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... Utilizing Program Development to Address Industry Trends: Thrive, a Successful Care Transitions Program Haley A. Brown May, 2018 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: James McPherson, PhD, OTR Running Head: THRIVE SUCCESSFUL CARE TRANSTIONS PROGRAM A Capstone Project Entitled Utilizing Program Development to Address Industry Trends: Thrive, a Successful Care Transitions Program Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Haley A. Brown Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 1 THRIVE 2 Abstract This doctoral capstone experience (DCE) sought to expose a DCE student to rehabilitation administration and management at the corporate level at Healthcare Therapy Services, Inc. (HTS), a contract therapy provider in the Midwest. The student was exposed to various aspects of the corporate rehabilitation industry including administration/management, corporate compliance, marketing and business development, program development, and operations. The primary project for this DCE was development of an interdisciplinary successful care transitions program known as HTS Thrive: Successful Care Transitions Program. The program was chosen as the chief project in response to recent insurance and industry regulations incentivizing valuebased care and transitions to the next level of care as soon as necessary supports can be obtained, and additionally in response to rehabilitation in skilled nursing facilities being highly scrutinized for the misuse of Medicare dollars in the form of unnecessary long lengths of stay and excessive Ultra-high Resource Utilization Group (RUG) utilization. The doctoral student, in collaboration with corporate executives, therapists, and other relevant healthcare experts developed an interdisciplinary successful care transitions program to be utilized in HTS-partnered facilities. The outcome of the DCE is a comprehensive interdisciplinary program that will allow HTSpartnered facilities to adhere to recent industry and insurance regulation trends while providing patients with quality care and a complete discharge process to promote a successful care transition to the next level of care. THRIVE 3 HTS Thrive: Successful Care Transitions Program Background/Literature Review Aging Population According to the U.S. Census Bureau (Ortman, J., Velkoff, V., and Hogan, H., 2014), by year 2030 more than 20% of the U.S. population will be aged 65 and older, a projected increase from 13% in 2010, and 9.8% in 1970. The oldest old age group (age 85 and over) is estimated to increase from 5.9 million in 2012 to 8.9 million in 2030 climbing to 18 million by year 2050 (Ortman, J., Velkoff, V., and Hogan, H., 2014). Many consequences will accompany the anticipated increase in the aging population. The expected growth in the older adult population will exponentially increase the need for healthcare for older adults in the United States. Medicare spending is expected to increase annually on average 4.1% per beneficiary from 2016-2025 compared to 1.6% per beneficiary from 2010-2015 (Centers for Medicare and Medicaid, 2017) Medicare Reform With these projections, the pressure to reduce Medicare spending is high and the Centers for Medicare & Medicaid Services (CMS) has consistently implemented programming to increase quality of care without increasing spending and in some cases while reducing spending over the past several years. Healthcare corporations are working hard to comply with CMS regulations in order to provide excellent care while sustaining revenues. Among these, post-acute care facilities such as skilled nursing facilities experience the burden of new regulations dually, as these facilities must comply with CMS regulations while also attempting to appeal to hospitals and potential clients for referrals. Recent CMS legislation affecting these facilities includes the Improving Medicare Post-Acute Care Transformation (IMPACT) act of 2014, which requires all post-acute care settings to report standardized patient assessment data by means of the SNF THRIVE 4 Quality Reporting Program (RTI International, 2017). Measures reported (current and to be implemented in FY 2020) include skin integrity, falls, functional, change in self-care, change in mobility, discharge self-care score, discharge mobility score, potentially preventable 30-day readmissions, discharge to community, and Medicare spending per beneficiary (RTI International, 2017). Post-acute care facilities face a 2% penalty for failing to report this data. Additionally, the SNF Value-Based Purchasing program as required by the 2014 Protecting Access to Medicare Act (PAMA) will withhold 2% of all SNF Medicare payments beginning October 1, 2018 and will provide incentive payments from 50-70% of the funds from this pool for facilities ranking highest on performance measures (SNF Value-Based Purchasing, 2017). Incentive payments will be based upon the 30-day All Cause Readmission Measure (SNFRM) which will transition to the SNF Potentially Preventable 30-day Readmission (SNFPPR) as soon as practicable (SNF Value-Based Purchasing, 2017). Similarly, hospitals are also required to participate in the Hospital Value-based Purchasing Program, which provides incentive payments to hospitals scoring highest on the Clinical Care domain, Patient and Caregiver Centered Experience of Care/Care Coordination domain, Safety domain, and Efficiency and Cost Reduction domain (Efficiency and cost reduction domain, n.d.). Of special interest to post-acute care facilities, the Efficiency and Cost Reduction domain is based on an assessment of payment for services provided to a beneficiary during a spending-per-beneficiary episode that spans from 3 days prior to an inpatient hospital admission through 30 days after discharge (Efficiency and cost reduction domain, n.d.) meaning that costs incurred in post-acute care facilities up to 30 days post hospital discharge will directly affect hospital reimbursements. Hospitals are also scored on readmission rates through the Hospital Readmission Rate Reduction Program (HRRP) initiated in 2012 and are penalized for THRIVE 5 high hospital readmission rates (Boccuti and Casillas, 2017). Hospitals participating in bundled payment programs are also particularly interested in hospital readmission rates as well as length of stay in post-acute care settings, as it has a direct effect on hospital reimbursement. Scrutiny of SNF rehabilitation services. As healthcare facilities and providers struggle to adhere to CMS regulations, they are faced with the task to provide quality care to patients in shorter amounts of time with the threat of potential consequences if unable to do so. For many years, post-acute care facilities have provided patients with care and rehabilitation services for long lengths of time in order for them to return to their prior level of function before discharging to the community. However, trends in steadily increasing Ultra High RUG utilization and patients receiving the minimum allowed minutes for each RUG category in skilled nursing facilities have led to accusations of skilled nursing facilities managing RUG levels for financial gains instead of patient needs (Acumen, 2017). For this reason, rehabilitation services in skilled nursing facilities have been highly scrutinized. Consequently, efforts to reduce this type of abuse of the system are being enacted including a proposed potential payment system that would eliminate the RUG system entirely. The Resident Classification System Version 1 (RCS-1) is the proposed payment model for rehabilitation services in skilled nursing facilities (Acumen, 2017). RCS-1 would pay facilities based on resident characteristics rather than volume of services provided. Although the RCS-1 system is intended to be budget neutral, many facilities may still feel the financial impact of this system, and contract rehabilitation providers are uncertain how the new payment system will affect them (Acumen, 2017). With no regulations on the amount of services provided to each patient proposed at this time, it is imperative that rehabilitation providers are able to articulate the value of their services in order to ensure that patients receive the rehabilitation services they desperately need. THRIVE 6 Justification for Student Project The rapidly growing aging population combined with a recent focus on quality care measures and reducing CMS spending in CMS legislation serve as the basis for this doctoral capstone project. As hospitals strive for lower readmission rates and shorter lengths of stay and post-acute care facilities are focused on reducing readmission rates and hoping to appeal to hospitals for referrals with shorter lengths of stay, a focus on successful care transitions is essential for patient success. In order to provide quality care in post-acute care facilities, successful care transitions from the hospital are vital, and additionally, to facilitate successful community reintegration and reduce hospital readmission rates for patients after a post-acute care stay, successful care transitions to the community are essential (Coleman, Parry, Chalmers, & Min , 2006). As our society ages and healthcare costs continue to grow, providers must be willing to shift type of care provided to meet societal needs. Hospitals and post-acute care facilities will no long be able to treat and rehabilitate patients to their prior level of function in the inpatient setting, as this has become too costly and will only continue to do so as the number of older adults requiring services grows. Avenues for reducing inpatient lengths of stays and readmission rates are potential methods to address this need. Among these, completing successful care transitions to the next level of care whether it is to home health services, outpatient services, or only follow-up with a primary care physician will be essential to provide patients with the best care possible in order to facilitate excellent outcomes for our patients, facilities, and society at large. Theoretical Basis This doctoral capstone project is primarily focused on developing advanced knowledge and skills in management and administration in the rehabilitation setting. Throughout the THRIVE 7 experience I have been embedded into the corporate rehabilitation setting including a focus on corporate compliance issues and quality improvement. Developing a new care transitions program for this site will serve as the main project for this experience and will provide an excellent opportunity to develop and showcase my ability to contribute effective healthcare solutions at the corporate level addressing both societal and facility needs. Dynamic Systems Theory. The Dynamic Systems Theory (DNS) will serve as the theoretical basis for this project. DNS is based upon chaos, complexity, and dynamic systems (Royeen, 2011, p. 63). With the unreliable healthcare climate today, it is only fitting that the theoretical framework to guide an effort to find solutions for societal healthcare needs would take into account the dynamic system that is healthcare in the United States. DNS allows consideration of this project to include potential varying outcomes that may become factual depending on the legislative actions that may take place within the next few months. Using DNS as a framework for this project forces consideration of the potential small changes that could undeniably impact the need for and execution of this program in the future. In considering DNS as a frame of reference for management, Royeen (2011) proposes that management in occupational therapy be renamed to facilitation of change (p. 67). I found this very fitting for the project, as it attempts to facilitate change within post-acute care facilities across the Midwest in order to provide patients with the support they need to transition between hospitals, post-acute care facilities, and the community successfully. It is my hope that I am able to facilitate change to provide better outcomes for our patients, facilities, and communities. Screening and Evaluation Screening and evaluation methods took place at the corporate office for Healthcare Therapy Services, Inc. (HTS). HTS provides contract rehabilitation services to over 100 skilled THRIVE 8 nursing facilities, hospitals, and outpatient clinics across the Midwest, primarily serving the older adult population in the skilled nursing facility setting. AOTA (2014) describes organization level occupational therapy services as a valid and important level of practice, claiming that the indirect application of occupational therapy services in administrative roles support and enhance the services provided to clients. The purpose of this doctoral capstone experience is exposure to administration duties and program development at the corporate level within the rehabilitation context. Thus the client for this experience is quite different than in traditional occupational therapy models. In this experience the client is the organization, Healthcare Therapy Services, Inc. To assess the needs of an organization it is important to perform a needs assessment. Sleezer, Russ-Eftt, and Gupta (2014) identify gathering data, data analysis, collaboration, and negotiation as important parts of identifying and addressing gaps in performance. Additionally, Sleezer et al (2014) states that a careful needs assessment builds support for program development with necessary data to substantiate the actions to follow. To gather information about the needs of my client, I immersed myself into the workplace culture, attending meetings, performing interviews, visiting sites, and reviewing pertinent literature (Scaffa & Reitz, 2014). I attended meetings with the owner, CEO, Executive Director of Clinical Services, and Human Resources Director as well as marketing meetings that included skilled nursing facility administrators. This gave me an idea of what is most important to the organization, and how I might become part of the solution for issues they wish to address. Next, semi-structured face-to-face interviews were performed with key informants I had access to, including the Executive Director of Clinical Services, Marketing and Business Development Director, one regional director, and one occupational therapist. After all interviews were completed, the data was analyzed and placed into categories. Additionally, I was able to visit THRIVE 9 several sites with my supervisor to gather more information about the varying needs of the facilities HTS serves and how my project might impact them. Finally, a thorough review of scientific literature concerning recent and upcoming legislative actions impacting the rehabilitation services HTS delivers provided a greater understanding of the current and potential issues at hand. From this process, a variety of needs emerged including the need to appeal to hospitals for referrals, strategies for improving quality indicators that are being tracked by the SNF Value-Based Purchasing Program, Skilled Nursing Facility Quality Reporting Program and Nursing Home Compare, creation of pathways to reduce lengths of stay, and an improved care transitions program. Ultimately, through careful analysis of the data collected and literature reviewed, in collaboration with my site supervisor (the Executive Director of Clinical Services) it was determined that a successful care transitions program would be the best fit for the needs of the organization. Current literature also suggests that care transitions interventions may lead to better outcomes (Kind et al, 2012; Carnahan e al, 2017; Rahman e at, 2017). An improved, evidencedbased care transitions program would serve as a way to improve quality outcome measures, appeal to hospitals for referrals and to skilled nursing facilities for new contracts, and attempt to improve quality of care to their clients in the changing healthcare climate. Baseline Measures To prepare for future outcomes evaluation of the program, data was collected from the SNF Value-Based Purchasing Program Quarterly Interim Reports (Medicare Program, 2017). All-cause 30-day readmission rates from a convenience sample of HTS-partnered facilities were obtained for future comparison of objective, measurable outcomes. THRIVE 10 Comparison and Contrast to Other Practice Areas This screening and evaluation could be compared to that of the actual clients HTS occupational therapists serve in post-acute care facilities on a daily basis. When performing evaluations in post-acute rehabilitation and long-term care, occupational therapists are focused on determining the needs of the client through careful administration of standardized tests, completion of an occupational profile, and ultimate determination of the deficits that are currently limiting the clients occupational performance. Similarly, the needs assessment of HTS incorporated a process including semi-structured interviews, review of relevant literature, assessment of the client through site visits, and ultimately synthesizing the data to determine the needs of the client to promote optimal performance. Additionally, in both settings, the data is then used to develop goals and objectives for intervention. Although there are similarities in the screening and evaluation process for these two occupational therapy models, there are also great differences between them. Chiefly, the time and effort put into a post-acute care evaluation versus the screening and evaluation for an organization. An occupational therapy post-acute care evaluation may include review of patient chart, evaluation including administration of standardized assessment and occupational profile, and finally the written evaluation which may take a therapist 1-3 hours to complete. In comparison, the process of screening and evaluation of the needs of an organization can take several weeks or longer to gather the necessary information in order to provide the most fitting services to the client. Additionally, when treating individuals, occupational therapists are most often focused on creating improvement in occupational performance, whereas in considering an organization it may more often be focused on limiting poor outcomes such as reducing the risk of financial penalties, rather than being solely focused on improvement of performance. THRIVE 11 Implementation Phase Healthcare Therapy Services, Inc (HTS) services a large geographic location including over 100 facilities across Indiana, Kentucky, Tennessee, and Michigan. Many of these facilities are privately owned, non-profit organizations. The Centers for Disease Control and Prevention reports that 69.8% of nursing facilities in the United States are for-profit, making the HTS clientele quite different from the norm in the long-term care world (Harris-Kojetin, Sengupta, Park-Lee, et al., 2016). These types of facilities do not possess large corporate management, and consequently must often depend on HTS for education regarding regulations and best practice in long-term care. As discussed previously, recent Centers for Medicare & Medicaid Services (CMS) legislation and initiatives including the IMPACT Act, SNF Quality Reporting Program, and SNF Value-Based Purchasing Program all place great emphasis on quality outcomes, including safe care transitions to the community and 30-day hospital readmissions (RTI International, 2017; SNF Value-Based Purchasing, 2017). Based on the current healthcare climate in the wake of recent CMS legislation, it was decided by the doctoral capstone student and site supervisor that development of a successful care transitions program would be the most beneficial project the student could develop for the organization at this time. The following paragraphs will discuss the process of implementation of the program. Program implementation within HTS poses unique challenges. First, the large geographic area makes implementing various programs and disseminating information problematic. One way HTS has combated this issue is to provide virtual presentations utilizing ZOOM online meeting software. ZOOM combines a slideshow with video conferencing to allow for face-toface meetings miles apart. Recording a ZOOM webinar presentation discussing the program will be the first step in implementing the HTS Thrive: Successful Care Transitions Program. The THRIVE 12 student will provide a virtual presentation via ZOOM explaining the need and purpose for, evidence behind, and implementation guide for the voluntary successful care transitions program provided by HTS. The presentation will be provided first to all HTS regional directors at a lunch and learn presentation. It will be sent to the regional directors a week prior to being sent out to the facilities in order to give the regional directors sufficient time to become familiar with the program and ask necessary questions. This is an important step in the implementation process, as regional directors are available to communicate with facilities more frequently and have a closer relationship with facility administrators than other corporate employees may. Next, the presentation will be presented to all HTS facilities that are appropriate for program utilization. This presentation will also be presented at a lunch and learn meeting for facility administrators. Presenting at a designated time in which viewers must log on to view will create more accountability for administrators to view the presentation. The presentation will be available at a later date to administrators who are unable to view the live presentation. Along with the presentation, facilities will be provided with a written program manual including specific guidelines for each discipline involved and interactive tools for the facility to use in their facility-specific transitions program. Information will also be included concerning reporting program outcomes to HTS for continuous evaluation of the program. This will be discussed further in the next section. After educating regional directors and facility administration, implementation will continue with rehabilitation, nursing, and social services managers. The program includes a large portion to be completed by nursing staff, signifying the need for facility-wide participation for successful implementation. Nursing managers will be provided with the virtual presentation as well as a complete step-by-step guide detailing the type of staff required to carry out the program and the THRIVE 13 specific duties these staff members will provide as part of the HTS Thrive: Successful Care Transitions Program. Additionally, the rehabilitation and social services managers will also receive the virtual presentation and a written step-by-step guide detailing the duties of each rehab discipline and social services representative as part of the safe care transitions program. It will then be the responsibility of the managers to relay information regarding the specific job duties to each staff member involved. This may include requiring staff members to view the provided virtual presentation, reviewing the HTS Thrive: Successful Care Transitions Program manual, and holding a department education meeting about the implementation of the program. Specific training needs will be determined by department managers on a facility-by-facility basis. Creating Buy-In Additionally, it is important to note the unique relationship HTS has with its clients (partnered facilities). HTS provides therapy services within facilities and often provides consultation and occasionally marketing services; however, HTS does not have directive over the facilities it serves. Thus, programming that includes personnel other than those employed by HTS is completely voluntary. Consequently, buy-in from facility administrators and staff is essential