= strongly disagree to 4= strongly agree). A knowledge check about 10 week one through week five content was administered before and after program completion. Week six content was not included as it did not provide any new content, only an opportunity to complete a mock interview and complete the post-assessments. The knowledge check consisted of short answer questions, matching, true/false, and fill-in-the-blank questions and was compared to an answer key. See Appendix A for the confidence survey and Appendix B for the knowledge check. An increased score on the confidence survey is indicative of improved confidence. Likewise, an increased score on the knowledge check indicates increased knowledge learned. A semi-structured interview was conducted after completing the program and assessments to gather feedback. The interview questions inquired about participants opinions on benefits, challenges, areas of growth, and confidence about the program. Participants were asked to elaborate upon their responses for clarification or further detail. Results Each recruited participant (n=5) completed the professional development program and its relevant assessments. Participants ranged in age from 22 to 29 years of age. Most participants (n=4) were Congolese refugees, and one was an Afghan refugee. Three participants were male and two were female. Each participant spoke at least an intermediate level of English. An increase in both confidence and knowledge surrounding professional development was observed through the pre-and post-assessments of each participant. The average score for confidence before implementation was 79.2 out of 104 and increased to 94 after program completion. The largest increase in confidence was 22 points. The average score for the pre-program knowledge check was 51.25%. Following implementation, the average score for the post-program knowledge check was 83.75%. Two participants demonstrated a large increase in 11 knowledge by doubling their scores from 43.75% to 87.5% and from 35.42% to 70.83% respectively. See Appendix D for figures of both knowledge and confidence results. During the semi-structured interviews at the final meeting, participants shared that they enjoyed taking part in the professional development program overall. Specific information referenced by participants included resumes, interviews, professional emailing, and stress management techniques. One participant, whose name has been redacted for anonymity, claimed that he was more comfortable talking about himself and the things he is good at (Client 1, personal communication, March 2, 2023). Another said even though some of it was not new information, it was good to increase my confidence and remember things I need to refocus on (Client 3, personal communication, March 3, 2023). Interestingly, the participant whose confidence only increased six points (92 to 98 points out of 104) shared that even though I ranked myself confident at first, I now feel a lot more confident about my own strengths and it was helpful to realize my weaknesses (Client 2, personal communication, March 3, 2023). Summary Many refugees experience a loss of identity as they become a refugee in the United States (Khiteki, 2021), which can impact self-worth and job satisfaction. To counteract this, much of the time spent with participants focused on a strengths-based approach (Crawford & Turpin, 2018) to increase confidence, identify personal strengths, and become familiar with external resources to gain skills. Overall, participants confidence scores increased as evidenced by the confidence survey. Knowing their personal strengths specifically was mentioned when asked What did you enjoy most about our time together? Each clients confidence score in interviewing skills and resume building increased, and these skills are essential for employment acquisition (Bartel, 2018). 12 Self-efficacy, career adaptability, job search clarity, and job satisfaction need to be considered when assisting refugees with meaningful employment acquisition (Yoon et al., 2019). Each participant shared that although they were currently working in a warehouse, they did not find the work meaningful to them. Thus, their job satisfaction rate was low. Many participants had ideas of careers they wanted to change to (e.g. nursing, business, or administrative work), but they did not know how to gain essential relevant skills The professional development program aided in job search clarity to improve job satisfaction through the completion of a career interest checklist. Career adaptability encompasses decision-making, exploration, and self-efficacy (Yoon et al., 2019), all of which were addressed throughout the 6-week program. After program completion, the average confidence score for participants' ability to get a meaningful job, utilize the necessary skills to get a meaningful job, and sense of control over their ability to get a meaningful job increased. A large focus of the professional development program was to build foundational skills to apply to career aspirations (Gee et al., 2021) that will take longer than the 6-week period to accomplish. Essential topics like professional communication skills, self-awareness, decision-making, stress management and mindfulness, and goal setting were included in the program. Each participants knowledge check score improved from pre-test to post-test, indicating comprehension of these skills. Conclusion The professional development project yielded positive results regarding participants confidence in and knowledge of professional development skills. In addition to improved outcome measure scores, all participants shared positive remarks about the program. Participants greatly valued the mentorship aspect of the program. As implementation continued and a 13 therapeutic relationship was established, participants contacted the mentor for additional support outside of the curriculum. For example, one asked for help to create an online networking account, and another asked for help to get connected to literature conferences or clubs in the community. Although no participants were ready to apply to different, more meaningful jobs, they gained transferable skills to utilize throughout the job readiness or acquisition process. Overall, RIS expressed satisfaction with the creation, implementation, and evaluation of the professional development program with the initial five participants. This program can benefit many different areas of the organization, including preferred communities, employment services, education management, or Match Grant upon referral. The professional development program will aid refugees in becoming self-sufficient through meaningful employment, which is one of the goals of the organization. Upon program completion, the content was uploaded onto the organizations shared virtual drive for future volunteers and refugees to access. Implications for OT Practice Although there is limited literature available regarding OT among refugees, RIS clients can benefit from OTs role in refugee resettlement, as evidenced by this program. An occupational therapist brings a unique perspective to the emerging practice area of refugee resettlement that considers personal, environmental, and cultural contexts. Through this lens, OT can facilitate self-sufficiency by building therapeutic relationships, creating client-centered programs, teaching transferable life skills, identifying clients interests and values, and encouraging participation in meaningful activities. The beneficial results of this program can serve as a call to action to advocate for OTs role in refugee resettlement. 14 References Al Hwayan, O. (2020). Predictive ability of future anxiety in professional decision-making skills among a Syrian refugee adolescent in Jordan. Occupational Therapy International. https://doi.org/10.1155/2020/4959785 Archdiocese of Indianapolis. (n.d.). About Us. Refugee Immigration Services. Retrieved February 28, 2023, from https://www.archindy.org/cc/refugee/about.html Bartel, J. (2018). Teaching soft skills for employability. TESL Canada Journal, 35(1), 7892. https://doi.org/10.18806/tesl.v35i1.1285 Bethuram, D.J. (2021). 2020-2021 Annual Report. Catholic Charities Indianapolis. Brown, C., Stoffel, V. C., & Munoz, J. P. Occupational therapy in mental health: A vision for participation. (2nd Ed.). Philadelphia. F. A. Davis Company3 Cipriani, J., Davis, M., Gralinski, E., Monforte, S., & Strausser, J. (2021). Examining the occupational needs and OT intervention strategies used with refugee populations: A scoping review. American Journal of Occupational Therapy, 7(2). https://doi.org/10.5014/ajot.2021.75s2-po113 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc Cultural Orientation Resource Exchange. (n.d.). Employment in the United States. CoreResourceExchange.org. https://coresourceexchange.org/curriculum-lesson-plans/ 15 Darawsheh, W. B. (2019). Exploration of occupational deprivation among Syrian refugees displaced in Jordan. American Journal of Occupational Therapy, 73, 7304205030. https://doi.org/10.5014/ajot.2019.030460 Gee, K. A., Beno, C., Lindstrom, L., Lind, J., Gau, J., & Post, C. (2021). Promoting college and career readiness among underserved adolescents: A mixed methods pilot study. Journal of Adolescence, 90, 79-90. Huot, S., Brower, J., Tham, A., & Yekta A. R. (2021). Cultivating social occupations, spaces, and networks: service providers perspectives on enabling immigrants social participation. Cadernos Brasileiros de Terapia Ocupacional, 29. https://doi.org/10.1590/2526-8910.ctoAO2184 Ingvarsson, L., Egilson, S. T., & Skaptadottir, U. D. (2016). I want a normal life like everyone else: Daily life of asylum seekers in Iceland. Scandinavian Journal of Occupational Therapy, 23(6), 416424. https://doi.org/10.3109/11038128.2016.1144787 Kielhofner, G. (2009). Conceptual foundations of occupational therapy practice. Philadelphia: F. A. Davis Company Kiteki, B. N. (2021). African refugee youths experiences and impact on career development: An adaptation of a culturally Responsive Career Exploration Group. The Journal for Specialists in Group Work, 46(1), 90107. https://doi.org/10.1080/01933922.2020.1856257 16 Kulcsr, V., Dobrean, A., & Balzsi, R. (2020). Does it matter if I am a worrier? The effect of worry as a moderator between career decision-making difficulties and negative dysfunctional emotions. Journal of Youth and Adolescence, 49(2), 549-564. McCarthy, K., Cantrell, J., Daine, J., Keagan Banuelos, K., & Chan, A. (2020). Transition in occupations of refugees during resettlement. The Open Journal of Occupational Therapy, 8(4), 1-15. https://doi.org/10.15453/2168-6408.1714 Miles, M. M., Szwedo, D. E., & Allen, J. P. (2018). Learning to cope with anxiety: Long-term links from adolescence to adult career satisfaction. Journal of adolescence, 64, 1-12. Trimboli, C., & Taylor, J. (2016). Addressing the occupational needs of refugees and asylum seekers. Australian Occupational Therapy Journal, 63(6), 434437. https://doi.org/10.1111/1440-1630.12349 United Nations Refugee Agency. (2019, April). Emergency handbook. UNHCR. Retrieved February 28, 2023, from https://emergency.unhcr.org/entry/55772/refugee-definition Yoon, H. J., Bailey, N., Amundson, N., & Niles, S. (2018). The effect of a career development programme based on the hope-action theory: Hope to work for refugees in British Columbia. British Journal of Guidance & Counselling, 47(1), 619. https://doi.org/10.1080/03069885.2018.1544827 17 Appendix A Directions: Complete each item by selecting the answer that best represents your agreement based on the scale below. 