for the success of this program. In order for the program to be utilized and given the chance to provide successful outcomes for the facilities and patients served, buy-in from administrators and other staff members must be generated. In addressing this area, the student has been able to develop leadership skills further by carefully considering and planning how to create buy-in from these facilities. To create buy-in the student must be able to successfully and professionally articulate the need for this type of program, the research completed to determine the best actions to promote successful outcomes, and why the student feels she is qualified to develop and oversee the implementation of this program. The development of this project has THRIVE 14 helped to improve the students leadership skills by providing opportunities for high-level conversations regarding real facility and patient issues in the current healthcare climate. It has also forced the student to be very professional in the development of the program, as the student understands the large consequences this program has the potential to provide. Although the large scope of the project has felt overwhelming to the student at times, she is confident that the development of this program has helped her grow as a leader in the profession and in the healthcare industry. Staff Development and Program Outcomes The implementation of this program combines efforts to improve patient outcomes with staff education. Educating staff on current regulations and updates within the healthcare climate, as well as best practice for successful care transitions promotes an understanding of the effect that current legislation is and will continue to have on rehabilitation service provision within the skilled nursing facility setting. The outcome of the program is two-fold. It will provide facilities with strategies to combat poor outcomes, allowing them to be looked upon more favorably by consumers, potential partners, and CMS. Additionally, it will provide staff with education regarding strategies for improving outcomes and patient care, as well as educating them on the current healthcare climate and its effect on rehabilitation service provision in the skilled nursing setting. Discontinuation & Outcome Phase Societal Need The population served by HTS facilities is largely comprised of older adults, many with multiple comorbidities and complex care needs. Evidence suggests that elderly people are particularly vulnerable to issues with discontinuity of care, potentially resulting in adverse THRIVE 15 outcomes (Coleman, 2003). In particular, elderly patients with cognitive deficits often experience repeated hospitalizations and uncoordinated care resultant from reliance on the healthcare system to effectively communicate and transfer care responsibilities to appropriate caregivers (Aase, Laugaland, Dyrstad, & Storm, 2013). The care success for the population served by HTS facilities is largely dependent on healthcare providers ability to maintain continuity of care. This is especially important in the current healthcare climate that incentivizes shorter lengths of stay in inpatient facilities and various transitions to lower levels of care. This DCE project is in response to the needs of the older adult population served by HTS in the context of recent industry trends in response to legislative and regulatory changes. These changes will determine the healthcare services and the amount of services that are provided to CMS patients, as well as the level of reimbursement facilities will receive for the services rendered. As previously discussed, the population in the United States is growing older at an exceptional rate with the number of seniors expected to double by the year 2030 and triple by the year 2050 (Ortman, J., Velkoff, V., and Hogan, H., 2014). This will put great strain on the United States government to support our aging population. Thus, efforts to reduce CMS spending while maintaining and/or improving quality of care are being implemented. These efforts will force service providers to render quality care in shorter amounts of time in order to transition patients to the next level of care at a lower cost to CMS. Thus, providers must learn to successfully transition their patients care to the next level of care providers to maintain continuity of care. This will be essential for successful patient outcomes in the new healthcare climate (Coleman & Boult, 2003). This DCE project aims to meet the needs of HTS facilities in order to provide best care to patients in the context of recent healthcare climate changes. By providing facilities with the tools to combat these issues, this project will be a key component to THRIVE 16 assisting HTS and its facilities to meet the needs of society in the context of a continually aging population and recent healthcare climate changes. Outcomes of the Program As previously described in the implementation phase, the relationship HTS has with its partnered facilities makes implementation and, consequently, measuring outcomes challenging. Due to the voluntary nature of the program, each facility may choose to implement or not implement the program. Additionally, facilities may choose to adapt parts of the program as necessary to meet that unique facility and patient population needs. To drive continuous improvement of the program, an established plan for measuring outcomes is imbedded within the program. The outcome measures for the program are largely focused on improving reported measures required by the SNF Value-Based Purchasing Program and SNF Quality Reporting Program such as SNF 30-Day All Cause Readmission Measures (SNFRM), average Medicare beneficiary spend, discharge to community rates, discharge mobility scores, discharge self-care scores, etc. Of these, the SNFRM is of chief importance, as it will determine the top ranking facilities that will receive the highest incentive payments via the SNF Value-Based Purchasing Program (VBP) beginning October 1, 2018 (SNF Value-Based Purchasing, 2017). Outcome measures for the HTS Thrive: Successful Care Transitions Program include monitoring 30-day hospital readmission rates via patient phone call surveys and SNF Value-Based Purchasing Program Quarterly Reports. Additionally, utility of the program will be evaluated via an HTSadministered facility survey of the program. To measure 30-day hospital readmission rates and the affect the program has on the rates, the facility will monitor 30-day hospital readmission rates via SNF VBP quarterly reports. These reports will give the facility an accurate measure of the facilitys hospital readmission rates that they can compare to their patient-reported rates. THRIVE 17 Quarterly rates should be monitored for one year, as the reports are sent several months after the quarter has ended. Additionally, the student has implemented a patient survey that includes items evaluating the patients use of hospital services since being discharged from the hospital and skilled nursing facility. The patient will be called by an employee from the skilled nursing facility beginning at 30 days post skilled nursing facility discharge to complete the survey. A staff member other than the staff member that completed the patient post-discharge calls (part of the HTS Thrive program) will complete the survey call to reduce survey bias. A non-skilled staff member may complete the survey calls, as this call is meant only to gather information. The information gathered from the survey will be entered into an Excel workbook that the student created, which will allow the facility to document and monitor hospital readmission rates. The Excel workbook also allows for additional items such as education level, condition category, Allen Cognitive Level score, and primary language to be added based on each facilitys unique needs to help identify and address facility-specific issues leading to hospital readmissions. The facility should note that patient reported rates may not be entirely accurate and should be compared to SNF VBP quarterly reports once they are available; however, patient-reported rates will give facilities a look at their readmission rates in real time. Based on the impact on readmission rates and quality of care post implementation, the facility may choose to continue or discontinue implementing the program, make necessary changes to improve the implementation and utility of the program, and/or suggest edits for HTS to develop for the program as a whole. The Excel spreadsheet included in the program will allow the facility to monitor their readmission rates and potentially pinpoint issues that their readmitted patients have in common. Quality improvement should be completed on a facility-by-facility basis, as the needs of each facility may vary and tailoring the program to meet these unique THRIVE 18 needs will allow for best outcomes. Facilities will be advised to evaluate and make necessary changes to the program each quarter. In addition, a facility survey will be sent out bi-annually for the first year of implementation to assess the utility of the program. The survey will include items monitoring the facilitys 30-day readmission rates, the facilitys assessment of the qualitative improvements to care resulting from implementation of the program, as well as the ease of use of the program and potential issues related to the program. The results of the facility surveys will allow HTS to assess the outcomes and usefulness of the program. Based on these results, necessary changes and/or additions, to the existing HTS program may be completed. Additional Doctoral Capstone Experiences In addition to the development of the HTS Thrive: Successful Care Transitions Program, the student also engaged in various other skill developing and educational opportunities. The student participated in weekly corporate compliance meetings with the Proactive Medical Review consultant, all HTS regional directors, the Executive Director of Clinical Services, CEO, Marketing Director, and owner of HTS. The student completed various site visits with the Executive Director of Clinical services; the student was able to sit in on best practice trainings for staff and regional director trainings, attend facility marketing meetings, complete therapist performance observations, and more during the site visits. The student helped facilitate a Virtual Dementia Tour event at an HTS facility and was able to experience the tour at the site. Throughout her time at HTS, the student has been exposed to various professional organizations that HTS is involved in and that impact the rehabilitation world. The student became involved with various organizations in which HTS is a member. The student attended the American College of Health Care Administrators District 3 Midwest Post-Acute Care Leadership Summit THRIVE 19 and completed a seven-hour Alzheimers Disease and Dementia Care Seminar course qualifying her to receive recognition as a Certified Dementia Practitioner. She also attended the Samaritan Alliance Spring Leadership Forum and Proactive Medical Review The New Long-Term Care Survey Process- What to Expect seminar in person and attended The National Association for the Support of Long-Term Care (NASL) virtual committee meetings. Additionally, the student contributed to the site through development of and contribution to the therapist skills competency check-off list and guide that will be used to assess the competency of all therapists at HTS. Evaluation/Outcomes of the Doctoral Capstone Experience Outcomes of the student doctoral capstone experience (DCE) were evaluated based on the goal attainment scale (GAS) developed to assess the students progress towards meeting the goals for this DCE. Goal attainment scaling as first described by Kiresuk and Sherman (1968) involves construction of a personalized goal attainment guide, and later quantifying progress through evaluation using the guide at a set time after the intervention or experience is completed. The goals determined to be most significant to the DCE were converted into a Goal Attainment Scale to be used for the students evaluation at the end of the DCE. The site supervisor monitored the students progress towards the goals by evaluating the advancement at midterm and final. At midterm, the student and site supervisor determined which goals were not yet met, how to work towards meeting these goals, and opportunities the student would still like to participate in prior to leaving the site. At the final evaluation, the site supervisor assessed the students success in meeting the set goals using the GAS created seen in Figure 1. THRIVE 20 Goal #1 Goal Success at end of DCE Somewhat more than expected (+1) Somewhat more than expected (+1) The student spent time with therapists, managers, regional directors, and all members of the corporate office team. The student was also exposed to fiscal and operational aspects of corporate administration. The student developed an interdisciplinary successful care transitions program for the company. The student created a presentation to educate staff on the program and set up a plan for continuous improvement of the program to take place. The student was able to provide accurate and valuable educational material concerning industry and insurance regulations as they relate to the program she developed. This information will be used to educate facility administrators and guide them in best practice related to recent industry trends. The student became familiar with all associations HTS is a part of and was able to attend events put on by the American College of Health Care Administrators, The Samaritan Alliance, and Proactive Medical Review during her DCE. Poor Understanding of Administrators role Unable to identify appropriate area for program development Familiar with corporate consultant role for industry regulations and insurance regulations No direct or indirect involvement in professional associations that HTS is active in - Spend time with 1 levels of administration No exposure to fiscal and business outcomes and corporate relations with both existing and new customers - Spend time with 1-2 levels of administration - Little exposure to fiscal and business outcomes and corporate relations with both existing and new customers - Understand administrators role within HTS - Spend time with several different levels of administration - Assist administrator in completing various duties to better acquaint myself with the role of rehabilitation administrators - Become well-informed Student demonstrates only general knowledge of industry and insurance regulations and is unable to navigate necessary resources - - Identify area for program development but not able to fully implement advances accordingly Understand corporate consultant role for industry regulations and insurance regulations - - Expected (0) Goal #4 Somewhat more than expected (+1) Fair Understanding of Administrators role Somewhat less than expected (1) Goal #3 Somewhat more than expected (+1) - Much less than expected (2) Goal #2 Identify areas for program development and implement advances accordingly, including research and education for best practice - Observe company culture and interview practitioners, managers, admin, etc. to assess the needs of the company. - Develop a program/protocol to address said needs of the Become informed about CMS regulations and reimbursements and managed care and reimbursements Learn to navigate CMS website and other resources for regulations Understand corporate compliance with these regulations Serve as assistant to corporate consultant for industry regulations and insurance regulations, ensuring compliance in all areas. - Become well-informed about CMS regulations and reimbursements and managed care and reimbursements - Learn to navigate CMS website and other resources for regulations Poor understanding of how these associations support HTS and rehabilitation professions in general Not able to attend any events Involvement in professional associations that HTS is active in - - Understand how these associations support HTS and rehabilitation professions in general Not able to attend any events Involvement in professional associations that HTS is active in - Attend events when appropriate - Understand how these associations support HTS and rehabilitation professions in general THRIVE 21 of fiscal and business outcomes and corporate relations with both existing and new customers Excellent Understanding of Administrators role - Somewhat more than expected (+1) Much more than expected (+2) - Spend time with all levels of administration Frequent exposure to fiscal and business outcomes and corporate relations with both existing and new customers Excellent understanding of Administrators role & ability to act as a manger or administrator - Spend time with all levels of administration Ability to collaborate and contribute to conversation on fiscal and business outcomes and corporate relations with both existing and new customers company - Implement program/protocol - Evaluate success of program/develop outcome measure to assess success of programs Identify areas for program development, implement program fully, and educates staff on use of program professionally and successfully - Understand corporate compliance with these regulations Serve as a corporate consultant for industry regulations and insurance regulations AND is able to provide accurate information and guidance to corporation, ensuring compliance in all areas - Develop program that meets needs of company, implement the program effectively, educate staff on the program, make continuous improvement changes to program based on measured outcomes of the program Able to assist in creating necessary content to educate staff on regulations and best practice related to new regulations Serve as a corporate consultant for industry regulations and insurance regulations AND is able to provide accurate information and guidance to corporation, ensuring compliance in all areas - Able to create necessary content individually to educate staff on regulations and best practice related to new regulations Involvement in professional associations that HTS is active in - Understand how these associations support HTS and rehabilitation professions in general Attend at least one event Be an active participant in the event/conference - - Involvement in professional associations that HTS is active in - - - Understand how these associations support HTS and rehabilitation professions in general Attend at least one event Present information at an event/conference Figure 1. Goal Attainment Scale. This figure depicts the stated goals in a Goal Attainment Scale used to determine if the students goals were accomplished and to what extent by the conclusion of the DCE. Success of Goals The student scored a Somewhat more than expected (+1) on the Goal Attainment Scale for each of the four established goals. Based on these scores, the student fulfilled and exceeded the expectations for this DCE. The success of each goal can be seen in Figure 1 and a description of each is found below. Goal 1: Understand administrators role within HTS Objective: Spend time with several different levels of administration Objective: Assist administrator in completing various duties to better acquaint myself with the role of rehabilitation administrators THRIVE 22 Objective: Become well-informed of fiscal and business outcomes and corporate relations with both existing and new customers Success of Goal 1: Somewhat more than expected (+1.) The student spent time with therapists, managers, regional directors, and all members of the corporate office team. The student was also exposed to fiscal and operational aspects of corporate administration. Goal 2: Identify areas for program development and implement advances accordingly, including research and education for best practice Objective: Observe company culture and interview practitioners, managers, admin, etc. to assess the needs of the company. Objective: Develop a program/protocol to address said needs of the company Objective: Implement program/protocol Objective: Evaluate success of program/develop outcome measure to assess success of programs Success of Goal 2: Somewhat more than expected (+1.) The student developed an interdisciplinary successful care transitions program for the company. The student created a presentation to educate staff on the program and set up a plan for continuous improvement of the program to take place. Goal 3: Serve as assistant to corporate consultant for industry regulations and insurance regulations, ensuring compliance in all areas. Objective: Become well-informed about CMS regulations and reimbursements and managed care and reimbursements Objective: Learn to navigate CMS website and other resources for regulations THRIVE 23 Objective: Understand corporate compliance with these regulations Success of Goal 3: Somewhat more than expected (+1). The student was able to provide accurate and valuable educational material concerning industry and insurance regulations as they relate to the program she developed. This information will be used to educate facility administrators and guide them in best practice related to recent industry trends. Goal 4: Involvement in professional associations that HTS is active in Objective: Attend events when appropriate Objective: Understand how these associations support HTS and rehabilitation professions in general Success of Goal 4: Somewhat more than expected (+1). The student became familiar with all associations HTS is a part of and was able to attend events put on by the American College of Health Care Administrators, The Samaritan Alliance, and Proactive Medical Review during her DCE. Overall Learning Throughout the doctoral capstone experience, the student was able to engage in various opportunities related to administration and management in rehabilitation at the corporate level, culminating in the overall learning experience. The student was exposed to several facets of the corporate rehabilitation industry throughout the experience including administration management duties concerning program development, corporate compliance, marketing and business development, and operations. Program development THRIVE 24 Program development comprised a large portion of this doctoral capstone experience. The student researched, collaborated on, and ultimately developed an interdisciplinary successful care transitions program for HTS. Through this experience, the student became knowledgeable about current industry and insurance regulations that guide current practice, effective strategies for increasing continuity of care after discharge from skilled nursing facilities, and the care transition needs of HTS clients and patients served. The student conversed with various HTS employees to gain an understanding of the current practices and needs as well as to gain feedback on the program as it was being developed. The student learned to express her ideas and work verbally and in writing in a professional and effective manner, which allowed her to gain the respect of her peers in the industry and will serve her well in future jobs and opportunities. The student also improved her professional presentation skills through a virtual presentation for all facilities receiving the program she had developed. The program was presented in such as way as to communicate the benefit of utilizing the program supported by evidenced-based research, and the potential for quality measure improvements in both quantitative and qualitative outcomes. Corporate Compliance Corporate compliance is of utmost importance at HTS, as the company strives to be the performance proven and acknowledged industry leader in therapeutic services, providing effective solutions and ethical practices (Healthcare Therapy Services, Inc., n.d.). Throughout the DCE, the student was exposed to several issues and meetings concerning corporate compliance. The student sat in on weekly compliance meetings with regional directors and assisted with occasional compliance issues as they arose. The student attended a Proactive Medical Review annual quality assurance site visit with a Proactive consultant, where she was able to observe THRIVE 25 first-hand the process of service quality audits at HTS. Additionally, the student assisted with therapist performance observations checking for best practice, accurate billing, and effective documentation. These experiences exposed the student to common compliance issues in the skilled nursing facility setting. As a result, the student now has an enhanced understanding of how care should be provided and documented to assure services are completed in a skilled and justified manner. In addition, the student was exposed to the ill consequences that poor compliance may lead to, further increasing her understanding of and appreciation for ethical provision of services in the skilled nursing setting. Marketing and Business Development This DCE has expanded the students understanding of the role marketing and business development plays in healthcare. The student had the opportunity to work with the marketing/business development team on her successful care transitions program and witness various other marketing and business development efforts throughout the experience. Through the collaboration, the student gained an understanding of how the program might affect the experience of patients as well as the facilities from a marketing and business development perspective. It was also brought to the students attention that the program may be used as a marketing effort to gain new partnered facilities, and thus edits were made to the program to make it more patient friendly and appealing to patients as well as potential partners. The student was also able to witness the marketing director/head of business development present the company to several potential partners. Prior to this experience, the student had a very narrow view of the role of marketing and business development in healthcare, believing that most of the work consisted of social media posts and brochures; however, this DCE has opened her eyes and allowed her to see the vast role and impact that marketing and business development plays in the THRIVE 26 healthcare world, largely driving the opportunities for service provision. Through this exposure, the student has gained a greater appreciation for the entire healthcare team, including the supportive healthcare services such as marketing and business development that help make healthcare possible. Operations Throughout the DCE experience, the student was exposed to the operational side of the corporate rehabilitation administration world including financial concerns and how they affect rehabilitation service provision. Although no extensive knowledge of operational and financial management was gained, the student now has an overall greater understanding of operational management in this setting. Patient care should always of utmost importance in healthcare provision; however, healthcare providers must be aware of the financial business that healthcare has become. This aspect of healthcare will to continue driving profitable margins for the companies and their employees; however, it may come with changes unwelcomed by employees. The student feels the knowledge and understanding she has gained concerning operations in healthcare will help her be a well-informed and flexible practitioner and potentially, manager one day. Conclusion Through this DCE, the student was exposed to rehabilitation administration and management at the corporate level. The student is grateful for this experience, as she understands that few practitioners have an opportunity to witness this side of the rehabilitation industry. The exposure and resultant knowledge and understanding of this industry gained are truly invaluable. The student feels that this experience will aid her in practicing as an effective and informed therapist and potential manager for many years to come. THRIVE 27 References Acumen (2017). Skilled Nursing Facilities Payment Models Research Technical Report. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/Downloads/SNF_Payment_Models_Research_Technical_Report2017 04.pdf American Occupational Therapy Association (2014) Occupational therapy practice framework: Domain and process (3rd ed ) American Journal of Occupational Therapy, 68(Suppl 1), S1 S48 http://dx doi org/10 5014/ajot 2014 682006 Aase, K., Laugaland, K. A., Dyrstad, D. N., & Storm, M. (2013). Quality and safety in transitional care of the elderly: the study protocol of a case study research design (phase 1). British Medical Journal Open, 3(8). doi:10.1136/bmjopen-2013-003506 Boccuti, C., and Casillas, G. (2017, March). Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. The Henry J. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/Issue-Brief-Fewer-Hospital-U-turns-TheMedicare-Hospital-Readmission-Reduction-Program. Carnahan, J. L., Slaven, J. E., Callahan, C. M., Tu, W., & Torke, A. M. (2017). Transitions from skilled nursing facility to home: the relationship of early outpatient care to hospital readmission. Journal of the American Medical Directors Association, 18(10), 853-859. doi:10.1016/j.jamda.2017.05.007 Centers for Medicare and Medicaid Services. (2017, February 15). 2016-2025 Projections of National Health Expenditures Data Released. Retrieved from THRIVE 28 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Pressreleases-items/2017-02-15-2.html Coleman, E. A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555. doi:10.1046/j.1532-5415.2003.51185.x Coleman, E. A., & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556-557. doi:10.1046/j.1532-5415.2003.51186.x Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The Care Transitions Intervention. Archives of Internal Medicine, 166(17), 1822. doi:10.1001/archinte.166.17.1822 Efficiency and cost reduction domain. (n.d.) Retrieved January 23, 2014 from https://www.medicare.gov/HospitalCompare/Data/efficiency-cost-reduction-domain.html Harris-Kojetin, L., Sengupta, M., & Park-Lee, E. (2016). Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 20132014. National Center for Health Statistics. Vital Health Stat 3(38). Healthcare Therapy Services, Inc. (n.d.) About. Retrieved from https://www.htstherapy.com/about/. Kiresuk, T., & Sherman, R. (1968). Goal attainment scaling: A general method of evaluating comprehensive mental health programs. Community Mental Health Journal, 4,443-453. Kind, A. H., Jensen, L., Barczi, S., Bridges, A., Kordahl, R., Smith, M. A., & Asthana, S. (2012). Low-cost transitional care with nurse managers making mostly phone contact with THRIVE 29 patients cut rehospitalization at a VA hospital. Health Affairs (Project Hope), 31(12), 2659-2668. doi:10.1377/hlthaff.2012.0366 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020. (2017, August 04). Retrieved from https://www.federalregister.gov/documents/2017/08/04/2017-16256/medicare-programprospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Ortman, J. M.,Velkoff, V. A., & Hogan, H. (2014). An Aging Nation: The Older Population in the United States, Current Population Reports. U.S. Census Bureau: Washington, DC. Rahman, M., McHugh, J., Gozalo, P. L., Ackerly, D. C., & Mor, V. (2017). The contribution of skilled nursing facilities to hospitals' readmission rate. Health Services Research, 52(2), 656-675. doi:10.1111/1475-6773.12507 Royeen, C. (2011). Dynamical systems theory in occupational therapy management. In K. Jacobs & G.L McCorkmack (Eds.), The Occupational Therapy Manager (pp. 61-72). Bethesda, MD: AOTA Press. RTI International. Center for Clinical Standards and Quality. (2017, August). Final Specifications for SNF QRP Quality Measures and Standardized Resident Assessment Data Elements. Retrieved from https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/NursingHomeQualityInits/Downloads/FinalSpecifications-for-SNF-QRP-Quality-Measures-and-Standardized-Resident-AssessmentData-Elements-Effective-October-1-2018.pdf THRIVE Scaffa, M. E., & Reitz, S. M. (2014). Occupational therapy in community-based practice settings. Philadelphia, PA: F. A. Davis Company. Sleezer, C., Russ-Eft, D., & Gupta, K. (2014). A practical guide to needs assessment (3rd ed. ed.). San Francisco: Wiley. SNF Value-Based Purchasing. (2017, December). Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html 30  ...

... Using Handwriting to Promote Interdisciplinary Collaboration Melanie Browne May, 2018 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: Taylor McGann, OTR, MS, OTD A Capstone Project Entitled Using Handwriting to Promote Interdisciplinary Collaboration Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Melanie Browne OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: HANDWRITING AND INTERDISCIPLINARY COLLABORATION Using Handwriting to Promote Interdisciplinary Collaboration Melanie Browne University of Indianapolis 1 HANDWRITING AND INTERDISCIPLINARY COLLABORATION 2 Abstract The purpose of this doctoral capstone experience was to effectively promote interdisciplinary collaboration between occupational therapy (OT) and applied behavior analysis (ABA) staff at the participating outpatient ABA center. A needs assessment revealed that staff felt the site could benefit from the creation of a standardized handwriting program to utilize with clients. The establishment and implementation of a handwriting program provided the media through which interdisciplinary collaboration occurred. Staff completed a pre- and post-implementation survey to rate their confidence and test their overall knowledge with scoring handwriting based on the established program criteria. An in-service was provided to all staff explaining the benefits of handwriting, how to utilize the data sheets and measuring tool to score and record clients handwriting data, and OTs role in handwriting. The program was implemented with ten clients at the participating site through one-on-one consultation between the behavior technicians and the occupational therapy student. The results from the surveys showed that staffs knowledge and confidence improved with scoring and implementing handwriting programs. ABA staff expressed that the implementation of the handwriting program helped increase their confidence with handwriting, their understanding of OT, and their likelihood of collaborating with occupational therapists in the future. HANDWRITING AND INTERDISCIPLINARY COLLABORATION 3 Using Handwriting to Promote Interdisciplinary Collaboration The World Health Organization (WHO) defines collaborative practice as occurring when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings (WHO, 2010, p. 13). By using an interprofessional or interdisciplinary approach to practice, occupational therapy practitioners can work with other healthcare workers to reach a common goal. Interdisciplinary practice will allow for overall better health outcomes and help combat the complex health challenges our world faces today (WHO, 2010). With the passing of the Patient Protection and Affordable Care Act of 2010, there has been a push to create new models of interdisciplinary practice to promote patient-centered care (Moyers & Metzler, 2014). There are multiple attributes which contribute to creating effective collaboration models such as: open communication, negotiation, assertiveness, lack of a hierarchy, and a shared base of knowledge (Fewster-Thuente & Velsor-Friedrich, 2008). Some barriers that prohibit effective collaboration include: patriarchal relationships, time, gender, culture, and lack of role clarification (Fewster-Thuente & Velsor-Friedrich, 2008, p. 42). If these barriers exist, it will be hard for a team to set and obtain goals. It is vital to determine ways to limit these barriers to have successful collaboration in the workplace. The purpose of this doctoral capstone experience was to increase the interdisciplinary collaboration between occupational therapy (OT) and applied behavior analysis (ABA), specifically regarding handwriting implementation, at the participating ABA center. The OT student created a handwriting program including how to score and progress a clients writing as well as data sheets and a measuring tool to collect and score data. HANDWRITING AND INTERDISCIPLINARY COLLABORATION 4 Literature Review With the increasing complexity of health problems, it is imperative that healthcare professionals work interdependently rather than independently (DAmour, Ferrada-Videla, San Martin-Rodriguez, & Beaulieu, 2005). DAmour et al. (2005) found that for a team-based approach to be effective, all members must understand each others roles to maximize team collaboration. Currently in the education system for healthcare professionals, each discipline learns the frameworks that drive their work and create their scope of practice (DAmour et al., 2005). However, to create a partnership between disciplines, educational systems need to break away from this traditional approach and implement a sense of collaboration rather than competition (DAmour et al., 2005). There is presently a push to reshape current healthcare education curricula to be more interprofessional to bridge the gap between professions (Moyers & Metzler, 2014; WHO, 2010). The hope is that this will prepare future practitioners to be more collaborative and use a team-based approach in practice (Moyers & Metzler, 2014; WHO, 2010). After a systematic review of the literature, DAmour et al. (2005) found the common concepts related to effective collaboration are sharing, creating a partnership, being interdependent, and understanding the power relationship. Sharing refers to the shared responsibilities disciplines have with planning, conducting interventions, and data collection. The collaborative partnership that is created should have common goals and desires to reach clients needs and have a shared power source between individuals (DAmour et al., 2005). The authors in this study also found that collaboration is a dynamic and ever-changing process. Overall, this shows that collaboration is an evolving process that changes over time and with the input of all the disciplines involved (DAmour et al., 2005). HANDWRITING AND INTERDISCIPLINARY COLLABORATION 5 One type of collaboration team is an interdisciplinary team, which involves an effort to integrate and translate, at least to some degree, themes and schemes shared by several professions (DAmour et al., 2005, p. 120). This type of team follows a common goal, often to achieve positive health outcomes for clients, and attempts to also integrate the knowledge and expertise of everyone (DAmour et al., 2005; Fewster-Thuente & Velsor-Friedrich, 2008). It is important to integrate the knowledge and expertise of each professional to create effective interdisciplinary collaboration (DAmour, 2005, p. 120). Establishing this type of team creates a flexible and open environment for professionals to work. One challenge that professionals must overcome for this type of team to be effective is breaking down existing territories to best address their clients needs (DAmour et al., 2005). An example of interdisciplinary collaboration is the relationship between occupational therapists and ABA professionals when working with individuals with autism spectrum disorder (ASD). OT and ABA services are two of the most frequently used services for individuals, especially children, with ASD (Welch & Polatajko, 2016). OT is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, routines, and rituals in home, school, workplace, community, and other settings (American Occupational Therapy Association [AOTA], 2014, p. S1). Whereas, ABA focuses on modifying human behavior to further improve quality of life (Schroeder, Lynch, & Turgeon, 2017). ABA therapy is commonly used to decrease problem behavior, increase language and communication skills as well as improve attention, focus, social skills, memory, and academics (Autism Speaks, 2012, p. 2). In ABA, these goals are typically achieved by using positive reinforcement for desired or socially acceptable behavior, in hopes that the rewarded behavior or skill will be repeated (Autism Speaks, 2012). Although OT HANDWRITING AND INTERDISCIPLINARY COLLABORATION 6 and ABA can address overlying areas of function, there is a lack of evidence to support the collaboration between these disciplines (Brodhead, 2015; Schroeder et al., 2017; Welch & Polatajko, 2016). Using an interdisciplinary approach for individuals with ASD involves determining the various strengths of multiple disciplines and combining them to increase client outcomes. This approach would create a well-rounded treatment plan to best meet clients individual needs (Brodhead, 2015). Similar to DAmour et al (2005), Schroeder et al. (2017) found common themes regarding successful collaboration between OT and ABA to include: effective communication, motivated team members and leaders, and data collection (p. 30). In addition, Welch and Polatajko (2016) believe that ABA and OT are compatible in that they both address similar areas and could work well together to reach shared goals, and in turn, enhance client outcomes. The areas that both disciplines have in common include: using a strengths-based approach, analyzing the environment, stressing the importance of a collaborative approach to treatment, and promoting growth in the areas of work, self-care, play, leisure, and social skills (Welch & Polatajko, 2016). Even though both professions stress a collaborative approach, it is not always carried out in practice (Welch & Polatajko, 2016). ABA professionals typically target the above skills by teaching them through the use of multiple trials and reinforcement to advance a client toward mastery (Autism Speaks, 2012). On the other hand, occupational therapists are trained to assess and address the specific performance skills and patterns impacting these areas. With this training, occupational therapists can use consultative techniques to work collaboratively with ABA professionals to reach the desired goals for each client (Welch & Polatajko, 2016). Handwriting is an area where OT and ABA can collaborate to reach communication and HANDWRITING AND INTERDISCIPLINARY COLLABORATION 7 educational goals for children and impact their performance in other academic areas as well (Carlson, McLaughlin, Derby, & Blecher, 2009; Case-Smith & OBrien, 2015). These goals are pertinent to, and addressed by, both OT and ABA professionals (AOTA, 2014; Autism Speaks, 2012). ABA professionals are trained to teach new skills, which can include handwriting, but they do not have the clinical expertise to understand the underlying performance skills impacting handwriting (Welch & Polatajko, 2016). However, occupational therapists are trained to evaluate clients specific handwriting challenges, determine which factors are impacting their skills, and implement ways to improve their handwriting either through direct intervention or consultation with other disciplines (Case-Smith & OBrien, 2015). Since ABA professionals do not analyze the underlying performance skills and patterns, they could benefit greatly from interdisciplinary collaboration with an occupational therapist to identify a clients specific handwriting needs and consult on how to address these needs within their ABA programming. A commonly used handwriting program for developing prewriting and writing skills is Handwriting Without Tears (HWT). HWT was developed by an occupational therapist for children of all ages, abilities, and learning styles, and includes multisensory and developmentally-appropriate activities to promote increased prewriting and handwriting skills (Case-Smith & OBrien, 2015; Olsen & Knapton, 2015). The program promotes the developmental progression of writing by taking a child from a no-paper, no-pencil approach to imitation and copying to independent writing of letters. It focuses on using simple vertical and horizontal lines to form letters and groups letters of similar difficulty together to increase success in writing (Olsen & Knapton, 2015; Roberts, Derkach-Ferguson, Siever, & Rose, 2014). Multiple studies have examined the effectiveness of HWT with children with ASD. Overall, the studies have found that HWT can help increase clients ability to write specific HANDWRITING AND INTERDISCIPLINARY COLLABORATION 8 letters, increase legibility, and increase the ability to write their names (Carlson et al., 2009; Cosby, McLaughlin, & Derby, 2009; Coussen, McLaughlin, Derby, & McKenzie, 2012; McBride et al., 2009). It should be noted that there is limited research as to what qualifies as legible, other than if the letter can be identified as the appropriate capital letter, it has all the required parts, and is not rotated or reversed (Carlson et al., 2009; Cosby et al., 2009; Coussen et al., 2012; Roberts et al., 2014). This is an area where further research is needed since legibility is very subjective and based on the observers opinion. Therefore, research could benefit from identifying objective ways to score/collect handwriting data, specifically when using HWT. In addition, one major component of ABA therapy is data collection, which is used to measure a clients progress to obtaining a certain skill (Autism Speaks, 2012). If an occupational therapist wishes to consult with an ABA professional and add handwriting as a target within the clients program, he/she would benefit from finding objective ways to measure the clients writing. Overall, there is a major push in healthcare to use interdisciplinary collaboration to help reach client goals. The collaboration consists of many factors to be effective, but with time and persistence it can help increase client outcomes. There are many benefits to this type of collaboration, however there is limited research on the specific use of interdisciplinary collaboration between OT and ABA for individuals with ASD. Differing viewpoints exist between the two disciplines with how to best reach goals when working with individuals with ASD, but there are commonalities they can pull from to achieve holistic service delivery. In handwriting programs, occupational therapists can consult with ABA professionals to assist clients in increasing their prewriting and handwriting skills and in turn help meet their overall communication and academic goals. To address this gap, this capstone experience included consultation with ABA professionals on the most effective way to implement the handwriting HANDWRITING AND INTERDISCIPLINARY COLLABORATION 9 program to make sure the clients are on track to meet their handwriting goals. This allowed the ABA center to have a standard way to teach, score, and collect data on handwriting, based on the HWT program. Theoretical Basis The theory that guided this project was the Person-Environment-Occupation (PEO) model. The focus of this model is to maximize the PEO fit, which is the continual interaction between the person, environment, and occupation (Law et al., 1996). The better the fit or overlap of the three factors, the better the occupational performance. The PEO fit changes over a persons lifetime as their occupational performance changes (Law et al., 1996). In this model, change is constantly occurring and as one aspect changes, so do the others (Law et al., 1996). When creating and implementing the handwriting program, all three factors were taken into consideration and how they were continually influencing