1- Strongly disagree 2- Disagree 3- Agree 4- Strongly agree 1. I am confident in my ability to get a meaningful job. 1 2 3 4 2. I have the skills necessary to get a meaningful job. 1 2 3 4 3. I feel in control of my own ability to get a meaningful job. 1 2 3 4 4. I know how to utilize transferable skills when finding a meaningful job. 1 2 3 4 5. I have a positive outlook on my professional life. 1 2 3 4 6. Overall, I am a confident person. 1 2 3 4 7. I am confident in my ability to create realistic professional goals. 1 2 3 4 8. I am confident in my ability to manage my time. 1 2 3 4 9. I am good at staying organized. 1 2 3 4 10. I am an adaptable person. 1 2 3 4 11. I am confident in meeting people for the first time. 1 2 3 4 12. I am confident in sending a professional email. 1 2 3 4 13. I am confident talking on the phone with someone from my work. 1 2 3 4 14. I work well within a team. 1 2 3 4 15. I am self-aware. 18 1 2 3 4 16. I can manage my emotions well, even when I am upset at work. 1 2 3 4 17. I am good at using resources to gain skills. 1 2 3 4 18. I am good at using the internet to search for professional opportunities. 1 2 3 4 19. I dress appropriately during interviews. 1 2 3 4 20. I interview well with future employers. 1 2 3 4 21. I am pleased with my current resume. 1 2 3 4 22. I am good at writing cover letters. 1 2 3 4 23. I have at least 5 people in my professional network. 1 2 3 4 24. I am good at managing stress. 1 2 3 4 25. I can identify signs of stress. 1 2 3 4 26. I use many different strategies to manage my stress. 1 2 3 4 19 Appendix B Week 1: Confidence 1. Self-confidence is not an important skill in the workplace or at school. a. True b. False 2. List 3 ways to build your confidence. a. _______________________ b. _______________________ c. _______________________ 3. Which of the following statements is NOT true about confident people? a. Confident people believe they can do many things well b. Are resilient and adaptable c. Have an overall positive view of themselves d. Do not think they have any weaknesses Week 2: SMART Goals & Self-Management 1. Write down what each letter in SMART stands for S: M: A: R: T: 2. Write one SMART goal: ______________________________________________________________________ ______________________________________________________________________ 3. What are 2 ways to stay organized? a. _______________________ b. _______________________ 4. What are 2 ways to manage your time? 20 a. _______________________ b. _______________________ 5. What does being adaptable mean? ______________________________________________________________________ ______________________________________________________________________ 6. List 3 aspects of professionalism. a. _______________________ b. _______________________ c. _______________________ Week 3: Social and Workplace Communication: 1. What are 3 things to do when you meet someone for the first time? a. _______________________ b. _______________________ c. _______________________ 2. What is important to include in a professional email? (Circle all that apply) a. Subject line b. ALL capital letters c. Personal greeting d. Body e. Signature f. Important personal information like your address 3. It is appropriate to interrupt the person on the other end of a phone call if you disagree. a. True b. False 4. How long should a professional voicemail be? a. Under 10 seconds b. Under 30 seconds c. Under 60 seconds d. However long it needs to be to get your information across 5. You encounter a problem at work. After you identify the problem, what should you do next? a. Brainstorm or predict outcomes b. Define the context of the problem- Why is it happening? Why is it important? c. Reflect on your decision 21 d. Act on the best solution 6. You become upset at work because your coworker took credit for your hard work. Instead of becoming upset and reacting negatively, what can you do? ______________________________________________________________________ ______________________________________________________________________ 7. What are 2 things to do to work well in a team? a. _______________________ b. _______________________ Week 4: Make Yourself Marketable 1. List at least 4 pieces of information you need to include in your resume. a. _______________________ b. _______________________ c. _______________________ d. _______________________ 2. It is appropriate to have a colorful resume with pictures. a. True b. False 3. What is the purpose of a cover letter? ______________________________________________________________________ 4. Which would NOT be an appropriate reference? a. A co-worker b. Your boss c. Your best friend d. Your case manager 5. Match the appropriate dress code with the correct letter. a. Business Casual ____ b. Casual ____ c. Business Professionals ____ 1. Comfortable, everyday shoes. Nice, clean jeans and blouse appropriate. 2. Dress shoes. Khakis, dresses, skirts, slacks. Button-up shirt with no tie. 3. Dress shoes. Pant or skirt suit. Button-up shirt and tie. Blazers. Week 5: Stress Management 1. What are 2 benefits of managing your stress? a. _______________________ 22 b. _______________________ 2. What are 3 ways to manage your stress? a. _______________________ b. _______________________ c. _______________________ 23 Appendix C Week DCE Stage Weekly Goal Objectives Tasks Date complete Meet with site mentor and introduce myself to staff 1 Independently Attend staff navigate site meeting location Quiz myself on Discuss project location of staff with site offices, personal mentor (as they space, meeting are different rooms than originally discussed) and Review MOU set up meeting and discuss times with goals with site other staff mentor/relevant members to personnel discuss current 1. Complete opportunities Review notes orientation to site and challenges from meetings location by the end to job readiness with staff, Orientation of the week transfer them Document onto Google Screening/Evalu 2. Begin needs notes from Drive if paper ation assessment meetings notes 1/10/23 1/13/23 TBD- carry over to next week 1/13/23 24 Establish supervision plan with site mentor Establish schedule to help CCI with site-specific tasks 1. Complete orientation to employee's roles by the end of the week Finalize Orientation 2. Complete needs assessment and submit finalized MOU 3. Begin Screening/Evalu recruitment 2 ation process Communicate with Employment Specialists at CCI to obtain current resources and ID gaps Meet with Case Managers to ID potential clients for program Schedule bi-weekly meeting with site mentor Contact Director of Education to obtain schedule for tasks Discuss meeting time to connect with employment team (has to be through site mentor for temperament issues) 1/19/23 Create a list of 1/18/23 prioritized potential clients 1/19/23 to reach out to 1/17/23 Attend cultural Assist in cultural orientation orientation 1/18/23 25 Help administer CORE model assessment Program Creation 3 Recruitment Discuss tasks Attend in home with Julie and cultural intern orientation Create "work" Ask for WhatsApp assignments Find participants Contact 4 schedule to families to ensure they will gather interest be available at offered times Set time/place 1. Dedicate 1 full for meeting Research in day to helping with Julie Education/Healt Julie from CCI h business Find more journals 2. Obtain at least 3 specific participants for program Create rough programming and planning outline of set schedule to research program on begin at least 1 outside of OT slides with next week specific talking Utilize Google points in 3. Create weeks Drive to create presentation 1-4 content slides notes 1/24/23 1/23/23 1/26/23 1/27/23 1/25-1/27/2 3 1/27/23 26 Complete Week 4-6 Powerpoints 1. Complete weeks 4-6 content Program Creation 2. Obtain at least 2 more participants for programming and schedule those for following week 3. Implement Recruitment week 1 programming 4 Implementation Thursday Week 4 PPT Week 5 PPT Week 6 PPT Complete Week 4 Ax Week 4-6 Week 5 Ax Activities Week 6 Ax Get contact info Contact 1 organized for person by potential Wednesday participants Reach out to 2 Contact 1 participants person by Obtain feedback Friday from programming Create plan for from Director of Thursday Education (driving times, Communicate etc) plan for Thursday with Make edits as Director of appropriate Education Meet with Implement week 1 Thursday programming with participants at appropriate meeting site participants Meet with Implement week 2 Monday programming with participants at appropriate meeting site participants Create outline Complete OT day of OT presentation by the presentation by 5 Implementation end of the week Wednesday Complete week 2 presentation and activities with clients on Thursday 1/30/23 1/31/23 1/31/23 1/31/23 2/1/23 2/1/23 2/2/23 2/2/23 2/1/23 2/2/23 2/9/23 Complete week 1 presentation with clients on Did not Monday/Tuesda complete- no y show and car troubles, After outline is postpone completed, add until next more detail and week information into topics and come 2/10/23 27 up with small activity to complete Complete week 1 session with Tuesday participants Meet with Tuesday participants Meet with Thursday Participants Implement relevant programming with participants Get OT related probs to pass Present OT Time around during 6 Implementation at staff meeting presentation Complete week 2/3 session with Thursday participants Email Kristin to 2/14/23 set up time to come to UIndy 2/16/23 Return equipment to Uindy Email Julie and Jessica reminders about midterm evaluation 2/12/23 2/14/23 Review midterm evaluation with Complete week site mentor and 2/3 session with supervisor Tuesday Ensure midterm participants evaluation is Meet with 2/20/23 completed Tuesday Complete week Participants 4 session with Implement participants, 2/21/23 relevant Meet with begin week 5 programming with Thursday session if time 7 Implementation participants participants allows 2/23/23 