each other. As clients worked to improve their occupation of handwriting, the environment and people, including clients and staff, all impacted the clients occupational performance. It was critical to make sure the staff were teaching and scoring handwriting correctly while at the same time providing the clients with the most beneficial learning environment. By doing so, the site could reach its optimal PEO fit. The frame of reference that guided this project was the lifespan frame. This frame of reference focuses on helping people establish or restore age-appropriate occupations (Cole & Tufano, 2008). The main occupation that was addressed through this project is education, specifically handwriting. This included training ABA professionals on how to address the performance skills and patterns regarding the clients handwriting and how to help the them establish age-appropriate handwriting skills. In the lifespan frame of reference, change occurs through learning new skills and motivation comes from an individuals need for mastery (Cole & HANDWRITING AND INTERDISCIPLINARY COLLABORATION 10 Tufano, 2008). During this experience, consultation with ABA professionals occurred including how to help teach the clients new handwriting skills and how to motivate them to obtain these skills. It was important to take into consideration the motivation and comprehension of the staff as well to increase the carryover of the program. Screening and Evaluation The spring before starting my capstone experience I met with my site mentor, who is the head occupational therapist at the participating ABA center to discuss possible program development ideas. We discussed several ideas including creating a handwriting program, making a video library to educate on OT and how to use various strategies in the ABA programs, and developing an education binder for staff about the importance of various OT topics such as tooth brushing, dressing, and feeding (A. Seal, personal communication, 2017). However, when meeting the month before starting, she emphasized that creating a standardized handwriting program was of high importance to her and the site. She explained that she wanted a protocol created for handwriting based on HWT that included designing a measuring tool to score clients handwriting, developing data sheets to collect progress, and setting the criteria to advance through the program (A. Seal, personal communication, 2018). Prior to creating the handwriting protocol, I conducted a needs assessment to understand how handwriting programs are currently carried out at the site as well as potential areas for improvement. One aspect of the needs assessment included informal interviews with various staff members including my site mentor, Board Certified Behavior Analysts (BCBAs), who write the clients ABA programs, and behavior technicians, who implement the clients programs. While interviewing the behavior technicians, I observed how they currently carry out handwriting programs with clients. I noticed there was a lack of consistency between clients HANDWRITING AND INTERDISCIPLINARY COLLABORATION 11 handwriting programs regarding what was expected of the clients, whether they used HWT or not, and the mastery criteria set to progress through handwriting programs. Some BCBAs required clients to practice letter formation on HWT worksheets, whereas other required them to practice on single or three-line paper. There was also not a single, standardized way to measure correct formation or legibility with the clients handwriting samples during ABA programming trials. The mastery criteria varied between clients and was subjective in nature as it was part of the behavior technicians role to decide if the handwriting was appropriate and legible even though no formal training had taken place on how to properly complete this task. The needs assessment also involved creating a pre- and post-implementation survey to assess the staffs knowledge and confidence regarding handwriting programs. The survey required the staff to score a pre-kindergarten and kindergarten handwriting sample. The scoring was based on the scoring criteria from the HWT Print Tool, including: start, sequence, orientation, placement, control, and size (Olsen & Knapton, 2008). The criteria listed focuses on the formation, neatness, and proportion of the letters (Olsen & Knapton, 2008). The survey also included a section for the staff to rate their confidence with scoring the handwriting examples and their ability to carry out clients handwriting programs. After conducting the needs assessment at the site, multiple problem areas related to the occupational performance and participation of handwriting were identified. Overall, the staff members felt they did not have the proper training and knowledge to carry out handwriting programs. The average confidence rating from the pre-implementation survey was a 2.8 on a five-point Likert scale. The staff noted they were not sure how to score the handwriting examples. Out of 43 staff members that completed the pre-implementation survey, 21% scored all parts of the pre-kindergarten example correctly and 37% scored the kindergarten sample HANDWRITING AND INTERDISCIPLINARY COLLABORATION 12 correctly. Some specific questions/concerns noted by staff included: defining the scoring criteria, age-appropriate pencil grasps, the developmental progression of handwriting, how often to practice handwriting with clients, and when to progress a client onto the next letter when using the HWT program (ABA Center Staff, personal communication, 2018). When observing the technicians complete various handwriting programs, it was evident that there was not a standardized way to carryout handwriting programs with clients. The technicians often noted that they were not sure if they were carrying out the programs properly and that they just gave it their best shot (ABA Center Staff, personal communication, 2018). The occupational therapist and BCBAs both stated that they had concerns about this and felt that it was vital to create a standard way to teach, score, and collect data on each clients handwriting (A. Seal & Site BCBAs, personal communication, 2018). The results of the needs assessment showed that the site would benefit from an occupational therapy perspective on how to implement a handwriting program. The BCBAs explained during their interviews that they do not receive specific training on how to teach a child handwriting (Site BCBAs, personal communication, 2018). Instead, they receive training on how to teach children various skills, which can include handwriting, using the concepts of reinforcement and discrete trial training (Autism Speaks, 2012; Site BCBAs, personal communication, 2018). On the other hand, occupational therapists are trained to evaluate the performance skills and patterns related to a clients occupations, in this case the clients handwriting (AOTA, 2014). After identifying the underlying deficits and problems, occupational therapists create and implement an intervention plan to reach targeted outcomes (AOTA, 2014). Regarding handwriting, occupational therapists can evaluate and treat the underlying components such as motor planning, motor control, muscle tone, endurance, and HANDWRITING AND INTERDISCIPLINARY COLLABORATION 13 coordination (AOTA, 2014; AOTA, n.d.). Occupational therapists can also help promote a proper grasp, letter formation, and body mechanics related to handwriting (AOTA, n.d.). Therefore, while completing my doctoral capstone at the participating ABA center I acted as an occupational therapy consultant with the ABA professionals as I created and implemented my handwriting program. Outpatient and School-Based OT When comparing outpatient OT, which is carried out at ABA centers, with other OT areas of practice such as school-based OT, there are clear similarities and differences (Six, 2016; Wisconsin Council on Developmental Disabilities [WCDD], 1999). Outpatient OT is governed by state and federal practice guidelines and focuses on reaching functional goals in both the home and community (Six, 2016; WCDD, 1999). This practice area uses the medical model to guide practice, which involves a diagnosis and referral from the physician (Six, 2016). The amount, frequency, and duration of OT services in outpatient OT is determined by the collaboration of the physician, family, and therapist as well as the approval from insurance (WCDD, 1999). At my site, the occupational therapist typically treats clients for 30 minutes to an hour either once a week, twice a week, or every other week (A. Seal, personal communication, 2018). Intervention is typically one-on-one and can address a variety of goals including but not limited to activities of daily living, play, social participation, and education (Six, 2016; WCDD, 1999). Unlike outpatient OT, school-based OT is governed by state and federal laws such as the Individuals with Disabilities Education Act (IDEA) (WCDD, 1999). The decision regarding the frequency and duration of services in school-based OT includes the input from the Individualized Education Plan (IEP) team, which can include the family, therapists, regular education teachers, HANDWRITING AND INTERDISCIPLINARY COLLABORATION 14 special education teachers, a representative of a public agency, the child if appropriate, and other individuals with knowledge and expertise regarding the child (Center for Parent Resources and Information, 2017; WCDD, 1999). Intervention can be provided in a group or one-on-one, typically 30 minutes once per week, and is based on the education model, meaning all goals must relate to the educational needs of the child (Six, 2016; WCDD, 1999). Examples of skills addressed by a school-based therapist include improving educational skills such as writing, cutting, and completing homework as well as increasing participation in school routines, and a childs social participation (AOTA, 2016). Therapy takes place where the child receives education including the classroom, hallways, gyms, playgrounds, lunchrooms, bathrooms, or in a separate therapy room (WCDD, 1999). This is different than OT at an ABA center, where intervention is only provided one-on-one and can address not only educational goals, but other goals such as activities of daily living, sensory processing, and play (A. Seal, personal communication, 2018). A major similarity between outpatient OT carried out at an ABA center and school-based OT is the role an occupational therapist can play as a consultant (Six, 2016). Since the clients at an ABA center typically are on site 40 hours per week for ABA therapy, the occupational therapist can act as a consultant for clients that are not on his/her caseload as well as making sure recommendations are being carried out with the clients on his/her caseload. The occupational therapist at my site will teach the BCBAs and behavior technicians how she wants them to practice the interventions she completes during her sessions. She may also have conversations with behavior technicians when concerns arise about areas that fall within the OT scope of practice (A. Seal, personal communication, 2018). School-based occupational therapists also act as consultants, where they can work with teachers and other staff (AOTA, 2016; Six, 2016). HANDWRITING AND INTERDISCIPLINARY COLLABORATION 15 Some examples include ways to help reduce the number of barriers present in the school environment, ways to modify classrooms and buildings to make them accessible for all as well as providing input on school initiatives such as bullying (AOTA, 2016). Working as an OT consultant during my doctoral project will be very beneficial not only for the site, but it will also help me gain important skills that I can use in other practice areas in the future. Implementation The implementation phase of my doctoral capstone consisted of designing a handwriting program, educating ABA staff on the program materials, and training them to effectively implement it. The first step in designing the handwriting program involved deciding which HWT programs would be included. Based on the needs assessment, it was clear that the pre-k and kindergarten HWT programs were the most appropriate for my site. Therefore, the data sheets and measuring tool were geared towards these grade levels. The data sheets consisted of two sections, one to record the morning probing results and one to record afternoon teaching. The areas tested for the pre-k program included tracing, start, and sequence. The kindergarten program tested orientation, start, sequence, placement, and control. These categories were based on the scoring criteria in the HWT Print Tool, an assessment tool used to evaluate the formation of letters and numbers (Olsen & Knapton, 2008). After determining what to include on the data sheets, I set the mastery criteria for each program. In ABA, mastery criteria are the number of independent correct responses over a number of days needed for a target to be considered mastered (learned) (ABA Teaching Ideas, n.d.). These criteria varied between the handwriting programs I created. Clients were required to score a 70% or higher on all the categories for two days in a row for each letter to be considered mastered. Along with the creation of the data sheets, I made a measuring tool, also based on the Print Tool, to help the behavior technicians HANDWRITING AND INTERDISCIPLINARY COLLABORATION 16 score clients handwriting (Olsen & Knapton, 2008). The measuring tool was printed on a transparency film which is laid over top of the clients worksheets to help score tracing, start, placement, and control. The measuring tool helped increase the objectivity of scoring as well as the inter-rater reliability between the behavior technicians. After creating the data sheets and measuring tool, I collaborated with my site mentor and the sites BCBAs to decide which clients would be appropriate to include in my handwriting program. It was decided that ten clients, four for pre-k and six for kindergarten, would be included in the program. These clients were chosen based on their age, ABA goals, and ability to comprehend and complete the handwriting expectations. The handwriting programs were designed to follow the developmental progression of letters set by HWT. However, since many of the kindergarten-level clients had previously participated in HWT, I created a baseline test to assess their formation of capital letters and determine their starting point in the HWT progression. This meant that for the kindergarten program each client could start at various letters within the HWT progression based on their performance on the baseline test. I had all the pre-k clients start at the beginning of the pre-k program progression. The data sheets were then customized to fit each clients individual program needs. The customizing included which days the data was probed, what program the client was working on, the number of letters the client was practicing, and the mastery criteria to progress through the program, if the 70% requirement was too hard for the client to meet. Once the handwriting programs were finalized, I began to implement them with the clients over a two-week period. The implementation consisted of probing (testing) clients handwriting skills in the morning and teaching in the afternoon. While implementing the programs, I consulted with and taught the behavior technicians how to carry out the programs, HANDWRITING AND INTERDISCIPLINARY COLLABORATION 17 score the handwriting, and record the data. To probe the clients handwriting, I had them complete three separate HWT letter worksheets. Clients received reinforcement of their choice after completing their worksheets. While the clients were in reinforcement, I explained how I was scoring the handwriting and recording the data to the behavior technicians. For the afternoon teaching sessions, I clarified with the technicians that I wanted them to focus on the areas that were difficult for the client. For example, if the client scored high on start and sequence, but low on placement, I would have them focus on teaching placement. During this two-week period, I realized that three of the clients were proficient with the kindergarten program and it would be more appropriate for them to move to a three-lined paper program. This program focused on how to correctly place letters on three-lined paper. This led to the creation of a data sheet for the three-lined paper program, various forms of three-lined paper, and additional scoring tools on the measuring tool to score start, placement and control on three-lined paper. In addition to the individual collaboration with the behavior technicians, I provided an inservice training for all the staff at the site. The presentation included information on the data sheets and measuring tool as well as videos of me scoring both a pre-k and kindergarten example using the materials. During the second half of my rotation, I had the staff continue to implement the clients handwriting programs and integrate them into their overall ABA programming. I was present during the sessions the first few weeks to ensure the behavior technicians were carrying out the programs properly and scoring the clients handwriting correctly. This gave the technicians a chance to ask questions as they arose. At the end of my rotation I had the staff complete a post-implementation survey. The post-implementation survey was identical to the pre-implementation survey and tested if the knowledge and confidence of the staff improved HANDWRITING AND INTERDISCIPLINARY COLLABORATION 18 through my program implementation and education. During my last week, I held a final inservice with the site staff to discuss the survey results, inform them of any final changes made to the data sheets or measuring tool, and encourage them to continue to use the program with clients in the future. The one-on-one collaboration with staff, in-services, and surveys were all used to help promote staff development. As mentioned previously, the pre-implementation survey showed that staff could improve both their knowledge and confidence with scoring handwriting and carrying out handwriting programs in general. Therefore, the benefits of handwriting and how to implement the handwriting program were constantly emphasized with the ABA center staff in hopes of increasing their comprehension as well as the use and carryover of the program upon completion of my capstone experience. This technique was successful as the postimplementation survey showed an overall increase in both the ability of staff to score handwriting and their confidence with scoring and programming. This is important because the staff are required to construct and carry out clients programs. It is vital that the staff have the confidence and knowledge base to make them successful. This project allowed the staff to increase their understanding of how to implement a handwriting program into their clients ABA programs. Leadership Skills To facilitate interdisciplinary collaboration between OT and ABA throughout my program development and implementation, I used various leadership skills including open communication, adaptability, positivity, and responsibility. Open communication allowed my site mentor, the ABA staff, and I to all be on the same page and working to the same goal of implementing a standardized handwriting program. After completing the CliftonStrengths HANDWRITING AND INTERDISCIPLINARY COLLABORATION 19 assessment, I discovered that one of my top five strengths is adaptability, which helped me throughout this project as plans were constantly revised (Gallup, 2012). When changes to my plan, or demanding situations arose, I used my adaptability skills to calmly handle the pressure and adjust my priorities and processes as needed. Another top strength of mine is positivity which is commonly used by people to get others excited about what they plan to do (Gallup, 2012). I used positivity at my site to help get staff on board about the idea of having a new handwriting program. I used enthusiasm when I met with each team at the beginning of my capstone and explained what I envisioned for my project to help get them interested in my idea. Finally, I had to take the responsibility of creating my program into my own hands. I had to stay on top of my program plan and independently manage my time to reach my desired goals. This was a difficult transition because I was used to basing my time on fieldwork educators schedules or goals for each day. Service Provision Using these leadership skills helped me advocate for myself as an occupational therapy consultant. The specific consultation models I used to guide me during this project were colleague and system consultation (Dunn, 1988). I used these models to help increase the skills and knowledge of the ABA professionals at my site, which in turn improved the overall effectiveness of the services provided to their clients. During my consultation, I used active listening skills to help address the needs and concerns staff brought to my attention. As the program leader, I felt it was my responsibility to continually adapt myself and my techniques to best address the needs of the individual staff members and the site overall. Through consulting, I increased the staffs understanding of handwriting, why it is important, what OTs role is with handwriting, and how to implement the specific handwriting program I designed. Overall the HANDWRITING AND INTERDISCIPLINARY COLLABORATION 20 strength of the services provided to clients at the site increased by adding a standard handwriting program. Discontinuation and Outcomes Outcome measures were used to assess the effectiveness of the handwriting program and interdisciplinary collaboration with ABA staff members. To evaluate the success of the program and collaboration, the post-implementation survey results were compared to those from the preimplementation survey. The post-survey results showed an increase in the staffs ability to score clients handwriting as well as an increase in their confidence level with implementing clients handwriting programs. The percentage of staff that scored all parts of the pre-kindergarten example correctly more than doubled, with 50% scoring it properly on the post-implementation survey. The percentage of staff that scored the kindergarten sample accurately also increased from 37% to 45%. Staffs average confidence level also increased from 2.8 to 3.8 on a five-point Likert scale. Sharing the survey results with the staff during the last week of my capstone provided them with proof of the knowledge they have gained regarding handwriting and how their confidence with implementing handwriting programs has improved. By reviewing the survey results, the staff will hopefully be more inclined to continue the program upon completion of my capstone. Sustainability is a key component to consider as part of the discontinuation phase. Scaffa and Reitz (2014) state that program sustainability is an ongoing process and to be sustainable a program must be adaptable and supportable. To support the program and staff, I created a folder on my sites shared drive with the handwriting resources I used and created during my capstone. During the in-service and one-on-one consultation with the behavior technicians I explained how to access and use the resources appropriately. As the implementation transitioned to the HANDWRITING AND INTERDISCIPLINARY COLLABORATION 21 behavior technicians, I made changes and adapted the handwriting resources and individual programs as concerns were brought to my attention. For example, if the handwriting program criteria was too difficult for a client to meet, the program was adapted to meet his/her individual needs. The