28 Complete week 4 session with Tuesday participants Complete week 5 and 6 session wih Thursday AM participants Meet with Tuesday participants Complete week 5 session with Thursday PM participants Meet with volunteer coordinator to discuss sustainability 2/28/23 N/A: Client cancelled so reschedule for next week Implement Meet with relevant Thursday programming with Participants participants 3/2/23 Record Weeks Begin 1 and 2 Read through 2/27/23 sustainability Sessions for and add notes on 8 Implementation portion of project Volunteers weeks 1 and 2 3/3/23 Complete week 5 session with Tuesday participants Meet with Tuesday participants Complete week 5 and 6 session wih Thursday 3/7/23 Implement Meet with AM participants relevant Thursday 3/9/23 programming with Participants Complete week participants 6 session with 3/9/23 Record Weeks Thursday PM Continue 3 and 4 participants 3/6/23 sustainability Sessions for 9 Implementation portion of project Volunteers Create 'advice 3/10/23 29 for mentors' document and begin jotting notes Read through and add notes on weeks 3 and 4 content Complete week 6 session with Tuesday participants 3/14/23 3/14/23 3/17/23 Administer post Meet with testing 3/16/23: Tuesday recording participants Upload post-test week 5/6 results into Data postponed to Implement Record week Analysis folder next week 2/2 relevant 5/6 session for increased programming with volunteers Add to 'advice time required participants for mentors' doc to assist with Begin training experience Continue new intern for Meet with new portion sustainability program intern to discuss 10 Implementation portion of project takeover program goals 3/13/23 Complete Data Analysis Enter data into Organize Google Sheets pre/post knowledge Run data check scores into analysis tabs 3/20/23 Edit Scholarly Report Discontinuation Work on Sustainability 11 Data Analysis Tasks Insert data Organize analysis into pre/post scholarly report confidence survey scores Complete into tabs informational 3/20/23 3/21/23 3/23/23 30 flyer for program Run averages and create bar charts Write results into scholarly report Complete Dissemination Presentation Create outline for dissemination presentation Find appealing PPT slides Book conference Send out Schedule room after poll information after Dissemination results are in poll results come Meeting in to attendees 3/28/23 Prepare points Dissemination Attend Volunteer to speak on at Print flyer for 3/27/23 Meeting to volunteer volunteer 12 Suststainability Advertise Program meeting meeting 3/30/23 Present on Monday 13 Dissemination Send presentation to people who are unable to make it Disseminate Results Complete Outcomes Edit Scholarly Report Write summary/abstr Write draft of act/conclusion summary Send Success Stories for Advertisement to Site Mentor Create outline of success story Resolve outcome comments 4/3/23 Email success story document site mentor 4/3/23 4/7/23 4/6/23 31 14 Wrap Up Complete Final Evaluation of Site Write draft of summary Go over final written evaluation of reflection student with site mentor and Touch base supervisor with site mentor and Complete supervisor to Scholarly Report plan meeting Draft time for evaluation Complete Uindy PPT Draft Edit suggestions by Complete Uindy the end of the Poster Draft week for drafts Email Kristina to ask for edits by Wednesday 4/13/23 Fill out evaluation on CORE 4/13/23 4/14/23 Submit assignments 4/15/23 32 Appendix D Figure C1. Knowledge check scores. Figure C2. Confidence survey scores.  ...

... Evaluation & Education of Texas Childrens Hospitals Constraint-Induced Movement Therapy Clinic and Implementation Process Katherine Kelley May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Kristina Watkins, OTD, MOT, OTR Abstract Neurological conditions in children impact their ability to participate in their daily activities. An intensive therapy approach called Constraint-Induced Movement Therapy (CIMT) was developed in the 1990s by Edward Taub, a neuroscientist. The approach was originally utilized to treat adults who suffered a stroke before being implemented in the pediatric setting. The goal of CIMT is to increase overall functional use of the affected upper extremity in an individual with a neurological condition through intensive therapy. The basis of CIMT is that intensive therapy reorganizes the neuropathways leading to improved function. Studies were done to measure the efficacy of CIMT in children with positive results. This led to the CIMT approach being implemented at hospitals around the country. Texas Childrens Hospital (TCH) is one of the many hospital systems to utilize this approach at two of their campuses in Houston. Their third campus does not have access to or the knowledge of CIMT which limits patient access and quality of care. My doctoral capstone project focused on educating the rehabilitation team at TCH Woodlands campus on CIMT and the process to implement the program at that site. Pre and post surveys were utilized to measure knowledge gained. The results of the survey found that occupational therapists and physical therapists have increased knowledge and believe CIMT to be beneficial. Additionally, the results showed that more therapists would be willing to be trained in CIMT if the program were implemented at the site. After disseminating my project to my mentor and the manager, they believe a CIMT clinic would add value to the program and increase access and quality of care for patients. Introduction Texas Childrens Hospital (TCH) is located in Houston, Texas. Texas Childrens is a not-forprofit organization which seeks to promote a healthier future for children through leading patient care, education, and research (Texas Childrens). The hospital opened in 1954 and has grown to a multi-campus hospital system that serves the Children of the greater Houston area and beyond. There are 10 locations, three of which are hospitals in downtown Houston, The Woodlands (WL), and Katy- West Campus. The other locations are scattered throughout the city and are specialty focused. According to US News TCH has been ranked the #2 childrens hospital in the nation as a result of continued research, dedication to patients, and quality of care (US News & World Report, 2022). One of the research-based specialty services TCH offers is constraint-induced movement therapy at the main medical campus in downtown Houston and at their Katy- West Houston location. Constraint induced movement therapy (CIMT) is a widely used therapeutic approach for individuals with a variety of neurological conditions that impair one side of the body. CIMT facilitates the use of an affected upper extremity by limiting use of the unaffected side. This, in turn, promotes strength, increased ROM, and coordination in the affected upper extremity. CIMT was originally used for adults but is now used in the pediatric setting to treat conditions such as brachial plexus injury, Cerebral Palsy, and hemiparesis. Implementing a CIMT clinic at TCH WL to address these types of conditions will further occupational therapys impact and quality of care. The limited access to the CIMT clinic for families who utilize TCH WL services poses an inconvenience as they are driving up to an hour to gain access to the clinic. The goal of my project is to evaluate the current CIMT clinic in downtown Houston and educate the rehab professionals at the Woodlands about CIMT and the implementation process. Implementing a CIMT program/clinic has the potential to increase revenue for the hospital, decrease burden of care by reducing transportation time and costs, and increase quality of life through CIMT. This scholarly report will continue to discuss the importance of constraint induced movement therapy and education about CIMT and the program implementation process provided to the rehab professionals at the Woodlands campus. Background After conducting a needs assessment, it was clear the rehabilitation team at Texas Childrens Hospital in the Woodlands, Texas, needed more resources that would enhance the quality of care provided to their patients. After discussing the needs of the site with the mentor assigned to the researcher, the researcher and mentor determined additional specialty care services would facilitate those outcomes. Through an educational in-service and a handout, the aim was to increase the knowledge and understanding of CIMT and how it can be implemented at TCH. Texas Childrens hospital is located in one of the largest cities in the country. That being said, access to specialty care services can become a challenge for the patients and families when there are only few locations that offer that specialty service. These campuses see children from the greater Houston area and beyond. There is an increasingly long waitlist for these children due to the high demand in CIMT services. Providing this service in at TCH WL would provide families and children who qualify for CIMT access along with a convenient location that will ultimately save time and reduce transportation costs. The Woodlands TCH is at least an hour drive to West campus where most children receive CIMT. The downtown TCH location (medical campus) is at least 45 minutes to individuals in the Woodlands and surrounding areas. This poses a need to increase access to these specialty services. Beyond TCH, pediatric Constraint -Induced Movement Therapy has been implemented around the country by renowned Hospitals including Cincinnati Childrens Hospital, Cleveland Clinic, Johns Hopkins All Childrens Hospital, and St Judes Childrens Hospital, supporting the importance and necessity of the expansion of CIMT programs around the country. Using the CIMT approach can increase function for children who live with a neurological condition affecting one of their upper extremities. The basis of CI therapy is that it enhances neuroplasticity and reorganizes the brain creating neuropathways that lead to improved function (Taub et al, 2002). The three main elements of CIMT intervention protocol developed by Edward Taub include repetitive task-oriented training of the more affected/ impaired upper extremity for several hours a day for 10 to 15 consecutive weekdays, applying a transfer package designed to enhance the carryover from the clinical setting to the patients real-world setting, and constraining the patient to use the more-impaired upper extremity over the course of treatment by restraining the less affected upper extremity (Morris et al, 2006). Taub, the founder of CIMT, began researching the efficacy of CIMT in the pediatric setting and found it to be efficacious for many neurological conditions such as cerebral palsy, brachial plexus injury, and hemiparesis, not only in children but also infants (Chamudot et al, 2018; Taub et al, 2002; Taub et al, 2004). The proven effects of CIMT is just one explanation as to why programs have been implemented all over the country. Additionally, multiple studies researching the long-term effects of CIMT found positive results at 2 month, 6 month and 1-year follow ups (Brogrdh & Lexell, 2010; CaseSmith et al, 2012; Eliasson et al, 2005). Showing the long term effects of CIMT can increase the likelihood of using the approach at major clinics. According to research completed by DeLuca et al., after completing CIMT for 5 days per week for 4 consecutive weeks, children demonstrated statistically significant improvements in function of their more affected upper extremity with 71% developing at least 15 new skills after Treatment 1 and 82% demonstrating absolute gains on the Emerging behavior Scale (EBS) from pretreatment to post-treatment 2 (DeLuca et al, 2015). Additionally, in a randomized control study done by Taub et al, 20 children with congenital hemiparesis ages 2-6, were assigned to receive CIMT or usual and customary care (developmental occupational therapy), with the control group crossing over to CIMT after 6 months (Taub et al, 2011). The study found that pediatric CIMT facilitated significant improvement in the affected arm compared to children receiving usual and customary care. Additionally, when the control crossed over to CIMT, the children demonstrated an improvement equivalent on all measures as the children receiving the CIMT treatment immediately (Taub et al, 2011). Although the study found significant improvements in function, the study also found that the immediate CIMT therapy group had a reduction in scores on the Pediatric Motor Activity Log from post-treatment to 6 months follow up, similarly to the cross over control group (Taub et al, 2011). There is no additional explanation as to why there is a reduction following the 6 months; however, the researchers report both groups still had large Pediatric Motor Activity Log improvements from pre-treatment to the 6-month follow up (Taub et al, 2011). A CIMT camp was held at Reid Hospital in Richmond, Indiana to better understand the impact pediatric CIMT had on children with cerebral palsy, brachial plexus, hemiparesis, and other neurological conditions affecting the body unilaterally. The camp was one week in duration and the children wore their cast for 7 hours with 1 hour of bimanual therapy (lunch and crafts). The primary investigator, Stephanie VanSlyke OTR, completed pre and post testing to determine the effects of CIMT in 6 different areas of upper extremity function including muscle tone, Range of Motion, Strength, Coordination, Stereognosis, Function use and quality of use (VanSlyke, 2022). The assessment tools used include Modified Ashworth scale, goniometry, dynamometer, Box and Blocks Test, Standardized Object Identification, and the Assisting Hand Assessment (VanSlyke, 2022). The post test revealed all campers showed improvements in 4 of the 6 functional categories and 4 of 6 campers showed improvement in the two remaining functional areas (VanSlyke, 2022). Its important to note the Assisting Hand Assessment is a tool characterized in the intervention protocol with substantial research to support its validity and reliability (Morris et al, 2006; Krumlinde-Sundholm, 2007). Johns Hopkins All Childrens Hospital offers CIMT at variable lengths resulting in improved overall function of the more affected upper extremity (Hopkins All Children, n.d). Cincinnati Childrens hospital offers a similar program in which has alluded to the same results as Johns Hopkins (Cincinnati Childrens, n.d.). The results of these studies in combination with existing effective CIMT clinics around the country support the implementation of a CIMT clinic at TCH WL. Researchers from South Africa studied the perceptions of occupational therapists and physical therapists on the use of CIMT for stroke rehabilitation therapy. The investigators suggested that although therapists know about CIMT, further education is required to bridge the knowledge gap (Mbuyisa et al, 2022). By providing education to the rehab team, the therapists will gain knowledge and understanding of an effective intervention that will lead to improved quality of care. Educating the therapists will offer an in-depth knowledge of a specialty service that will serve to improve their impact as occupational therapists. Theory and Frame of Reference The model I chose to guide my doctoral capstone project (DCE) is Person-EnvironmentOccupation-Performance (PEOP). The PEOP model focuses on the person, environment, occupation, and performance interaction and its related factors that contribute to occupational performance (Cole & Tufano, p 128). Specifically, the model addresses disruptions in performance, participation, and well-being (Cole & Tufano, p 128). I chose this theory because it examines the whole system that influences occupational performance (Cole& Tufano, p 129). My DCE project will explore the constraint-induced movement therapy Texas Childrens Hospital offers at two of their central locations as part of their specialty care services. I will then educate the occupational therapy team on the replication and implementation of the CIMT clinics. Based on the needs assessment completed with the occupational therapist at TCH -WL outpatient clinic, there is a substantial population that could benefit from CIMT but cannot afford to TCH main campus or TCH- West campus due to time restrictions. The PEOP model will guide me through the assessment of the person-environment-occupation-performance interaction and how to optimize the populations occupational performance through CIMT. An analysis utilizing this model will inform decisions about how to enhance occupational performance at the clinic. In addition to the PEOP model, the Motor Learning frame of reference can be utilized to inform my project. The Motor learning Frame of Reference focuses on acquisition of skills. According to Latash et al, motor learning is a process focusing on practices, feedback, and involvement of the learner (Burgess, 1989; Jarus, 1994; Latash et al, 2010). The child, task, environment, and their interaction should be considered during the evaluation process. Information from observations of childs performance, their caregivers on daily performance, analysis of the task, analysis on demands and characteristics of the environment are considered during the evaluation process (Burgess, 1989), similarly the CIMT clinic uses a similar approach to gain an understanding of the patient. During interventions, the therapist facilitates and structures learning situations that promote the childs ability to perform the tasks, which are functional activities that fit the childs occupation (Latash et al, 2010). Through this frame of reference, well-being and Quality of life can be improved through facilitation of skill development, and improved interactions between the person and their environment. This FOR aligns with the PEOP model and my DCE project because it facilitates improved function and occupational performance. Project Design Texas Childrens hospital, as mentioned previously, is a multi-campus organization. Two of their locations offer Constraint-Induced Movement Therapy (CIMT) while their third location does not. Through the completion of a needs assessment, the researcher found there was a necessity for CIMT at their third location. The absence of a CIMT clinic at the Woodlands location affects their patients ability to participate in the CIMT program. The CIMT program is intensive with a 100% attendance policy creating a barrier for families who live further away. A survey of the occupational therapy team at the Woodlands campus was completed to gain clarity on the practitioners current knowledge of CIMT and whether they had patients who could benefit from the program. The survey showed that 81.8% of the occupational therapists have an average knowledge of CIMT and 18.2% have very little knowledge of CIMT. The researcher later decided to include physical therapists in a two-question pre-survey since they would be attending the educational in-service. The physical therapists were asked how much they knew about CIMT using the same Likert scale provided to the occupational therapists and how many patients they treated that could be potential candidates for CIMT. Additionally, the same post-survey was provided asking three questions after the rehabilitation team attended the presentation. After analyzing the survey results, it was clear there was a gap in knowledge of CIMT and a need and desire for the program to be implemented. The results of these surveys can be found in Project Outcomes. To create educational resources for the occupational therapists, the researcher began by gathering research about constraint induced movement therapy. It was important that the researcher had a thorough understanding of CIMT to effectively educate the therapists. Through extensive research, the researcher had increased their own knowledge and preparedness to educate the therapists. In addition to research, the investigator shadowed the occupational therapist at the CIMT clinic to evaluate the program and gather necessary material to provide to the Woodlands therapists. Shadowing the clinic increased the investigators understanding of the relationship between CIMT research, the clinic, and the carryover into a clinical setting. Educational resources, such as an in-service informing the rehab team about CIMT, handouts about casting used in CIMT, and a resource binder that holds information about all necessary components of the CIMT clinic were provided to the clinic. Multiple challenges presented themselves as the project progressed. Developing a new project that was relevant to the clinic posed a challenge because this was not the original site the researcher was going to complete the capstone experience at. Additionally, the manager of the clinic is a physical therapist and did not initially understand what CIMT was or what it would look like to implement the approach. The manager expressed to the researcher that the clinic did not have the resources, however, upon researching and reviewing necessary components and resources necessary, it was clear that was not a problem. Because there was a misconception, the researcher made sure to include a section about finances and resource needed to implement the clinic. Project Outcomes To evaluate the needs of the Woodlands campus and identify areas of improvement, a needs assessment was completed. The needs assessment showed the need for specialty services such as constraint-induced movement therapy. A survey was then created to understand the current knowledge and perceptions about CIMT of the occupational therapists at TCH the Woodlands campus. There was a total of 18 respondents for each pre-survey given to the occupational therapists (11) and physical therapists (7). The results are broken down separately between two per-surveys because the research decided to include physical therapists after the initial survey was provided to the occupational therapists. The initial survey given to the occupational therapists contained 5 questions related to Constraint-Induced Movement Therapy. Eleven therapists responded to the survey. Question six was added after two participants had already answered the survey. The questions are listed below: 1. How much do you know about Constraint-Induced Movement Therapy? 