staffs feedback also led to changes on the data sheets and the measuring tool to make them easier to use and understand. I am confident that these changes will increase the sustainability and carryover of the handwriting program for years to come. My site mentor anticipates that this program will be expanded to the companys other locations and used to train new staff to increase consistency with handwriting programs (A. Seal, personal communication, 2018). Following discussion with my site mentor and the BCBAs about sustaining my project, we decided that it will be the responsibility of the BCBAs and behavior technicians to continue implementing the handwriting programs (A. Seal, Site BCBAs, personal communication, 2018). It will be essential for the behavior technicians to incorporate the data sheets and measuring tool when teaching, scoring, and recording data on handwriting. The BCBAs will also collaborate with my site mentor, who is an occupational therapist, to decide when other clients are appropriate to start working on handwriting. The BCBAs will contact my site mentor when they feel a client has appropriate attention and pre-writing skills to start handwriting. Then, my site mentor will complete an informal consult, if the client is not on her caseload, to assess the clients pre-writing strokes, fine motor skills, motor planning skills, etc. My site mentor will also take over my role and answer any questions or concerns that arise regarding clients handwriting (A. Seal, Site BCBAs, personal communication, 2018). HANDWRITING AND INTERDISCIPLINARY COLLABORATION 22 Quality Improvement It is important to consider quality improvement throughout the discontinuation process. Quality improvement can be used to incorporate scholarly evidence with a clinical problem or issue and in turn improve the quality of care (Bonnel & Smith, 2018). After determining the needs of my site, I used evidence-based practice to guide the creation and implementation of the handwriting program. I also used evidence-based collaboration techniques to promote interdisciplinary practice. Batalden and Davidoff (2007) state that quality improvement can be used in healthcare to improve patient outcomes, system performance, and professional development. The intent of my capstone was to use interdisciplinary collaboration to create and implement a handwriting program that would improve the quality of the services provided to the clients at the participating ABA center. The handwriting program and techniques that were taught to the behavior technicians during consultation helped decrease any inconsistencies between the quality of services provided to clients at this site by creating a standardized way to teach and score handwriting. By collaborating with the ABA staff to create and implement the handwriting program, the clients outcomes and sites overall performance will hopefully improve overtime. The handwriting program and my consultative role helped improve the professional development of the staff at my site. The clinical director at my site required all staff members to attend the in-service to ensure consistency with the handwriting programming going forward. Batalden and Davidoff (2007) explain that quality improvement will not occur until it becomes an intrinsic part of everyones day and mindset. By having the staff implement the program while I was on-site, I made sure they were independently incorporating the handwriting program into their daily routines and ABA programs as well as understanding how to score and record the HANDWRITING AND INTERDISCIPLINARY COLLABORATION 23 handwriting data. I had the behavior technicians save the handwriting worksheets after the clients completed them and when time allowed, I went through and scored the worksheets myself to crosscheck if the staff had scored and recorded the handwriting data correctly. The intent of the crosschecking was to increase inter-rater reliability with scoring and ensure that the staff will adequately carry out the program after my capstone. Addressing Societys Needs The long-term goals of my project aim to address the changing needs of society. This project facilitated both the clients and staff at my site to be more productive members of society. Regarding the clients, the handwriting program will not only improve their academic skills, but can also increase their communication and motor skills. Communication skills are vital to ones everyday functioning in society. By teaching handwriting, a child can communicate their wants and needs, provide safety information if needed, and form relationships with others. A research review conducted by HWT discussed a survey of kindergarten to fifth grade teachers which found that students spend 24 to 58% of their classroom time writing on paper (Olsen & Knapton, 2015). With educational standards and overall demands on students increasing, we, as a society, need to create ways to enable children to succeed. The handwriting program specifically increases the handwriting skills of the clients at my site. The program can help prepare individuals with autism to stay on track with their typically-developing peers if they transition out of the ABA site to mainstream schooling. Regarding staff, this project has taught them the benefits of handwriting and how to effectively collaborate with another discipline, in this case occupational therapy. The collaboration skills can be used with other staff members and disciplines at the site, outside consults, and people the staff encounter in society. In addition, by HANDWRITING AND INTERDISCIPLINARY COLLABORATION 24 having the staff learn about occupational therapy they can be advocates for the profession, its benefits for children with special needs, and increase appropriate referrals to OT. Overall Learning and Communication Throughout my doctoral capstone experience, I learned and practiced valuable skills which I will be able to use in my future practice. These skills included working independently, being adaptable and flexible, collaborating with other disciplines, and using critical thinking skills. I worked independently to create and design the handwriting program and checked in with my site mentor periodically via email, or in person, to update her on my progress as well as ask questions about the program. Working independently will be vital to my future practice since I will not have a fieldwork educator or site mentor constantly monitoring my every move. To reach my intended goals and objectives it was important to be adaptable, flexible, and collaborate with staff due to frequent schedule and/or program changes. Examples of changes included: shifting the probe dates from a frequency of three times a week to two times a week, altering my schedule to work well with the staffs schedule, and modifying how I explained various OT topics to staff to increase their comprehension. As an occupational therapist, it will be important to be adaptable as I collaborate with peers, clients, and families daily. Lastly, I think my critical thinking skills improved during my capstone. I used critical thinking to develop and change the handwriting program as needed to best fit the needs of the site and the clients. In my future practice, critical thinking skills will be key when completing evaluations and designing interventions for clients. Through consultation with staff, I practiced teamwork and continued to improve professional characteristics such as being organized, timely, and accountable. Teamwork was vital to my capstone as it allowed for interdisciplinary collaboration and for me to successfully HANDWRITING AND INTERDISCIPLINARY COLLABORATION 25 implement the handwriting program. Acting as an OT consultant, I continuously collaborated with ABA staff members to design and implement the handwriting program. The staff and I bounced ideas off each other to help determine the best design of the data sheets, what aspects of the measuring tool were easiest to use and understand, and various OT techniques to get the clients to be more successful with handwriting. When consulting with the staff, I advocated for the profession of OT and used my OT mindset to increase collaboration and improve services for the clients at my site. I also acted as a leader throughout my doctoral capstone experience. The behavioral technicians relied on me for guidance and direction when implementing the handwriting program. At times, the staff became too reliant on me and my feedback which required me to take a step back and let them implement the clients handwriting programs independently which further developed my skills in delegating. This assisted staff in gaining confidence as well as a better understanding on how to score and record the handwriting data. By removing myself from the day-to-day implementation from the program, the staff realized they have the knowledge and skills to continue the handwriting program following my capstone. When I start my career as an occupational therapist, continuing to collaborate with other disciplines and using teamwork, leadership, and advocacy will be key to my success. Communication skills were vital to help me successfully design and implement the handwriting program. I was expected to have good written, verbal, and non-verbal communication skills. Written skills were used when writing emails and creating resources for the handwriting binder. I used email to keep my site and faculty mentors up to date as well as send out information regarding my program and in-service to ABA and senior staff at my site. I used professional language when composing emails and creating my resources to ensure my verbiage was clear for other disciplines at my site to understand. In addition, I ensured people of HANDWRITING AND INTERDISCIPLINARY COLLABORATION 26 all educational backgrounds could understand the information in my emails and resources by using simple language and providing examples. Verbal communication skills were used daily when talking with my site mentor, the BCBAs, behavior technicians, and clients. I was in constant contact with other individuals on site, requiring me to use professional and appropriate language every day. During my in-service, I used language that was easy for staff to comprehend and follow to increase the carryover of the program. Non-verbal communication skills were very important during my interaction and collaboration with staff. This included having a professional appearance, making appropriate eye contact, having good posture, and conveying my facial expressions appropriately. Non-verbal skills can often be overlooked, but it was essential for me to continually assess all my communication skills when interacting with staff. If overlooked, poor communication skills can have detrimental effects on collaboration and client care. The communication skills I gained and practiced during my capstone experience will be carried over into my future practice and continue to develop as I work with peers and future clients. HANDWRITING AND INTERDISCIPLINARY COLLABORATION 27 References ABA Teaching Ideas. (n.d). ABA glossary. Retrieved from https://abateachingideas.wixsite.com/aba-teaching-ideas/aba-glossary AOTA. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. AOTA. (2016). Fact sheet: Occupational therapy in school settings. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fa ct-Sheets/School%20Settings%20fact%20sheet.pdf AOTA. (n.d). Handwriting. Retrieved from https://www.aota.org/About-OccupationalTherapy/Patients-Clients/ChildrenAndYouth/Schools/Handwriting.aspx Autism Speaks. (2012). Applied behavior analysis: A parents guide. Retrieved from https://www.autismspeaks.org/docs/sciencedocs/atn/atn_airp_applied_behavior_analysis.pdf Batalden, P.B. & Davidoff, F. (2007). What is quality improvement and how can it improve healthcare? Quality & Safety in Healthcare, 16, 2-3. doi:10.1136/qshc.2006.022046 Bonnel, W. & Smith, K.V. (2018). Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company Brodhead, M. T. (2015). Maintaining professional relationships in an interdisciplinary setting: Strategies for navigating nonbehavioral treatment recommendations for individuals with autism. Behavior Analysis in Practice, 8(1), 70-78. doi: 10.1007/s40617-015-0042-7 Carlson, B., McLaughlin, T. F., Derby, K. M., & Blecher, J. (2009). Teaching preschool children with autism and developmental delays to write. Electronic Journal of Research in Educational Psychology, 7(1), 225-238. HANDWRITING AND INTERDISCIPLINARY COLLABORATION 28 Case-Smith, J., & OBrien, J.C. (2015). Occupational therapy for children and adolescents. (7th ed.). St. Louis, MO: Elsevier Mosby. Center for Parent Information and Resources. (2017). The IEP team. Retrieved from http://www.parentcenterhub.org/iep-team/ Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Cosby, E., McLaughlin, T. F., & Derby, K. M. (2009). Using tracing and modeling with a Handwriting Without Tears worksheet to increase handwriting legibility for a preschool student with autism. The Open Social Science Journal, 2(1). 74-77. Coussen, M., McLaughlin, T. F., Derby, K. M., & McKenzie, M. (2012). The differential effects of Handwriting Without Tears chalkboard, wooden letters, and worksheet using highlight, model and start point on legibility for two preschool students with disabilities. International Journal of English and Education, 1, 302-310. Dunn, W. (1988). Models of occupational therapy service provision in the school system. American Journal of Occupational Therapy, 42(11), 718-723. D'Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., & Beaulieu, M. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, 19(Suppl. 1), 116-131. Fewster-Thuente, L. & Velsor-Friedrich, B. (2008). Interdisciplinary collaboration for healthcare professionals. Nursing Administration Quarterly, 32(1), 40-48. Gallup. (2012). Strengths insight and action-planning guide. Retrieved from https://gx.gallup.com/services/pdf?v=pdfGeneration.prince.7.0.binPath HANDWRITING AND INTERDISCIPLINARY COLLABORATION 29 Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The personenvironment-occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9-23. McBride, M., Pelto, M., McLaughlin, T. F., Barretto, A., Robison, M., & Mortenson, S. (2009). The effects of using Handwriting Without Tears procedures and worksheets to teach two preschool students with severe disabilities to write their first names. The Open Education Journal, 2, 21-24. Moyers, P. A., & Metzler, C. A. (2014). Health policy perspectivesInterprofessional collaborative practice in care coordination. American Journal of Occupational Therapy, 68, 500505. http://dx.doi.org/10.5014/ajot.2014.685002 Olsen, J., & Knapton, E. (2015). Handwriting Without Tears: Research review. Retrieved from http://www.hwtears.com/hwt Olsen, J. Z., Knapton, E. F. (2008). Handwriting Without Tears: The print tool: The tool to evaluate and remediate. (3rd ed.). Cabin John, MD: Authors. Roberts, G. I., Derkach-Ferguson, A. F., Siever, J. E., & Rose, M. S. (2014). An examination of the effectiveness of Handwriting Without Tears instruction. Canadian Journal of Occupational Therapy, 81(2), 102-113. Scaffa, M. E. & Reitz, S.M. (2014). Occupational therapy in community based practice settings (2nd ed.). Philadelphia: F.A.Davis Schroeder, E., Lynch, K., & Turgeon, A. (2017). Strategies for effective collaboration among multidisciplinary teams: Integration of an ABA professional. 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... Use of the Occupational Adaptation Model for Quality of Life Enhancement: Educating Staff on Assistive Technology Use to Support Independence and Decrease Caregiver Burden Jordan F. Jennings April 28, 2018 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. Rebecca Barton, OTR, DHS, FAOTA Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 2 A Capstone Project Entitled Use of the Occupational Adaptation Model for Quality of Life Enhancement: Educating Staff on Assistive Technology Use to Support Independence and Decrease Caregiver Burden Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Jordan F. Jennings, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 3 Use of the Occupational Adaptation Model for Quality of Life Enhancement: Educating Staff on Assistive Technology Use to Support Independence and Decrease Caregiver Burden Jordan F. Jennings University of Indianapolis April 14, 2018 Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 4 Abstract Joys House is an adult day center located in Indianapolis, Indiana and provides interactive services to older adults through a non-medical model. Although many guests Joys House remain active in their communities, the majority of them need some type of assistance when completing daily activities. Assistive technology is a term that has been around for decades to describe any device that can be used to improve function in an individual (Christiansen & Matuska, 2011). Although no-tech forms of AT have been proven to enhance independence in activities of daily living, knowledge on the topic is still unfamiliar for most. The purpose of this doctoral capstone project was to present an educational presentation for staff members of Joys House pertaining to the use of AT in order for staff to effectively explain how to safely and properly use such equipment. This educational presentation was provided on site, and organized as a meeting for all staff members to attend. At the conclusion of the presentation, a survey was given to the staff members to allow for quantitative feedback in terms of how beneficial the staff felt that the presentation was in enhancing their knowledge on the use of this equipment, and successful feedback was obtained. A detailed plan for the implementation of a future Joys House Store was also created and organized into a binder that includes evidence-based articles, as well as the types of adaptive equipment that would eventually be available for purchase. Through evidencebased research, a correlation was identified in both enhanced independence in individuals that use no-tech AT, as well as a decrease in caregiver burden with its use (Marasinghe, 2015). Thus, with the potential incorporation of AT, this knowledge can hopefully be introduced to the populations that could best utilize it, while also advocating for the field of occupational therapy. Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 5 Introduction Adult day centers (ADC) have become increasingly more utilized in recent years as a unique, cost-effective option for long-term, community-based care. With over 4,600 adult day service centers in the United States, ADCs provide a variety of services for both guests and caregivers (NADSA, 2010). Joys House is an adult day center located in Indianapolis, Indiana and provides interactive services to older adults through a non-medical model. While about 50% of ADCs have medical personnel on staff to address any health issues, the other half prefer a nonmedical approach to the services they offer (NADSA, 2010). Joys House staff is trained for best care practices of older adults in terms of transferring, feeding and eating, medication management, and more. However, they do not hire skilled health professionals to complete these responsibilities, nor do they accept new guests with severe health impairments in which this level of care would be necessary. They also provide a multitude of caregiver resources free of cost, and have even discussed plans of creating a caregiver resource center that connects to Joys House for caregivers to utilize. Occupation and Assistive Technology With discussion of a caregiver resource center potentially being developed this year, a potential addition to this area could be inclusion of a Joys House Store to benefit both caregivers and their loved ones who attend Joys House. This store would focus on trialing different types of low-tech or no-tech assistive technology devices that guests or caregivers could conveniently purchase to assist with daily occupations. Occupation, specifically in the healthcare field, refers to the daily life activities in which people engage (AOTA, 2014, pg. S6). Occupations are typically broken down into categories, which include activities of daily living (ADLs) instrumental activities of daily living (IADLs), work, play, sleep, and more (AOTA, Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 6 2014). Assistive technology (AT) is a broad term in healthcare which includes any item, piece of equipment, or product system, off-the-shelf, modified, or customized that is used to increase, maintain, or improve function (Christiansen & Matuska, 2011, pg. 273). Occupational therapists are the health professionals that typically identify and recommend AT for individuals to promote independence and occupational performance in everyday tasks (Gitlow, Dininno, Choate, Luce & Flecky, 2011). Some common diagnoses among guests at Joys House include dementia/cognitive impairment, visual impairment, arthritis, and Parkinsons disease (PD). With diagnoses such as these, along with the normal aging process, declining independence is a common trend. This process can be emotionally destructive and challenging to accept. It has been found that when individuals are able to remain independent in ADLs, they are less likely to depend on caregivers (Marasinghe, 2015, pg. 354). This is important to note, as many caregivers can experience negative effects when it comes to caring for a loved one. One study revealed, depression, stress or burnout deteriorates caregiver quality of life and increases the risk of institutionalization of the person being cared for (Marasinghe, 2015, pg. 354). However, utilization of AT may provide hope for preserving independence and enhancing safety in older adults, while also alleviating some responsibility from their loved ones who care for them. Literature Review In order to identify benefits and most appropriate types of AT with older adults, a literature review was conducted, and the theory of Occupational Adaptation (OA) was used to guide this process. The theory of OA is best fit to guide this search, as it emphasizes the importance of the adaptation process in maintaining satisfying and meaningful occupational behaviors (Cole & Tufano, 2008, pg. 107). The use of AT specifically contributes to the process of adapting to ones environment to positively enhance performance and safety in occupations. By utilizing this Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 7 theory as a guide to current research, The Ebscohost database was used to search for information on AT. Databases including CINAHL Plus and Health Source (Nursing/Academic Edition) were searched were searched using keywords Assistive technology devices AND activities of daily living. Out of 239 results from the CINAHL database, 25 articles were included in the review after the exclusion criteria were considered. Articles were excluded from the review if: (1) an electronic device was the focus of the study; (2) the study was published prior to 2008; (3) mobility devices or AT for cars was articles focus; (4) if no AT was addressed in the study or (5) the device was customized/complex (prosthetics, for example); (6) if the study was in another language, and (7) if the studys population focus was children. Inclusion criteria for the review focused on low or no tech, cost-effective types of AT, as well as a focus population of adults that used AT in the included articles. Scholarly journal/magazine articles or academic research papers were also included if they were published in 2008 or later and available in English. A review of current literature signified numerous benefits when considering the provision of AT among adults with disabilities. One study focused on community participation in individuals with disabilities. Researchers surveyed over 800 participants to determine what factors best enabled this participation. Communication ability, quality of life ratings, and the use of AT were all significantly linked to participation in community events (Puumalainen, 2011). Additionally, it was determined that individuals using assistive devices were more active than those who did not (Puumalainem, 2011, pg. 279), signifying enhanced activity with the addition of AT. Impaired vision is one of the most common diagnoses seen with guests at Joys House and in general for the older adult population. Researchers evaluated a program that utilized AT when considering needs of older adults with vision loss. The program involved training staff members through demonstration of various types of AT for individuals with low vision. These Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 8 demonstrations were then completed with sixty user participants with low-vision. Prior to demonstration of assistive device use, participants were asked about their opinions and understanding of different types of AT. During this time, most users reported that they lacked knowledge and confidence as regards utilizing daily living devices (Percival, 2012, pg. 85). After demonstration of some no-tech AT, items that received the most positive feedback included dycem mats, drop and chop boards, and long handled sponges (Percival, 2012). Participants, however, had no knowledge of these existing devices, indicating a need for increased education in AT for individuals with sight loss. Another important outcome of this program study is that low-tech devices should not be overlooked, as they were seen has useful and important in increasing independence in ADLs for older adults experiencing sight loss (Percival, 2012). Assistive technology is a concept that is within the scope of practice of occupational therapy. Consequently, the studys results also illustrate the need for occupational therapists (OTs) to increase education through demonstration of AT, which has potential to enhance patient independence and participation in ADLs and self-care tasks. Cognitive impairment, specifically dementia, is another common diagnosis seen in guests that attend Joys House. A review of literature identified types of AT that were recommended by OTs working in the mental health field. The most dominant categories associated with the suggested types of AT included ADLs, mobility/seating, and low vision. The devices that were most frequently recommended to assist with ADLs were feeding and medication management devices, various long-handled tools, and bathroom equipment (Gitlow, Dininno, Choate, Luce & Flecky, 2011). The most beneficial types of AT recommended for individuals with low vision included magnification tools for enlargement of everyday objects. These are just a few tools that were identified as commonly recommended by OTs in order to assist individuals in optimizing Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 9 their abilities to accomplish ADLs with items that are readily available and inexpensive (Gitlow, Dininno, Choate, Luce & Flecky, 2011, pg. 184). Another study involving a randomized-controlled trial of participants in an intervention and control group identified types of AT to assist with osteoarthritis, particularly in the hands (HOA). For three months, use of AT in individuals with HOA was tracked in the intervention group. Commonly used items trailed in the study included self-opening scissors, silverware with built-up handles, enlarged bottle grips, and jar-keys (Kjeken, Darre, Smedslund, Hagen, & Nossum, 2011). Using the Canadian occupational performance measure (COPM), significant, positive changes in self-perceived performance and satisfaction in activities such as personal care, household management, and leisure were noted (Kjeken, Darre, Smedslund, Hagen, & Nossum, 2011). Therefore, these results support the use of AT to enhance activity participation and performance in individuals with HOA. Assistive technology has also been proven to improve the quality of life in individuals with Parkinsons disease, another diagnosis frequently seen in the Joys House community. Specific devices noted to assist those with PD in ADLs include weighted pens and silverware, swivel spoons, plate guards, enlarged handles, and handrails (Swann, 2008). Weighted items have been found to ease tremors typically associated with this condition. Swivel spoons also counteract movements associated with tremors to allow for more controlled movements and less spillage when eating. Plate guards also assist in ensuring fewer spills when scooping up bites on a plate. Enlarged handles can aid in better control of device is being used, and handrails placed in areas where balance is a concern can help support safety and stability during household activities (Swann, 2008). Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 10 By reviewing current literature, three main themes were identified. The importance of utilizing AT to enhance participation and independence for individuals with disabilities is apparent. According to the literature, the most beneficial types of AT were those that were low or no-tech, simple to use and affordable. Not only will the use of AT have a direct effect on the individual using it, but it also has the ability to decrease caregiver burden. These ideas compliment the Joys House mission, providing a convenient and cost-effective way to benefit the lives of guests and their caregivers. However, the literature also identified a gap in knowledge and accessibility when considering the types of products available and how to use them. For this reason, education for staff members, and therefore caregivers, is going to be a crucial component of this project. Evaluation/Screening Methods In order to first determine what areas of program development and education could best assist the Joys House community, a needs assessment was conducted. This assessment is necessary to identify the primary needs of the target population, which in this case includes staff, guests, and caregivers (AOTA, 2018). The following procedures that were included in the needs assessment are as follows: Observation of Joys House guests Meetings and consultations with all staff members of Joys House Review of all initial assessments of active Joys House guests Review of the literature based on identified topics in needs assessment Based on the above protocols, it was noted that although many caregiver resources are offered at Joys House, high levels of caregiver burden are still evident. Through guest observation, it was noted that most guests needed some type of assistance with ADLs, but no adaptive Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 11 equipment was utilized or available at Joys House for completing these activities. ADL levels were obtained from completing a thorough screening of all guest assessments. The bar graph in appendix A illustrates whether minimal assistance (min A), moderate assistance (mod A) or maximum assistance (max A) is required for guests when in toileting, bathing, eating and dressing. A precise method for gathering data included to pull guest files and read each assessment, where all ADL levels were recorded. A graph was then created to illustrate assistance levels in toileting, bathing, eating, and dressing for 73 active Joys House guests. The information included identifies assistance levels for 1/3 of the guests who were not independent in their ADLs. In some instances, levels that were recorded in the guest assessments were simply labeled as, assist. When this occurred, staff report or guest observation was also used to more accurately obtain what level of assistance was required for a certain activity. Joys House guest demographics were also obtained through guest files. The average age of a guest is 71, and 49% of guests are white, 47% are black, and 3% are Latino. The majority of guests are living at home either with their spouse or child, which is why caregiver support is imperative for this community. When consulting with staff members at Joys House, another topic was evaluated to consider innovative ways to further support caregivers and guests. This is when the idea of a caregiver resource center was brought to the forefront. A Joys House store has the potential to provide new caregiver resources, as well as AT guests to trial and purchase, if desired. Not only would this be a great financial opportunity to support Joys House as a not-for-profit organization, but this store also has the potential to better support caregivers while enhancing their loved ones independence in everyday activities. Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 12 Caregiver resources offered currently at Joys House include planned retreats, online videos, a caregiver crossing radio station, support groups, and a binder of resources to take home (Joys House, 2018). This is similar to other ADCs in the community, yet none of their competitors yet offer an option for trialing or purchasing adaptive equipment. However, other organizations that have occupational therapists on staff, such as assisted living facilities and nursing homes, do provide this option. While Joys House wishes to remain a non-medical model, advanced staff and caregiver training on proper use of AT provided by an occupational therapy graduate student could provide an avenue for demonstrating how to use AT, while also having such equipment available conveniently at the facility. The University of Indianapolis or a local Indianapolis vendor in the area will provide equipment that will be used for the initial educational demonstration to Joys House staff. Vendors that have been contacted for consideration of permanent demo equipment include: At Home Health Equipment (AHHE), Home Health Depot, and Phoenix Medical Equipment and Supplies. Comparison of Competitors Skilled nursing, assisted living, and adult day facilities are primarily considered when contemplating options for long-term or daytime care for a loved one. Clearvista Lake Health Campus is a popular choice in the Indianapolis area, and includes both assisted living and skilled nursing options. When comparing a facility like this with Joys House, the differences are evident. Clearvista, and nearly every assisted living or skilled nursing facility utilizes a medical model when providing care to residents. Consequently, Clearvistas OT staff can provide assistive device recommendations and education on their use. Joys House, however, strives to emphasize their appeal through their idea of a non-medical environment. Clearvista does have some similarities to Joys House in that there are organized activities and events. These events Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 13 range from gardening and field trips, to family nights at the facility (Trilogy Health Services, 2017). While Joys House does not have an OT on staff due to their non-medical approach to care, they could potentially have staff to provide proper education and use of adaptive equipment with the consideration of this project model. While staff will not be able to recommend certain types of equipment to guests, they will be able to properly and safely demonstrate the use of such devices. The average cost of a skilled nursing facility is $90,500 annually, which estimates to $248 per day (Mullin, 2013). Joys House, however, is only $75 per day (Joys House, 2018). If Joys House could provide the option for trialing and purchasing AT, the appeal of the organization would be enhanced by offering something that many competitors already do, but for a much more affordable price. Sarah Care is another adult day center in the Indianapolis area that has similarities to Joys House, but operates as a more medical model, with therapy and nursing staff to provide medical services if necessary (Sarah Care, 2018). While physical therapy is a component of this adult day center, occupational therapy is not an option. Moreover, the website doesnt identify any information relating to AT, so it is assumed that this is not offered. For this reason, the addition of AT at Joys House would improve the organization in terms of what they could provide for guests and caregivers while still operating as a non-medical facility. Plan Implementation With the completion of the assessment for the needs of Joys House, an educational presentation to staff members was then scheduled and presented. Six different types of AT were utilized for an in-person demonstration to show how the devices are properly used. At the conclusion of the presentation, a survey was given to the staff members to allow for quantitative feedback in terms of how beneficial the staff felt that the presentation was in enhancing their Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 14 knowledge on the use of this equipment, as well as how prepared they now feel with how to properly use the equipment. The survey contains three short questions that the staff members will answer by circling a number 1-5 on a likert scale, where 1= not at all, and 5= extremely. After collecting and reviewing the surveys after the formal presentation, the Goal Attainment Scale (GAS) will then be used as an outcome measure to determine how effectively the project goals have been met. I organized and led the AT demonstration and presentation after receiving approval from an OTR and professor from the University of Indianapolis. A binder of information on specific types and prices of AT, as well as caregiver resources is also in the process of being created for Joys House as a resource for future use. The end of the survey asks for suggestions on useful caregiver resources that any staff members feel should be included in this binder. These suggestions will be taken into consideration when finalizing this portion of the project. A company known as At Home Health Equipment (AHHE) provided various types of notech AT that were utilized for demonstration during the presentation. AHHE is a family owned business that sells various types of medical equipment in Indianapolis and surrounding areas (AHHE, 2018). By scheduling and meeting with the sales manager of AHHE, I was able to explain the basis of the Joys House Store project idea. He was more than willing to donate equipment for use in the demonstration, and expressed interest in future plans to potentially work with Joys House to provide adaptive equipment. Leadership skills were exemplified during the implementation phase of the project by reaching out and scheduling meetings with vendors around the Indianapolis area. Not only was I able to explain the purpose of the project in terms of potential service provision, but I also familiarized local vendors with the various services that Joys House already offers. Because of Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 15 this opportunity, one particular AHHE vendor was then willing to donate equipment for the project, as well as keep Joys House in mind as a future business partner. By scheduling and organizing an educational presentation for the staff members of Joys House, staff development was promoted in terms of gaining knowledge pertaining to proper use of types of AT. The presentation also provided evidence-based research on the benefits of AT in both guests and their caregivers, as well as how OT is involved in this process. After the conclusion of the presentation, the vast majority of staff members felt confident in describing how to properly use six different types of AT. After surveys have been collected and analyzed in accordance with the GAS, they will then be used to provide detailed information on the success of the project presentation. Outcomes Quality improvement is a method utilized in most any organization and refers to a systematic, formal approach to the analysis of practice performance and efforts to improve practice (American Academy of Family Physicians, 2018, pg. 1). In healthcare specifically, quality improvement is a detailed plan necessary to refine the quality and delivery of patient care (Mainz, 2003). Many models and tools have been created to organize and assess quality improvement over time. One of most straightforward models used to guide this project currently and in the future is known as the Plan-Do-Study-Act cycle. This cycle includes four parts, including: Developing a plan with a set goal and plan for implementing that goal Implementing the plan that was developed Using measures to analyze results of the executed plan Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 16 Adjusting the initial plan based on results to facilitate improvement (U.S. Department of Health and Human Services, 2017). The goals for this project are to: (1) prepare and present an AT presentation to Joys House staff to familiarize them with how to properly and safely use six types of no-tech AT, and (2) to organize a binder with information on types of AT and caregiver resources that would potentially be available for purchase at a future Joys House Store. In order to quantitatively assess and measure the success of the first defined goal, the GAS scale was used. This is an outcome measure that can be used to determine to what degree a goal is met or not met. This simple tool contains five outcome scores that will correlate with numbers 1-5 on a survey the student created to be filled out by staff members. Correlating the GAS scale with the survey numbers, a score of 0 indicates that the outcome (goal) was attained; -1 indicates the outcome was somewhat less than expected, and -2 indicates the outcome was much less than expected. A score of 1 shows that the goals outcome was somewhat more than what was expected, and a score of 2 shows that the outcome was much more than expected based on quantifiable results (Turner-Stokes, 2014). Pertaining to the first goal, one of the survey questions asked how much more prepared do you feel after the presentation in explaining what/how these types of assistive technologies are used?. Scores ranged from 1-5, where 1=not at all prepared, 2=somewhat prepared, 3= prepared, 4= very prepared and 5=extremely prepared. A score of a 3 would correlate to a 0 on the GAS scale, a 4 would correlate to a +1, and so on. Results from seven surveys indicate that one staff member felt prepared after the presentation, two felt very prepared, and the remaining three members felt extremely prepared to explain the use of the types of AT after demonstration. Although the GAS scale identified achievement of the first stated project goal, there are still many uncertainties that would need to be considered before the plan of an AT store could be Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 17 put into place. However, continuous quality improvement was involved throughout the project process by developing resources that Joys House would have available for use in the future. The presentation is now a permanent resource that Joys House can use to refresh their understanding of different types of AT, or they can have this information available for caregivers to access. A binder was also created with detailed information on types of AT that could benefit their loved ones, as well as evidence-based research to further explain the value and importance of AT. Using the plan-do-study-act cycle to assess quality improvement should be continued as the project idea progresses in order to continue making adjustments to the plan as Joys House staff members see fit. The resources left after the project are intended to guide and aid the larger plan for a future Joys House AT store. The idea to create a store that offered a convenient way to learn about and use assistive technology stemmed from a common theme of a lack of knowledge on the subject that was apparent through evidence-based research. The Technology Related Assistance for Individuals and Disabilites Act coined the definition of assistive technology in 1988, yet much of society is still unaware of the purpose of these devices or where to purchase them (Goodrich & Garza, 2015). However, research supports the use of no-tech or low-tech AT as a means of increased independence in older adults. One study initiated a plan to have demonstration sessions to teach participants how to use low-tech forms of AT. The demonstrations were so helpful that researchers who conducted the study concluded that this type of learning should be implemented as an ongoing strategy, to raise awareness and share knowledge about assistive technology, and also, possibly allow for the borrowing of devices so that service users can try out before buying (Percival, 2012, pg. 88). This complements the students idea of having basic forms of AT Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 18 available at a future Joys House store for individuals to try out to see if it works for their limitations before purchasing. If a guest attending Joys House requires a recommendation on a specific piece of equipment based on his or her own functional limitations or environmental barriers, occupational therapy would then be recommended. Joys House staff members would not be able to make individualized recommendations, but they would be able to suggest reaching out to their OT (if the guest has one) or perhaps consulting with an OT in the area for more individualized help with choosing the best type of AT for them. Although OT wont be directly integrated at this site due to the non-medical model of Joys House, the student has given staff members permission to use the resources created from the project to enhance knowledge on the topic of AT and OT. This is a strategy that will enable OT to respond to societys lack of knowledge regarding the use of AT to enhance their independence in ADLs, and thus decrease the burden on their caregivers. Learning Process in Community Practice Overall, I have learned a great deal about the details of business structure and health promotion of a not-for-profit, community-based practice model through my experience at Joys House. To facilitate the needs assessment, meetings were scheduled with staff members one-onone to better understand their unique roles in the Joys House community. When meeting with the Senior Vice President of family care, the Joys House business model was explained in more detail. I was asked to consider the aspects of OT could be incorporated into their business model to directly benefit the guests and/or their caregivers, while also potentially increasing revenue. By reviewing current literature and considering the needs of Joys House after meeting with staff, my project idea began to evolve. This evolution took weeks of communication with both staff and guests at Joys House, so that I could better understand the contextual factors of this Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 19 organization. I effectively communicated verbally and nonverbally when sitting in on meetings with staff, and with guests during activities. My site mentor and I also completed a presentation at the University of Indianapolis for doctoral occupational therapy students to describe Joys House and the process of the capstone project in a community-based setting. To communicate my project idea to my site, a formal presentation was also completed for staff members. This involved the demonstration of low-tech assistive technology that would potentially be available for sale in the future at Joys House. I also completed a transfer training/ assistive technology seminar for the community during a Joys House caregiver retreat. Through these various types of professional communication, I was able to promote use of assistive technology to enhance independence, while also advocating the profession of occupational therapy. Joys House worked through a non-medical model, and thus did not have an OT working on site. However, I learned a great deal from this experience based how the organization still consistently incorporated aspects of OT when considering topics like their assessments with caregivers, and activities with guests. Each assessment intently focused on the future guest and their caregivers separately, asking them questions to gather as much information as they could about their individual interests, occupations, as well as areas where they may need extra support. When considering daily activities for guests, these interests are always taken into consideration, and can be altered depending on guest energy levels that day, or other contextual factors. Both of these examples mirror the client-centered concept and driving force behind OT. Even their vision directly mirrors that of OT and my project, where it states that they envision a world where individuals with life-altering diagnoses and their families are living fulfilled lives of knowledge, choice, and comfort (Joys House, 2018). To be able to introduce new knowledge to Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 20 this community resonates directly with the Joys House vision, while also advocating for the incredible, multi-faceted profession of occupational therapy. Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 21 References: American Academy of Family Physicians. (2018). Basics of quality improvement. Retrieved from https://www.aafp.org/practice-management/improvement/basics.html American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy,68(Supp. 1), S1S48. American Occupational Therapy Association. (2018). Needs assessment. Retrieved from https://www.aota.org//media/corporate/files/practice/aging/driving/assessments/needs.pdf At Home Health Equipment. Welcome to at home health equipment. Retrieved from https://www.ahhe.com/ Chapleau, A. (2016). Goal Attainment Scaling: The Technological Journey From Idea to Application. SIS Quarterly Practice Connections. 1(4), 3233. Christiansen, C., & Matuska, K. M. (2011). Ways of living: intervention strategies to enable participation(4th ed.). Bethesda, MD: AOTA Press. Cole, M.B. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Inc. Gitlow, L. Dininno, D., Choate, L., Luce, A.R., & Flecky, K (2011). The provision of assistive technology by occupational therapists who practice in mental health. Occupational Therapy in Mental Health, 27(2), 178-190. Goodrich, B., & Garza E. (2015). The role of occupational therapy in providing assistive technology devices and services. American Occupational Therapy Association. Retrieved from Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 22 https://www.aota.org//media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/Fa cts/AT-fact-sheet.pdf Joys House. (2018). Caregiver support services. Retrieved from http://joyshouse.org/programs/caregiver-support/ Joys House. (2018). FAQ. Retrieved from http://joyshouse.org/about/faq/ Kjeken, I., Darre, S., Smedslund, G., Hagen, K. B., & Nossum, R. (2011). Effect of assistive technology in hand osteoarthritis: a randomized controlled trial. Annals of the Rheumatic Diseases,70(8), 1447-1452. doi:10.1136/ard.2010.148668 National Adult Day Services Association (2010). The metlife national study of adult day services: providing support to individuals and their family caregivers. Retrieved from https://www.metlife.com/assets/cao/mmi/publications/studies/2010/mmi-adult-dayservices.pdf Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Healthcare, 15(6), 523-530. Retrieved from https://academic.oup.com/intqhc/article/15/6/523/1823652 Marasinghe, K. M. (2015). Assistive technologies in reducing caregiver burden among informal caregivers of older adults: a systematic review. Disability and Rehabilitation: Assistive Technology, 11(5), 353-360. Mullin, E. (2013). How to pay for nursing home costs. U.S. News and World Report. Retrieved from https://health.usnews.com/health-news/best-nursinghomes/articles/2013/02/26/how-to pay-for-nursing-home-costs Percival, J. (2012). Demonstrating daily living devices to older people with sight loss: A programme evaluation with implications for good practice and Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 23 policy development. The British Journal of Visual Impairment,30(2), 79-90. doi: 10.1177/0264619612442069 Puumalainen, J. (2011). Participation in community and political life of persons with severe disabilities. International Journal of Rehabilitation Research, 34, 274-281. doi: 10.1097/MMR.0b013e32834a8fc1 Swann, J. (2008). Parkinsons disease part 3: Assistive devices. British Journal of Healthcare Assistants,2(3), 111-114. Sarah Care. (2018). A day at sarah care: Nursing services. Retrieved from http://sarahcare.com/nursing-services/ Trilogy Health Services. (2017). Signature Programs. Retrieved from http://trilogyhs.com/signature-programs Trilogy Health Services (2017). Rehabilitation. Retrieved from http://trilogyhs.com/services-andamenities/rehabilitation Turner-Stokes, L. (2009). Goal attainment scaling in rehabilitation: A practical guide. Clinical Rehabilitation, 23, 362-370. United States Department of Health and Human Services. (2017). Section 4: Ways to approach the quality improvement process. Agency for Healthcare and Research Quality. Retrieved from https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4approach-qi-process/index.html Running head: ASSISTIVE TECHNOLOGY USE TO SUPPORT INDEPENDENCE AND DECREASE CAREGIVER BURDEN 24 Appendix A Figure 1. Guest ADL Assistance Levels # of Guests Requiring Assistance 30 25 20 min A 15 mod A 10 max A 5 0 Toileting Bathing Eating Dressing Basic Activities of Daily Living Figure 1. ADL Guest Assistance Levels. This graph depicts ADL assistance levels for guests who actively attend Joys House.  ...

... OTS ROLE IN COMMUNITY MENTAL HEALTH 1 Title: Understanding Occupational Therapys Role in the Community Mental Health Setting Through the Introduction of Occupation-Based Groups Zachary Selby, OTS August, 2018 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: Julie Bednarski, MHS OTD, OTR/L, OTD Capstone Coordinator OTS ROLE IN COMMUNITY MENTAL HEALTH A Capstone Project Entitled Understanding Occupational Therapys Role in the Community Mental Health Setting Through the Introduction of Occupation-Based Groups Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Zachary Selby OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 OTS ROLE IN COMMUNITY MENTAL HEALTH 3 Abstract Objective: The purpose of this Doctoral Capstone Project involved initiating three groups at a mental health clubhouse to better determine the role of occupational therapy for the mental health population. Groups included a creative arts group utilizing narrative medicine, a theater group, and a self-care group. Methods: Results from the groups were gathered quantitatively from members involved in the theater group via self-efficacy survey. Results were gathered qualitatively from staff, members of all three groups, as well as members not affiliated with the groups, using various questionnaires. Results: Overall, results indicated that the groups had a positive impact on members in the areas of interpersonal skills, confidence, self-care habits and routines, and self-reflection. Conclusion: The results support occupational therapy at the mental health clubhouse setting, as well as the overall mental health setting. Occupational therapists can perform groups such as these, to help clients achieve greater occupational participation and performance in all areas of life. OTS ROLE IN COMMUNITY MENTAL HEALTH 4 Understanding Occupational Therapys Role in the Community Mental Health Setting Through the Introduction of Occupation-Based Groups For my doctoral capstone project, I introduced three occupation-based groups at Park Center South, a mental health clubhouse setting in Nashville, Tennessee. The groups met once a week, and were attended voluntarily by Park Center members. Two of the groups culminated in performances for all members and staff of Park Center South (a theater production and a creative art showcase). Outcomes gathered from these groups informed the need for occupational therapy services at an outpatient community mental health setting such as Park Center. Literature Review Hohl, Moll, and Pfeiffer (2017) completed a literature review of international studies regarding occupational therapy used as treatment for people with severe mental illness. Overall, the studies they reviewed supported the use of occupational therapy for adults with severe mental illness. Researchers found that behavioral activation, an occupation-based treatment that involves changing behaviors and activity scheduling to enable clients to participate in activities they are avoiding, has been shown to produce significant improvements in patient-reported levels of depression, levels of reported negative symptoms, and activity levels. The therapists who administered behavioral activation treatments in these studies included occupational therapists, among other clinical therapists. Additional studies have linked a variety of occupational therapy interventions in the inpatient hospital setting to improved functional independence. While the studies in this review help to justify the role of occupational therapy in helping adults with mental illness, additional studies of a larger size are needed to further explore the OTS ROLE IN COMMUNITY MENTAL HEALTH 5 positive benefits that occupational therapy can have on adults with mental illness (Hohl et al., 2017). The three groups I introduced during my DCE are occupation-based and served to further explore and justify the benefits that occupational therapists can provide for adults with mental illness. One of the groups I established at Park Center for my DCE was a theatre group. This group included weekly practices, with a final performance for the site after 6 weeks of practice. Theater participation and performance had previously been used as therapy for those with mental illness. Wasmuth and Pritchard (2016) conducted a study in which veterans with substance-use disorders participated in a 6-week occupation-based theater project that included practice three times a week and two performances for the community. Improvements in social and occupational participation were noted at postintervention, and at 6-weeks follow-up, but were not retained at 6 months follow-up. Social and occupational participation were measured using the Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS). Lack of significant results at 6-months follow-up may have been due to the small final sample size of the study (n=7) reducing the statistical power of the results (Wasmuth & Pritchard, 2016). The script used for this production was written by a local playwright who was a collaborator in the study. This allowed for more flexibility for researchers in that the script could be adapted based on the number of participants and dropouts. The script touched on themes of addiction in a discrete way, allowing all study personal to participate in discussions about the themes presented in the script (Wasmuth & Pritchard, 2016). This method of script synthesis influenced the method I used for creating the script for the theatre group I established at Park Center. During our first group meeting OTS ROLE IN COMMUNITY MENTAL HEALTH 6 for our theatre group, I asked members to contribute topics and themes related to mental illness that they would like to see covered in the play. All group members who attended the group meeting contributed ideas, and I created a script based on these themes and topics. The script was altered based on the number of available actors and actresses, and based on how many participants wanted a large, medium, or small role in the play. Wasmuth and Pritchard (2016) illuminate the benefits that theatre intervention may have in improving social and occupational participation in adults with mental illness. Additional studies utilizing therapeutic theater have demonstrated positive psychosocial results in youth with Fetal Alcohol Spectrum Disorder (Keightley et al., 2018) and teenagers (Costa Hermeto, de Arajo Fernandes, da Silva, Coelho de Holanda, 2013). In Keightley et al., (2018) a theater skills training program was initiated for indigenous Canadian youth with Fetal Alcohol Syndrome. Results showed perceived improvements in participants development of self-esteem, social skills, and emotional awareness, according to participants, their caregivers, and program facilitators. In Costa Hermento et al., (2013), teenagers participated in a two-month theater intervention that involved acting out various scenarios relating to illicit drug use and prevention. Results indicated that participants improved in self-esteem, social skills, and emotional awareness, based on self-reports and observations from researchers. Additional studies need to be carried out to better determine the range of benefits of theatre interventions with the mental health, and overall population. Another group I established at Park Center was a self-care group that discussed safety and independence with daily self-care, hygiene, grooming, and wellness activities, to promote increased functional independence for members. Numerous studies have OTS ROLE IN COMMUNITY MENTAL HEALTH 7 identified a link between mental illness and lack of self-care (Hatsumi, Nobutaka, Kouhei, and Hidemitsu, 2017). One area of self-care in which this link is pronounced is in oral care. Hatsumi et al., (2017) wanted to address this problem by implementing an educational intervention on oral hygiene with adults with mental illness in Japan. This program included a narrated slideshow that covered various aspects of oral care. In addition, participants were given a booklet with printouts of the slideshow, with the accompanying narration. Using a questionnaire, researchers gathered results before the intervention was initiated (baseline), and at 1 week, and 1, 3, and 6 months after participants were finished with the program. Significant increases in use of fluoride toothpaste, and frequency of using interdental toothbrushes or floss were noted from baseline to 6 months (Hatsumi et al., 2017). This study shows that an educational program focused on self-care can make lasting impacts on the self-care habits of adults with mental illness. However, this study only covers oral care, and does not cover any other aspects of self-care. For my DCE, it was my belief that initiating an educational group that focused on many aspects of selfcare could benefit participants in aspects of self-care other than oral care, including bathing, dressing, toilet hygiene, and sleep. Netto, Yeung, Cocks, and McNamara (2016) carried out a study that explored factors that were facilitators and barriers to obtaining employment for adults with mental illness. Themes emerged from focus groups and individual in-depth interviews, from which researchers identified facilitators and barriers to obtaining employment. Common barriers included loss of valued life roles, challenges of the vocational environment, and restrictions in opportunities. The theme "loss of valued life roles" included the loss of OTS ROLE IN COMMUNITY MENTAL HEALTH 8 roles such as husband, mother, and employee, and included the negative results associated with these loses. These results included loss of socialization, losing the satisfaction of doing something well, and lower self-esteem (Netto et al., 2016). The theatre group created aimed to target these three negative outcomes of losing valued life roles, as well as additional psychosocial factors. Socialization was addressed when members communicated to me and other members through reading script lines, and was addressed through necessary collaboration/discussion to ensure scenes were presented in a way that works well for everyone involved (e.g. blocking, timing, and dialogue). Member satisfaction with the process and final performance was reinforced through continual positive reinforcement from myself and other members, and from the audience of the final performance, made up of other Park Center members and staff. This project worked to help improve participants' self-esteem through being a part of a team, having an individual role that was needed, and encouraging positive praise and support from all participants and staff. In Netto et al., (2016), the theme "challenges of the vocational environment" included feelings such as mistrust of fellow employees and anxiety caused by new and uncertain work conditions. These are both feelings that may arise when becoming a part of a theater production, especially if one has never been a part of such an experience before. One may mistrust fellow actors/actresses about their dedication to their part, and the production as a whole. Regarding anxiety, multiple members expressed to me hesitance due to stage fright, or the fear that they would not be able to fulfill their role well. Thus, being a part of a theatre production can help participants face and conquer some of the specific feelings that work as challenges in their vocational environment. OTS ROLE IN COMMUNITY MENTAL HEALTH 9 The third and final group I implemented at Park Center was a creative arts group, titled Exploring Your Story. Caddy, Crawford, and Page (2012) analyzed mental health hospital records to determine if there was a relationship between participation in a creative arts therapy group and ones mental health status. Data from 403 patients who attended the group over a 5-year period were analyzed, and mental health status was measured quantitatively by four separate clinical assessment tools. Significant improvement was noted for the creative arts group sample for four different psychometric measures. The creative arts therapy sample also had significant reductions in patient and clinician-reported symptoms associated with mental illness. This study demonstrates some of the potential benefits that a creative arts group can have on people with mental illness (Caddy et al., 2011). Exploring Your Story utilized an approach called narrative medicine. Narrative Medicine is a medical approach that uses people's narratives in clinical practice, research and education to promote healing (Charon, 2006). In Exploring Your Story, a different form of art was explored every week. Art was used as a medium through which discussion about one's own perspective on and experience with mental illness (one's "narrative"), and how it relates to others' experiences, could be facilitated and discussed. The group culminated in a creative arts showcase put on for all members and staff at Park Center South. All members who had attended at least one session of the group were invited to share their favorite work (e.g. poem, short story, drawing) that they created in the group, and explain what their work meant to them. Rodriguez, Welch, and Edwards (2012) measured the impact that the addition of a creative arts journal had on medical students, faculty, and staff at a medical school. OTS ROLE IN COMMUNITY MENTAL HEALTH 10 Qualitative data gathering yielded themes from students, faculty, and staff that included strengthened professional relationships and educational enhancement. This study demonstrates positive psychological and communal benefits from the addition of a creative artistic outlet rooted in narrative medicine (Rodriguez et al., 2012). Screening and Evaluation The screening and evaluation process included multiple steps at various points throughout my project. The first step of the process involved performing a needs assessment at Park Center about what needed to be addressed in groups. This was done through a combination of research and communication with my site mentor, Kathleen Newbold. As discussed in the literature review, researchers have identified a link between mental illness and lack of self-care (Hatsumi, Nobutaka, Kouhei, and Hidemitsu, 2017). These findings suggest a need for occupational therapy services to help those with mental illness improve their self-care routines. Netto, Yeung, Cocks, and McNamara (2016) identified a link between mental illness and lower levels of employment. Due to this relationship, there is a need for organizations like Park Center, and the groups the organizations provide. The groups I established all aimed to help members live more independent and fulfilling lives, and develop the skills necessary to obtain employment. Consultation with Ms. Newbold involved a discussion of what occupational therapy is and what it can provide for the mental health population. Through this discussion, Ms. Newbold highlighted self-care, including hygiene and grooming, as a primary area of deficit exhibited by members of Park Center. Ms. Newbold also agreed that a theater group could be greatly beneficial in helping members lead more OTS ROLE IN COMMUNITY MENTAL HEALTH 11 independent and fulfilling lives, and gain skills necessary to secure employment opportunities. Ms. Newbold additionally supported my idea of a creative arts group utilizing narrative medicine as a viable method of facilitating discussion about mental illness and difficult situations. The next part of the screening/evaluation process involved finding the right members for each group. This involved explaining the nature of my groups to Ms. Newbold and the recovery coaches (psych rehabilitation workers who each have a caseload of members), and asking the recovery coaches if they had any members they knew of that would be appropriate for, and would benefit from the groups. After a list of potential members was created, I explained the groups to members, asking if they felt comfortable attending the groups. This process proved to be the most difficult for the theater group, as it was important to find members that fit individual roles based on a variety of factors including time commitments, ability to play characters of various personality types, and comfort with performing in front of an audience. Regarding these difficulties identified for bringing members into the theater group, time commitments were resolved through mutual discussion with members and their recovery coaches. If a member was currently attending a group during the theater group timeslot which their recovery coach deemed to be more important for the members recovery plan, as was the case with one of the lead actors in the play, practice sessions were solely individual, with the member working one on one with myself. Roles in the play were assigned during the second week of group. After I read through the entirety of the script, members were asked which roles they preferred. Most members intuitively selected a role that fit their personality type and acting abilities OTS ROLE IN COMMUNITY MENTAL HEALTH 12 reasonably. However, to resolve the few significant mismatches that occurred between actor and role (e.g. actor was too quiet or emotionless to play an expressive character), I facilitated switching of roles by means of positive language. For example, instead of saying You do not express enough emotion for this role, here is a role that requires less expression, I would say Your demeanor is more laid back and calm, how about a character that matches this personality? All members accepted these role switches, and the majority of roles were established by the end of the second group session. When asked if they would like to join the theater group, many members initially responded that they were not interested, or unsure of joining due to stage freight. For some members, this stage freight was so strong that they would not give any consideration towards joining the group. However, for the members who expressed