2. Do you Believe CIMT is Beneficial for patients? Yes/No/Maybe 3. Choose the perceived benefits from CIMT program. 4. If CIMT clinic was developed at TCH in the Woodlands, would you be willing to be trained in CIMT? 5. How many patients do you have that could be potential candidates for CIMT? A 5-point Likert scale was used in question 1 to gage occupational therapists knowledge about CIMT. The 5 components of the scale include none, very little, average, advanced, and expert. Of the 11 responses 18.2% had very little knowledge of CIMT and 81.8% have an average knowledge of CIMT. Those statistics suggest a gap in therapists knowledge of CIMT, however 100% believe CIMT to be beneficial as shown in the responses to question 2. Additionally, the responses to question three varied, further supporting the need to educate the therapists about CIMT and its benefits. The results of the perceived benefits of CIMT program are listed in Table 1. Lastly, question 5 supports the importance of a CIMT program at the Woodlands clinic. Six of the nine therapists responded to this question as it was added after two participants had already taken the survey, finding that up to 17 children total could be potential candidates for the CIMT program. The third participant responded to the question stating, Id like to learn more about modified CIMT for babies showing early signs of unilateral preference. Table 1. Perceived Benefits of CIMT Benefits # of therapists who perceived component as beneficial Improved muscle tone 6 Increased ROM 8 Increased strength 8 Improved sensation 9 Coordination (FM/GM) 9 Improved functional use and quality of use 11 Self-confidence 7 Other 2 Additionally, the pre-survey was provided to the physical therapists who attended the presentation as well. The pre-survey included the same 5-point Likert scale the occupational therapists received and how many patients they treated that could be potential candidates for CIMT. The survey results included 71.4% indicating they had average knowledge of CIMT and 28.6% indicating they have little knowledge of CIMT. The survey also showed between the 7 physical therapists who took the survey, 21 patients could be potential candidates for CIMT, putting the total for OT and PT patients who could benefit at around 30. Many responses included indicators such as greater than, or over, suggesting the number could be even higher. A post survey was provided after presenting the CIMT presentation and other educational handouts. The survey included three questions. The three questions are as follows: 1. Do you feel the CIMT presentation increased your knowledge and understanding of CIMT and program implementation process. 2. After CIMT presentation, how much do you feel you understand about CIMT. 3. Has your interest and willingness to be trained in CIMT changed after learning about CIMT. The post-survey was filled out by 15 out of 18 of the attendees who took either the initial OT survey or PT survey. One participant was unable to attend the presentation, therefore preventing participation in the post survey, and 2 participants did not fill out the post-survey prior to the researchers departure at the site. Responses to the first questions showed 100% of respondents felt the CIMT presentation increased their knowledge and understanding of CIMT and program implementation process. After the presentation 66.7% felt they had average and 33.3% felt they had advanced knowledge. When asked if interest and willingness to be trained in CIMT changed after learning about CIMT 60% (9) answered yes, 27% (4) answered no, 7% (1) answered maybe, and 7% (1) answered other. The other response was, seeing the casting process definitely made it more feasible for me to do CIMT. Though the decision to create a survey for the physical therapists was decided later in the semester, it was to ensure that the education provided to the entire rehab team was informational and ultimately beneficial to the development of the CIMT program. The researcher was then able to examine the knowledge before and after the presentation with a larger sample size. The initial surveys provided to occupational therapists and physical therapists showed a gap in knowledge of CIMT. The post-surveys show and increase in knowledge and interest in CIMT. Both occupational and physical therapists have a substantial number of patients who could benefit from CIMT. The survey does not consider the overlap of patients seen by both PT and OT, which could also alter the number. Regardless, there is a large number of patients who could benefit but do not have access to the service due to time, cost, and ultimately access to services. Summary Constraint-Induced Movement Therapy (CIMT) is a therapeutic approach used to treat individuals who have a neurological impairment. The goal is to improve overall function and quality of use of the affected upper extremity to enhance participation in the individuals ADLs and occupations. The approach has been implemented across the country at renowned hospitals such as Cleveland Clinic, Johns Hopkins, and Cincinnati Childrens Hospital. Texas Childrens Hospital offers CIMT programs at two of their campuses limiting access to patients who could benefit from it. Not only is there a substantial wait list at both campuses, patients and their families are driving up to an hour or more to receive treatment. Furthermore, continuation of care at the same facility can build rapport and trust between the patient and therapists. Evaluating and educating the rehab team about CIMT at TCH WL would increase knowledge and allow for the implementation of the program. Educational material including CIMT handouts, a handout on how to CIMT cast, and an in-service presentation were provided to the therapists. Pre and post surveys were given to measure perceived knowledge of CIMT. The pre-survey results suggested a gap in knowledge about CIMT and the process of the program. The pre-survey also showed the occupational and physical therapists have approximately 40 children as potential CIMT candidates. The post survey results suggested an increase in therapists knowledge and understanding of CIMT. Additionally, desire to implement the program at TCH WL has increased with multiple therapists expressing interest in getting trained in the CIMT approach and implementing the program at the site. Overall, the evaluation and education of the CIMT program has increased therapists knowledge and revealed a need for the implementation at TCH WL. Conclusion Throughout this project, I evaluated and educated therapists about CIMT. CIMT is used to improve function of an affected upper extremity in individuals who have a neurological condition such as cerebral palsy, brachial plexus, and stroke. The therapists found the presentation and handouts to be beneficial and a pre and post survey measured increased knowledge of the therapists after the in-service presentation. A need for the implementation of a CIMT program has been shown and could ultimately increase the quality of care provided for individuals at the clinic who qualify for the program. Therapists have an increased desire to implement the program, which, can lead to increased quality of life for patients who receive this therapeutic approach. Though intensive, CIMT intervention protocol shows long term results that improve functional use of the affected upper extremity. This should change the way we treat neurological conditions as a profession. The intensive aspect facilitates the development of the neuropathways necessary to improve functional use and participation in ADLs. References Burgess M. K. (1989). Motor control and the role of occupational therapy: past, present, and future. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 43(5), 345348. https://doi.org/10.5014/ajot.43.5.345 Brogrdh, C., & Lexell, J. (2010). A 1-year follow-up after shortened constraint-induced movement therapy with and without mitt poststroke. Archives of physical medicine and rehabilitation, 91(3), 460464. https://doi.org/10.1016/j.apmr.2009.11.009 Case-Smith, J., DeLuca, S. C., Stevenson, R., & Ramey, S. L. (2012). Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month followup. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 66(1), 1523. https://doi.org/10.5014/ajot.2012.002386 Chamudot, R., Parush, S., Rigbi, A., Horovitz, R., & Gross-Tsur, V. (2018). Effectiveness of Modified Constraint-Induced Movement Therapy Compared With Bimanual Therapy Home Programs for Infants With Hemiplegia: A Randomized Controlled Trial. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 72(6), 7206205010p17206205010p9. https://doi.org/10.5014/ajot.2018.025981 Cole, M. & Tufano, R. (2020). Applied Theories in Occupational Therapy: A Practical Approach (2nd Ed.). Slack, Inc. Constraint Induced Movement Therapy (CIMT) plus Bimanual Training (BIT). Cincinnati Childrens. (n.d.). Retrieved from https://www.cincinnatichildrens.org/service/o/ot-pt/cimt Constraint-Induced Movement Therapy. Cleveland Clinic. (n.d.). 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... DISABILITY EDUCATION PROGRAM 1 Disability Education Program for Managers at The Childrens Museum Megan Johnson May 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Erin Peterson, DHSc, OTR, CHT DISABILITY EDUCATION PROGRAM 2 Abstract Authors of recent evidence-based practice literature have shown that disability education programs increase knowledge and understanding of disabilities in program participants; these programs have also produced a short-term increase in positive attitudes toward disabilities. This doctoral capstone project took place at The Childrens Museum of Indianapolis. A disability education program was created for managers to increase knowledge about support for disabled employees and increase positive attitudes toward disabilities. The program took place in four sessions; topics included destigmatizing disability, education on common disabilities, the Americans with Disabilities Act (ADA) of 1990 and universal design, and providing workplace accommodations. Pre- and post-assessments were used to measure program outcomes. The change in scores demonstrated a significant increase in knowledge among participants, as well as a slight decrease in comfort in scenarios related to attitude towards disability. DISABILITY EDUCATION PROGRAM 3 Disability Education Program for Managers at The Childrens Museum The Childrens Museum of Indianapolis (TCM) is the largest childrens museum in the world. Located in downtown Indianapolis, the facility stretches across twenty-nine acres of the city. The museum has a mission of creating extraordinary learning experiences across the arts, sciences, and humanities that have the power to transform the lives of children and families and a vision of being recognized as the global leader among all museums and cultural institutions serving children and families, which they have been striving towards for close to 100 years (The Childrens Museum, n.d.). Families from all over the world visit the museum, with an average of 1.3 billion visitors a year before the COVID-19 pandemic (The Childrens Museum, 2022). This doctoral capstone project took place at TCM under the supervision of the Director of Training and Professional Development. The focus of the project was to develop a training program for management staff. The program provided education about disabilities and disabilityrelated topics to foster an inclusive work environment and provide managers with ways to best support disabled staff. This program was needed due to a lack of knowledge of best practices for supporting disabled staff in the workplace. Creating this program allowed managers to access information they would not otherwise have regarding collaborating with a colleague who has a disability. Background The Childrens Museum of Indianapolis has close to four hundred employees from Indianapolis and surrounding cities. According to the 2020 U.S. Census, approximately 887,642 people are living in Indianapolis (U.S. Census Bureau, n.d.). The 2020 census found that 60% of Indianapolis citizens are White/Caucasian, about 30% of citizens are Black, and 10% of the population is Hispanic or Latino (U.S. Census Bureau, n.d.). According to a survey conducted by the museums Diversity, Equity, Accessibility, and Inclusion (DEAI) task force in April 2022, DISABILITY EDUCATION PROGRAM 4 approximately 18% of staff members have a disability (Martin, 2023). The staff at the museum have been heavily focused on DEAI efforts to create a more inclusive environment. A needs assessment was conducted to determine what project would be most beneficial to the museum. Two stakeholders, the Director of Training and Professional Development and the Accessibility Manager, provided information regarding the demographics, health needs, and health disparities of the museum staff, as well as the values and both the physical and social environment of the museum as a company. The main service gap identified was staff training. The Director of Training and Professional Development mentioned that all museum employees typically receive training regarding disabilities and how to interact with disabled guests. There was no training available regarding working with staff who have disabilities at the time of the interview. According to the Director of Training and Professional Development, It would be beneficial to have some training that focuses on topics such as the process for providing accommodations and supervising disabled employees (personal communication, March 8, 2022). The information gathered from the needs assessment was used as the starting point for developing a project that addressed the identified gap in service. There are limited evidence-based practice articles regarding disability inclusion or accessibility in museums, which makes it challenging to examine the need in this area; however, there is evidence regarding the need for disability awareness training among employees that can be generalized. Several articles focused on the impact disability awareness training had on staff who collaborated with disabled guests, customers, or consumers with disabilities (Brannen et al., 2017; Hall, 2008; Hayward et al., 2021; Rochette et al., 2017). The researchers found that disability awareness training not only increased the staffs knowledge about shared challenges disabled people face in the community, but the training also increased positive attitudes toward DISABILITY EDUCATION PROGRAM 5 individuals with disabilities. Although the articles support the benefits of providing disability education to staff, they do not discuss training for working with disabled staff in the respective settings. The researchers findings could be generalized to support the disability training program at The Childrens Museum. This doctoral capstone project examined the impact of disability education on managers who may be supervising disabled employees. A few articles focused on attitudes toward disability. Castillo and Larson (2020) found that a variety of methods could be utilized in interventions focused on changing attitudes toward disability; these methods included formal instruction, contact, simulations, and solo interventions. Hayward et al. (2021) also discussed attitudes toward disabilities and found that disability education provided a short-term change in attitudes toward disabilities (p. 264). These articles both supported this capstone project by providing evidence of instruction leading to attitude changes. This capstone project focused specifically on formal instruction regarding disabilities and the effect on manager attitudes. There was limited evidence supporting the role of occupational therapy in museums; however, there is evidence supporting the role of occupational therapists in the workplace. Occupational therapists understand functional abilities and demands that a job can place on individuals with disabilities, and this knowledge allows them to assist employers by providing education on disabilities and reasonable accommodations for disabled employees (American Occupational Therapy Association, 2000; Shamberg, 2005). To summarize, there is evidence to support disability awareness training or education as a method to increase knowledge about disabilities and increase attitudes toward disabilities. This information was analyzed and used to further explore the impact disability awareness education can impact the knowledge and attitudes DISABILITY EDUCATION PROGRAM 6 of managers working with disabled employees. The project was further supported by occupationbased models and theories. Foundational Basis Two theories were utilized to guide the doctoral capstone experience. The PersonEnvironment-Occupation-Performance (PEOP) model is an occupation-based model that puts the client or organization at the center of the system and focuses on the relationship between individuals, populations, and organizations who have varying needs (Cole & Tufano, 2020). This model was used to explore the relationship between managers (person), the museum (environment), work (occupation), and their ability to support disabled employees within their departments (performance). The PEOP model was further utilized throughout the project to assess the population and guide informed decision-making regarding supporting occupational engagement among managers and their employees. The second theory that guided the doctoral capstone experience was the Theory of Planned Behavior (TPB), which is often utilized within the field of public health. TPB draws on the idea that behavior is driven by behavior intentions, which have three determinants: attitude toward a specific target behavior, subjective norms, and perceived behavioral control (Azjen, 1991). These determinants influence an individuals ability to change behavior. This theory was utilized to develop a training that produced a behavior change. TPB aligned well with PEOP, as intrinsic factors such as attitude could impact occupational engagement. Project Design and Implementation The Director of Training and Professional Development and the Accessibility Manager both indicated in the needs assessment that management staff needed more training regarding providing support to staff who have disabilities. The Occupational Therapy Practice Framework (American Occupational Therapy Association, 2020) was used to determine which domains DISABILITY EDUCATION PROGRAM 7 should be addressed through the program. The domains addressed through the program were environmental factors (the museum), and client factors (values and beliefs) regarding the performance patterns (the role of the managers). The topics selected were as follows: destigmatizing disability, education on common disabilities, the Americans with Disabilities Act (ADA) of 1990 and universal design, and providing workplace accommodations. The goal of the program was to increase knowledge and change attitudes about disability at TCM, so the outcome measure needed to reflect this goal. There were no existing tools that adequately assessed changes in knowledge and attitudes based on the specific program content, so an assessment tool had to be created. The program was implemented at TCM as a pilot due to time constraints and the size of the targeted population, as there are over a hundred managers across the departments. The program was offered in four sessions that were under an hour long. All managers were sent an email containing ten signup slots for the pilot; all ten slots were filled. The first session was focused on addressing the stigma surrounding disability, disability stereotypes, and identifying ableism in the workplace. The book Demystifying Disability: What to Know, What to Say, and How to Be an Ally by Emily Ladau (2021) was used to assist with explanations of abstract topics such as ableism and stigma. The second session focused on common conditions that can result in disability, and how disability may impact occupational performance. Conditions in Occupational Therapy: Effect on Occupational Performance (2017) was utilized to explain specific conditions, and clinical reasoning was supplemented to provide information regarding the impact of symptoms on occupations within the context of job roles at the museum. Session three examined the concepts of access versus inclusion in the built environment through a discussion of ADA Title III and Principles of Universal Design. A position paper from the American Occupational DISABILITY EDUCATION PROGRAM 8 Therapy Association (2022) was used to guide this session, as the authors explained the role occupational therapy can play in creating an inclusive physical environment. The final session addressed the rights of disabled employees under ADA Title I, focusing specifically on workplace accommodations and disclosure of disability. Several articles about workplace accommodations and disclosure were used to guide session content (Geyer, 2021; Phillips et al., 2016; Prince, 2017; Sally et al., 2021). The program concluded by reviewing the concepts discussed across the entire training, and recommendations for what managers could do as a next step in promoting disability inclusion in the workplace. Project Outcomes Project outcomes were evaluated using pre- and post-assessments. Both assessment tools consisted of thirteen Likert items. Statements one through seven assessed knowledge, while statements eight through thirteen assessed attitudes. Participants were asked to rank each statement on a scale from 1 (strongly disagree) to 5 (strongly agree). The post-assessment also contained open-ended questions about program content, and answers from this section were utilized to revise and finalize the program content before delivering the materials to the site for ongoing future use. The statements chosen for the assessment tools were created based on the content of the program. It was necessary to create a new assessment tool rather than modify or use a tool that already existed so that the statements most accurately reflected the content being covered in the program. The pre-assessment was administered to the ten program participants at the start of the first session. The mean for each item was calculated to find the average score, and ranges of scores were identified. Most of the participants ranked statements regarding knowledge between two and five on the Likert scale. This indicated that they disagreed, agreed, or strongly agreed that they had knowledge about the topics covered in the statements. The means and range of DISABILITY EDUCATION PROGRAM 9 scores for items assessing knowledge are found in Table A1. Most of the participants ranked statements regarding attitudes between three and five on the Likert scale. This indicated that participants agreed or strongly agreed with the statements in this section. The means and ranges for items assessing attitudes can are found in Table A2. The post-assessment was administered at the end of the final program session. Due to unforeseen circumstances, only nine participants returned the post-assessments following the final session. Most of the participants ranked the statements regarding knowledge between four and five on the Likert scale; this indicated that they agreed or strongly agreed that they had knowledge regarding the topics in each statement. There was a significant positive change in scores from the pre-assessment to the post-assessment, as seen in Table A1. This indicates that participants had an increase in knowledge regarding disabilities. Most of the participants ranked statements regarding attitudes between four and five on the Likert scale, meaning they agreed or strongly agreed with the statements in this section. There was a negative change in scores from the pre-assessment to the post-assessment, as seen in Table A2. There are several factors that could have impacted the scores. One factor was the small sample size of the pilot group. There would have been a better distribution of scores if there were a larger sample size. A second factor is that participants were not asked if they had any previous experience working with disabled individuals; a few participants may have already had some knowledge about disabilities. Finally, participants may have ranked items based on the knowledge they thought they had prior to the program, and ranked items lower on the postassessment when they realized they did not have as much knowledge as they thought they did. This could also apply to the items assessing attitude; it is possible that the participants felt more comfortable in the given scenarios based on their perceived knowledge of disabilities prior to the DISABILITY EDUCATION PROGRAM 10 program. Overall, there was a significant increase in scores on items pertaining to knowledge, indicating that participants gained knowledge regarding disabilities; although there was a slight decrease in scores for the items about attitudes, participants verbalized that they felt more comfortable working with disabled employees and therefore continued to have positive attitudes toward disabilities. Summary The doctoral capstone project took place at The Childrens Museum. The museum staff have been focusing heavily on DEAI efforts to create a more inclusive space for both visitors and staff. The main gap in service was staff training, specifically training about ways managers can better support disabled employees within their departments. There were several pieces of literature that support disability education training as a method of increasing knowledge and changing attitudes toward disability. A training program was created for managers at the museum. The development of the program fulfilled a need at TCM, as the site did not have any training that addressed working with disabled employees. The program took place over four sessions; each session covered a separate topic. Assessments were administered to program participants during the first and fourth sessions. Results showed an increase in scores on items assessing knowledge and a decrease in scores on items assessing attitudes; however, feedback throughout the program showed that participants continued to have positive attitudes toward disabilities. Conclusions There were several takeaways regarding the sustainability of the disability education program at the museum. The Director of Training and Professional Development anticipated utilizing the training program to provide more education to managers across all departments. DISABILITY EDUCATION PROGRAM 11 This would allow managers to have an increased understanding of disabilities and shared challenges their staff may face. Having this knowledge would result in managers providing better support to disabled staff in their departments; however, the Director did not have the knowledge or experience needed to implement the new program independently. A facilitator guide was given to the Director to assist with implementing the program for a large audience. In addition to this, the Director was provided with PowerPoint slides and audio recordings of the training sessions. These resources allow the site the option of providing the training in-person, virtually, or in a hybrid format going forward. There are two implications for future practice within the occupational therapy profession. One implication is the importance of expanding the role of occupational therapy into less traditional community settings, such as museums. This doctoral capstone project resulted in a greater understanding of the role of occupational therapists in less traditional settings. Continuing to expand occupational therapy into these settings allows practitioners to reach populations settings where there may be occupational injustices that are not being addressed. The second implication is the need for continued growth of occupational therapys role in the workplace and in disability education. These practice areas are within the occupational therapy scope of practice, but there are unfulfilled needs within the workplace such as education about disabilities, assistance with providing reasonable accommodations, and addressing physical barriers to occupational engagement. This project resulted in an increased understanding of the role occupational therapists can play within the workplace. DISABILITY EDUCATION PROGRAM 12 References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179211. doi:10.1016/0749-5978(91)90020-T. American Occupational Therapy Association. (2000). Occupational therapy and the Americans with Disabilities Act (ADA). American Journal of Occupational Therapy, 54, 622625. American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). https://doi-org.ezproxy.uindy.edu/10.5014/ajot.2020.74S2001 American Occupational Therapy Association. (2022). Inclusive environments: Home, work, public spaces, technology, and specialty environments. American Journal of Occupational Therapy, 76(Supplement 3). https://doi.org/10.5014/ajot.2022.76S3001 Atchison, B., and Dirette, D. (2017). Conditions in occupational therapy: Effect on occupational performance (5th ed.). Wolters Kluwer. Brannen, M.H., Milewski, S. and Mack, T. (2017). Providing staff training and programming to support people with disabilities: An academic library case study. Public Services Quarterly, 13(2), 61-77. https://doi.org/10.1080/15228959.2017.1298491 Castillo, Y.A. and Larson, A. (2020). Attitudes towards people with disabilities: A systematic review of intervention effectiveness. COUNS-EDU: The International Journal of Counseling and Education, 5(2), 40-57. https://doi.org/10.23916/0020200526120 The Childrens Museum of Indianapolis. (2022). 2021 annual report. https://www.childrensmuseum.org/2021-annual-report DISABILITY EDUCATION PROGRAM 13 The Childrens Museum of Indianapolis. (n.d.). Mission. https://www.childrensmuseum.org/about/mission Cole, M. and Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Geyer, P.D. (2021). Acquiring workplace accommodations when management support is voluntary: Crafting jobs and accommodations. Journal of Rehabilitation, 87(3), 31-35. Hall, E.W. (2008). Changing the way employees interact with guests with disabilities. Journal of Disability Policy Studies, 19(1), 15-23. https://doi.org/10.1177/1044207308315284 Hayward, L., Fragala-Pinkham, M., Schneider, J., Coe, M., Vargas, C., Wassenar, A., Emmons, M., Lizzio, C., Hayward, J., & Torres, D. (2021). Examination of the short-term impact of a disability awareness training on attitudes toward people with disabilities: A community-based participatory evaluation approach. Physiotherapy Theory & Practice 37(2), 257270. https://doi.org/10.1080/09593985.2019.1630879 Ladau, E. (2021). Demystifying disability: What to know, what to say, and how to be an ally. Ten Speed Press. Martin, S. (2023). DEAI staff survey disability responses 2022 [PowerPoint slides]. Phillips, B.N., Deiches, J., Morrison, B., Chan, F., and Bezyak, J.L. (2016). Disability diversity training in the workplace: Systematic review and future directions. Journal of Occupational Rehabilitation, 26, 264-275. Prince, M.J. (2017). Persons with invisible disabilities and workplace accommodation: Findings from a scoping literature review. Journal of Vocational Rehabilitation, 46, 75-86. DISABILITY EDUCATION PROGRAM 14 Rochette, A., Swaine, B., Kehayia, E., Roche, L., Gurard, C., and Bourque, L.E. (2017). Can training offered to shopping mall employees improve their knowledge about disability and perceived self-confidence in interacting with persons presenting various limitations?. Cogent Social Services, 3(1), 1-8. https://doi.org/10.1080/23311886.2016.1274226 Sally, L., Osten, V., Rezai, M., and Bui, S. (2021). Disclosure and workplace accommodations for people with autism: A systematic review. Disability and Rehabilitation, 43(5), 597610. https://doi.org/10.1080/09638288.2019.1635658 Shamberg, S. (2005). Occupational therapy practitioner role in the implementation of worksite accommodations. Work, 24, 185-194. US Census Bureau (n.d.). Indianapolis QuickFacts. Retrieved January 2023, from https://www.census.gov/quickfacts/indianapoliscitybalanceindiana DISABILITY EDUCATION PROGRAM 15 Appendix A Analysis of Outcomes Data Table A1 Results of Assessment Questions Regarding Knowledge Table A2 Results of Assessment Questions Regarding Attitudes DISABILITY EDUCATION PROGRAM 16 Appendix B Program Assessment Tools Supporting Staff with Disabilities Pre-Assessment Directions: Read each statement and circle the number that corresponds with your level of agreement. I can identify at least 1 barrier to creating an inclusive workplace. 1 Strongly Disagree 2 3 4 5 Strongly Agree 2 3 4 5 Strongly Agree 4 5 Strongly Agree I know what ableism is. 1 Strongly Disagree I can identify 1 way to prevent ableism in the workplace. 1 Strongly Disagree 2 3 I can identify how a specific disability (ex. Anxiety) can impact ones performance in the workplace. 1 Strongly Disagree 2 3 4 5 Strongly Agree I can list examples of how The Childrens Museum is ADA-compliant. 1 Strongly Disagree 2 3 4 5 Strongly Agree I can list examples of Universal Design within The Childrens Museum. 1 Strongly Disagree 2 3 4 5 Strongly Agree DISABILITY EDUCATION PROGRAM 17 I know who to contact if a member of staff needs accommodations. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has a physical disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has a mental health disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has an intellectual/developmental disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree 4 5 Strongly Agree I am comfortable discussing disability in the workplace. 1 Strongly Disagree 2 3 I am comfortable collaborating with staff to provide reasonable accommodations. 1 Strongly Disagree 2 3 4 5 Strongly Agree 4 5 Strongly Agree The Childrens Museum is inclusive of staff with disabilities. 1 2 3 DISABILITY EDUCATION PROGRAM 18 Strongly Disagree Supporting Staff with Disabilities Post-Assessment Directions: Read each statement and circle the number that corresponds with your level of agreement. I can identify at least 1 barrier to creating an inclusive workplace. 1 Strongly Disagree 2 3 4 5 Strongly Agree 2 3 4 5 Strongly Agree 4 5 Strongly Agree I know what ableism is. 1 Strongly Disagree I can identify 1 way to prevent ableism in the workplace. 1 Strongly Disagree 2 3 I can identify how a specific disability (ex. Anxiety) can impact ones performance in the workplace. 1 Strongly Disagree 2 3 4 5 Strongly Agree I can list examples of how The Childrens Museum is ADA-compliant. 1 Strongly Disagree 2 3 4 5 Strongly Agree I can list examples of Universal Design within The Childrens Museum. 1 Strongly Disagree 2 3 4 5 Strongly Agree DISABILITY EDUCATION PROGRAM 19 I know who to contact if a member of staff needs accommodations. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has a physical disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has a mental health disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree I am comfortable working with a colleague who has an intellectual/developmental disability. 1 Strongly Disagree 2 3 4 5 Strongly Agree 4 5 Strongly Agree I am comfortable discussing disability in the workplace. 1 Strongly Disagree 2 3 I am comfortable collaborating with staff to provide reasonable accommodations. 1 Strongly Disagree 2 3 4 5 Strongly Agree 4 5 Strongly Agree The Childrens Museum is inclusive of staff with disabilities. 1 Strongly Disagree 2 3 Supporting Staff with Disabilities Training Series Feedback DISABILITY EDUCATION PROGRAM Directions: Please take time to read and fully answer each question. Your feedback will assist with improving the training series. Thank you again for attending this pilot group! Session 1 (Discussing Stigma and Ableism) What information was beneficial to you? Was there any information that felt unnecessary to include? If so, please specify. Was there any information you were expecting to learn that was not included? If so, please specify. Optional- Additional comments: Session 2 (Discussing Common Conditions) What information was beneficial to you? Was there any information that felt unnecessary to include? If so, please specify. Was there any information you were expecting to learn that was not included? If so, please specify. Optional- Additional comments: Session 3 (ADA Title III and Universal Design) What information was beneficial to you? 20 DISABILITY EDUCATION PROGRAM Was there any information that felt unnecessary to include? If so, please specify. Was there any information you were expecting to learn that was not included? If so, please specify. Optional- Additional comments: Session 4 (ADA Title I and Workplace Accommodations) What information was beneficial to you? Was there any information that felt unnecessary to include? If so, please specify. Was there any information you were expecting to learn that was not included? If so, please specify. Optional- Additional comments: General Feedback What questions do you still have? What topics would you like to learn more about? Do you feel you will be able to apply the information from this training series in your role as a people manager/supervisor? 21 DISABILITY EDUCATION PROGRAM 22 Do you feel that all people managers/supervisors at TCM would benefit from completing this training? Why or why not? Other Comments DISABILITY EDUCATION PROGRAM 23 Appendix C Doctoral Capstone Experience Weekly Planning Guide Week 1 DCE Stage Orientation Weekly Goal Complete first part of Orientation by end of week. Begin outlining project timeline Objectives Meet with site mentor and other site personnel to introduce myself and educate them on why I am here and what I will be doing during the next 14 weeks. Understand site environment, locate appropriate workspace, etc. Create loose outline based on current idea 2 Screening/ Evaluation Update MOU by end of week Update DCE goals Tasks Create talking points/elevator pitch to explain my role as a capstone student 01/26 Attend scheduled Orientation days on 01/06, 01/11 and 01/26 Complete any paperwork or trainings assigned by site Meet with site mentor to discuss current project idea, end goal, etc. Update all sections of MOU as needed Meet with faculty mentor to ask questions Update Needs Assessment Date complete 01/10 Meet with stakeholders to ask 01/12 01/13 01/20 01/17 01/17 DISABILITY EDUCATION PROGRAM 3 4 Screening/ Evaluation 24 Continue updating literature Continue lit search based on updated project idea Continue learning about site Begin attending staff meetings Implementation Begin designing program with more details Continue learning about roles of key personnel at site Project Objective: Identify 4 session topics for program by end of week 4 of DCE. Experience Objective: Meet with OTR to learn about their role at site by end of week 4 of DCE. Experience Objective: Meet with Research and Evaluation staff by week 4 of DCE to create survey questions. 5 Implementation Continue designing program Project Objective: Identify at least 2 objectives for each topic by the end of week 5 of DCE. Project Objective: Reach out to staff to determine 2 potential time blocks when in- new questions Read and level articles found Get connected with personnel at site who focus on museum accessibility Utilize trainings, literature, needs assessment and discussions with staff to determine session topics by end of week Schedule meeting with OTR 01/27 01/26 02/03 02/01 02/02 Schedule meeting with staff from Research and Evaluation 02/01 Schedule meeting with Director of Volunteer Services Outline training 02/10 topics Email pilot group DISABILITY EDUCATION PROGRAM 6 Implementation Create training module for museum management staff, measured by completing a checklist of required items for each lesson plan, by the end of week 6 of DCE 25 person training could be offered by end of week 5 of DCE. Project Objective: Create checklist of activities/materials for each topic, measured by time allotted for each pilot session and objectives identified for each topic, by end of week 6 of DCE Project Objective: Disseminate schedule for inperson training program to museum management staff by end of week 6 of DCE. 7 8 Collaborate with the Research and Evaluation staff to create and distribute a visitor survey regarding experience at Museum My Way event by end of DCE week 6. Implementation Assess quality of training module prior to pilot sessions Implementation Implement inperson training Experience Objective: Attend Museum My Way event during week 6 and assist in distributing surveys Review training content to ensure it meets program objectives Collect data using outcomes measure Complete outlines of each training session Discuss recruitment strategy with site mentor 02/17 02/15 02/14 Collect survey materials from Research and Evaluation Staff and discuss survey script Finalize PowerPoints for trainings for sessions 1 & 2 Print copies of assessment tool to 2/24 2/28 DISABILITY EDUCATION PROGRAM 9 10 11 program for museum management staff during week 8 of DCE, as measured by materials being created and sessions being scheduled. Implementation Continue implementation Implementation Continue implementation of program by leading sessions 3 and 4 Implementation Begin revising program materials for LMS 26 provide to program participants Review content for Finalize sessions 3 and 4 PowerPoint slides and postassessment questions Collect data and Print copies of program feedback assessment tool to from pilot group provide to participants 3/10 Revise PowerPoint Plan out changes slides based on to make for each feedback from session pilot group 3/22 Create additional materials for LMS 12 Discontinuation Prepare for presentation on 04/05 13 Discontinuation Collaborate with OTR on site to present about role of OT during April InfoSharing all staff meeting (middle of DCE week 13). Prepare for Create a brief PowerPoint presentation explaining role of OT by week 12 of DCE. Record presentation for canceled InfoSharing meeting Plan presentation Invite additional stakeholders to Assemble supplemental resources Meet with OTR at site to assemble slides and practice presentation Review presentation notes prior to recording Assemble presentation slides. 3/17 3/24 3/22 4/5 4/13 DISABILITY EDUCATION PROGRAM 14 Dissemination project dissemination at end of week 14 Disseminate project findings to site by end of week 14 27 dissemination Check on details with site mentor Conduct presentation over project and experience Review presentation 4/14  ...