some stage freight and were on the fence about joining, I encouraged members to come to practice and try reading a few lines in front of the group to see how they felt. From the members who obliged, a few members left the group before the first group had finished, stating that the group reaffirmed the stage freight they had feared would come about. However, for a few other members, the first practice went better than anticipated, and they were assigned a role in the play. The final part of the screening/evaluation process involved gathering initial data from the theater group. This data served as a baseline, from which improvements in selfefficacy for group members could be measured. A survey containing questions about one's perceived abilities relating to gaining employment, socialization, and becoming a member of one's community was given to all members on their first day of practice. The questions were all answered on a semantic differential scale, ranging from "not at all OTS ROLE IN COMMUNITY MENTAL HEALTH 13 confident" to "very confident". The survey was not adapted from any existing format; questions were created specific to Park Center, the theater group, and the goals of this capstone project. All members were able to understand and complete this form. Early results suggested a broad range of self-efficacy in these areas among members. Implementation For my capstone project, I implemented three weekly groups at Park Center. The first of these was a group titled "Exploring Your Story", which used the creative arts as a medium through which individual experiences with mental illness and difficult life circumstances/situations were discussed as a group. This group utilized narrative medicine theory, as the discussion of mental illness revolved around individual members' narratives about their own experiences. This group ended with a showcase for Park Center, in which members shared one piece of art (e.g. poem, drawing) that they created during the group, and described what the art represented and how it was meaningful to them. This experience helped to move the conversation about mental illness from the group out to the entire center, to encourage creative expression and discussion about one's own perspective on and experience with mental illness. The second group I implemented was a theater group. The group began with collective collaboration to create a play based on themes highlighted by participating members. Group members were encouraged to name themes, topics, and ideas that were meaningful to them, and related to their own experiences with mental illness. Group members shared themes and experiences that they wanted to see covered in the play, and I wrote a script that highlighted these themes and experiences, told through the stories of fictional characters. Once the play was written, members were assigned roles and given OTS ROLE IN COMMUNITY MENTAL HEALTH 14 lines. Members practiced their lines as a group, and during individual sessions with myself before and after they attended their other groups. Throughout the process, group members worked to overcome barriers including stage freight, self-doubt, and unease with standing close to others. Multiple group members expressed stage freight at various points throughout the 6-week process. A few group members brought up the topic of stage fright during the initial stage of the process, but soon overcame this fear, and it was not a problem for the rest of the theater process. However, for a few other members, intense feelings of stage freight began or resurfaced in the middle or end of the process. For one member, who expressed little to no stage freight initially, her stage freight became so bad during week 4 that she did not show up for practice. When approached after practice was over, she stated that she no longer wanted to be a part of the play due to stage freight. For these members, I initiated discussions in which I gave encouragement about their abilities, their accomplishments thus far in the process, and helped to reframe their schematic about the process (e.g. the other actors hate me, everyone is going to laugh at me). After these discussions, these members re-joined group practices, with a new lens of greater selfconfidence about their abilities, and their role in the team. After six weeks of practicing, a performance was put on for Park Center South in the dining room. The third group I implemented was a self-care group. This group involved weekly educational discussions about hygiene, grooming, relaxation, and other healthy and positive habits. Each week covered a new topic, and all group members were expected to contribute to the discussion. Educational resources from sessions were distributed to members to help them retain and implement new information into their self-care routines. OTS ROLE IN COMMUNITY MENTAL HEALTH 15 The process of implementing these groups demanded from me multiple leadership qualities and skills. The first, and perhaps most important of these was advocacy. Advocacy began when I first arrived at the site. Many staff members were unfamiliar, or only vaguely familiar with the profession of occupational therapy, and thus needed clarification about my purpose as a student at the site. The most important explanation of occupational therapy I gave was to my site mentor, Ms. Newbold. With this explanation, I had to advocate for not only my presence as a student, but also for the groups I wanted to implement, by stating how these groups related to occupational therapy. I also explained how the implementation of these groups provided members with skills that would help them live and work in their communities. Through collaboration, discussion, and continued advocacy with Ms. Newbold and other staff, I was able to get my three groups added to the weekly group schedule. Another leadership quality that greatly helped the implementation of my project was flexibility. This skill was needed most for implementing the theatre group. There were many challenges throughout the process of this group that included, but were not limited to: members wanting to quit halfway through the practice timeline, members not showing up the day of practice, members leaving the play, finding replacements for members, working with members with impairments in reading and memory, being unable to find an existing script that included themes suggested by members, and having one of the main actresses plan a move to a new city a week before the original planned performance date. When I was originally planning the theatre group, I was considering putting on the performance at a stage in a performance hall, open to the community, with OTS ROLE IN COMMUNITY MENTAL HEALTH 16 professionals working lights and sound. However, upon discussing this possibility with my faculty mentor, and watching multiple practices, it soon became apparent that this would no longer be a possibility, and the performance would need to be put on at Park Center. Additionally, my original plan called for the group to use an already-existing script. However, after members expressed which themes they would like the play to cover, I was unable to find an existing play that covered more than a couple of these themes, and could be put on in regards of props and number of musical numbers, among other factors. Thus, I ended up writing a script that satisfied the needs of the group. If I had not been flexible at every point in the process, I would not have been able to adapt to the challenges presented, and there would have been no performance. These experiences helped to solidify my abilities in advocacy and flexibility as a leader. I now feel more confident advocating for my profession, for myself, and for my clients. I feel more confident adapting to sudden challenges that present themselves my way as a practitioner, especially if I find myself working in the mental health setting. These skills will be greatly beneficial regardless of which setting I find myself in, and will be especially helpful if I find myself once again in program development, as I was during this project. Outcomes Outcomes of the three groups were measured through qualitative and quantitative means. Exploring Your Story outcomes were measured qualitatively. Group members were periodically asked questions about their experience with the group, and group members, non-group members, and staff were asked about their thoughts regarding the creative arts showcase after this was put on for Park Center. Regarding participation in OTS ROLE IN COMMUNITY MENTAL HEALTH 17 the group, anecdotes gathered from group members were overall positive. Multiple members of EYS praised the environment created by the group, in which open and nonjudgmental discussion about mental illness was encouraged. Group members also praised how creative expression was enabled and encouraged in the group. One group member in particular stated that the group felt like a community. Impressions of the creative arts showcase, gathered from group members, nongroup members, and Park Center staff were gathered via structured interviews. Most group members stated they were glad that they participated in the showcase. Most group members felt that the showcase helped them express themselves creatively and enabled them to share their experience with mental illness. When asked what they learned from the experience, group members shared a variety of personal insights, including: Through creative projects, I can get through other peoples bullying, I learned not to be so shy, I learned about other peoples feelings, and I learned that I havent lost my touch. Outcomes of the theater group were measured by both quantitative and qualitative means. Quantitative results were gathered by giving members of the production a survey during the first week of practice, and after the performance. Questions asked about members self-efficacy regarding socialization, community integration, and the process of finding employment. Each question was presented as a 5-point semantic differential scale. Of the 13 theater group members, 6 had lower overall scores of self-efficacy after the performance, 6 had higher scores, and 1 remained equal. However, when summing all results, there was an overall increase of scores by 28 points. Thus, overall increases in scores were stronger than decreases. Survey questions that increased the most overall were: OTS ROLE IN COMMUNITY MENTAL HEALTH 18 #4: After this experience, do you feel like a member of a community? ( +8) #5: After this experience, how well do you think you work in a team? (+8) #10: After this experience, how confident do you feel speaking to others? (+7) Qualitative results from the theatre group were measured by interviewing members (all who were in the production, and 10 who were not) and Park Center South staff who had attended the production. The interviews consisted of prepared questions asking about ones reaction to, and thoughts about the play, and the theater group in general. Common themes among staff and non-group members included the experience being beneficial for the members involved, as well as for members who watched the performance. Specific benefits listed included increased confidence, social skills and ability to work in a team. Staff and non-group members stated that the play adequately covered themes of mental illness. Common themes among members who were a part of the production included gaining confidence, working better with others, and further exploring others experiences with mental illness. Outcomes of the self-care group were measured qualitatively. Group members were periodically asked questions about their experience with the group, and what they learned/gained from the sessions. Group members expressed mostly positivity about their experiences in the group. Group members stated that they had learned new skills and information, which they were applying to their self-care routines. Two group members were able to give specific examples of ways they were applying new information into their routines. These included brushing their teeth the correct way and more frequently, and utilizing strategies for organizing their belongings. OTS ROLE IN COMMUNITY MENTAL HEALTH 19 Results obtained from groups demonstrate the positive effect that occupationbased groups and performances can have on self-efficacy, interpersonal skills, open discussion, self-exploration, team/project skills, and self-care routines. An occupational therapist working at a site such as this one could employ these groups, as well as other occupation-based groups and occupational therapy interventions (e.g. consultations with members and sites, ADL training) to solidify improvements in occupational performance. Discontinuation The discontinuation phase of my project included the creation of two resources. The first resource was a binder that served to help staff continue the groups I established at Park Center. For the Exploring Your Story and self-care groups, the binder included outlines of various sessions, with included resources, and instructions on how to lead the individual sessions. For the theater group, the binder included the script from the play put on for Park Center, with included advice for assigning roles, working with members on lines, conducting practice sessions with members, and putting on the performance. The binder also included other recommended plays that could be put on for the center, as well as advice for how to create a script based on themes and ideas suggested by members, as I had done to create the script. The second resource was a document that states occupational therapys potential role at Park Center South. The document used results gathered from the groups I implemented, research, the Occupational Therapy Practice Framework (3rd edition), and AOTA resources to explain how occupational therapy could be greatly beneficial for the site and its members. The document explains additional roles, in addition to leading the groups I implemented, that an occupational therapist could carry out at Park Center South OTS ROLE IN COMMUNITY MENTAL HEALTH 20 to serve its members. These roles include consultations with other professionals (e.g. house managers, job coaches), home evaluations and adaptations (to ensure safety and independence), ADL training, professional-skills training, interpersonal skills training, conducting evaluations, and evaluating/treating sensory processing deficits. As the public becomes increasingly aware of the necessity of effective services for those with mental health conditions, it is becoming more crucial to advocate for occupational therapys role in the mental health population. This document serves as a piece of this advocacy, giving clear and convincing data and reasoning for occupational therapys unique and necessary role as a profession that addresses mental health conditions. Overall Learning This experience reinforced to me the need for occupational therapy in the mental health setting. While leading my groups, I saw firsthand the occupational deprivation faced by many in this setting. Members faced difficulties in areas including self-care, working with others, organization, planning, completing a long-term commitment, finding activities to participate in, finding meaningful employment, and expressing themselves. Though some of these difficulties were addressed by groups already in place at the site, many of these difficulties would have been better addressed with the addition of an occupational therapist. Occupational therapists are well equipped to conduct evaluations on clients, evaluate and adapt clients home and work environments, conduct treatment with a client-centered and holistic approach that incorporates valued occupations, evaluate and educate clients on activities of daily living, consult with other professions to increase clients occupational performance in various contexts/environments, and evaluate/treat sensory processing deficits (AOTA, 2018). The addition of these OTS ROLE IN COMMUNITY MENTAL HEALTH 21 intervention approaches would help members increase their occupational participation in safe, meaningful, and valued occupations, including attaining and maintaining employment. Occupational therapy can help clients establish valued and meaningful roles, improve performance in a variety of daily activities and contexts, and lead more meaningful lives based on individual goals, dreams, and passions, regardless of ones condition. I have learned and improved on valuable skills from this experience, including flexibility, finding creative solutions to problems, motivating and inspiring clients, and gaining trust and building rapport. Moving on from this experience, I will apply the skills I have learned to new settings and new ideas. I have seen firsthand that every person is capable of creative expression, working with others, and helping to create something that is meaningful for many. Different people are inspired in unique ways, and it is the role of the occupational therapist to help find their clients inspiration, and guide therapy based on this inspiration. This knowledge will help guide therapy regardless of setting. During this experience, I learned from colleagues about the importance of advocacy and leadership. While completing weekly forums, I could see that I was not the only student who needed to advocate for myself, and take on the role of leader in some fashion. Everyone found themselves taking on these responsibilities, as this experience required us to be advocates for ourselves and leaders at our settings to complete our projects. We all had to use a combination of evidence, clinical reasoning, common sense, and gumption to see to it that our projects came to fruition. We had to overcome selfdoubt, reminding ourselves that our projects could truly make a difference in peoples lives, and that the profession of occupational therapy could enable this change to happen. OTS ROLE IN COMMUNITY MENTAL HEALTH 22 Throughout my project, I had to advocate for my groups, advocate for my role at the site, and advocate for the profession of occupational therapy. I had to be a leader by establishing new groups at the site, putting together multiple performances at the site, and working with members to improve their occupational performance based on individual goals, abilities, and passions. During the fifth week of the DCE, my project, and role at Park Center was challenged. I held a strong belief that this challenge was unfounded, and worked to advocate for my place at Park Center, my project, and for the members whom my project was serving. This unexpected process of advocacy necessitated researching state occupational therapy practice laws, gaining a better understanding of ACOTE standards as they related to my project, and gaining a network of supportive professionals from multiple disciplines, in multiple settings. From these efforts, a proposal was created that argued for the continuation of my project. The challenge to my project was withheld, and I was able to continue on with my groups. This advocacy effort gave me a much greater appreciation for the necessity of familiarizing oneself with local, state, and national practice laws, and ensuring that ones practice occurs strictly within these guidelines. The experience also gave me a greater appreciation for the duty and power that occupational therapists and other professionals have when advocating for one another, to ensure that practice laws are upheld, and that clients receive the care they deserve. OTS ROLE IN COMMUNITY MENTAL HEALTH 23 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68(Suppl. 1), S1S48. http://doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association. (2018). Occupational Therapys Role in Community Mental Health. Retrieved from https://www.aota.org/AboutOccupational-Therapy/Professionals/MH/Community-Mental-Health.aspx Caddy, L., Crawford, F., & Pafe, A. C. (2012). 'Painting a path to wellness': Correlations between participating in a creative activity group and improved measured mental health outcome. Journal of Psychiatric & Mental Health Nursing, 19(4), 327-333. doi:10.1111/j.1365-2850.2011.01785.x Costa Hermeto, E. M., de Arajo Fernandes, L. L., da Silva, N. M., & Coelho de Holanda, I. L. (2013). Theater as a Therapeutic Resource for the Prevention of Substance Abuse: Teenagers Perception. Revista Brasileira Em Promoo Da Sade, 26(3), 329-335. Charon, R. Narrative Medicine: Honoring the Stories of Illness. New York, NY: Oxford University Press, 2006. Print. Hatsumi, Y., Nobutaka, K., Kouhei, A., & Hidemitsu, S. (2017). Effects of an educational intervention on oral hygiene and self-care among people with mental illness in Japan: a longitudinal study. BMC Oral Health, 171-8. doi:10.1186/s12903-017-0372-7 OTS ROLE IN COMMUNITY MENTAL HEALTH 24 Hhl, W., Moll, S., & Pfeiffer, A. (2017). Occupational therapy interventions in the treatment of people with severe mental illness. Current Opinion in Psychiatry,30(4), 300-305. doi:10.1097/YCO.0000000000000339 Keightley, M., Agnihotri, S., Subramaniapillai, S., Gray, J., Keresztesi, J., Colantonio, A., & ... Wiseman-Hakes, C. (2018). Investigating a theatre-based intervention for Indigenous youth with fetal alcohol spectrum disorder: Exploration d'une intervention base sur le thtre auprs de jeunes Autochtones atteints du syndrome d'alcoolisme ftal. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergotherapie, 85(2), 128-136. doi:10.1177/0008417417719722 Netto, J. A., Polly, Y., Cocks, E., & McNamara, B. (2016). Facilitators and barriers to employment for people with mental illness: A qualitative study. Journal of Vocational Rehabilitation, 44(1), 61-72. doi:10.3233/JVR-150780 Rodrguez, J. E., Welch, T. J., & Edwards, J. C. (2012). Impact of a Creative Arts Journal on a Medical School Community: A Qualitative Study. Journal of Poetry Therapy: The Interdisciplinary Journal of Practice, Theory, Research, And Education, 25(4), 197-204. doi:10.1080/08893675.2012.736179 Wasmuth,S.,& Pritchard, K. (2016).Theater based community engagement project for veterans recovering from substance use disorders. American Journal of Occupational Therapy, 70, 7004250020. http://dx.doi.org/10.5014/ajot.2016.018333  ...

... TWITTER IN POLITICS: THE CONTENT AND CONVENTIONS BEHIND CANDIDATES TWEETS By Hannah Nieman An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Robert Gobetz. April 17, 2016 Approved by: __________________________________________________________________ Robert Gobetz, Faculty Advisor ______________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader Abstract This study was designed to determine how political candidates use Twitter. The tweet analysis considered both content of the tweets and the use of technical Twitter functions. A total of 1347 tweets were analyzed from 10 candidates participating in Kentucky elections. Using a list of rules adapted from other studies, tweets were categorized. The results show that certain content categories and technical conventions are embraced by some candidates while others exclude them. This suggests that Twitter use may be influenced by the biographical history of the candidate, the candidates familiarity with Twitter, and the circumstances of the campaign. H. Nieman iii List of Tables Table 1: Summary Results of Personal and User Interaction Tweets ....................14 Table 2: Summary Results of Non-Native Tweets ................................................15 Table 3: Summary Results of the Inclusion of # and @ ........................................16 Table 4: Summary Results of Link Types .............................................................17 Table 5: Summary Results of Candidate Characteristics .......................................18 H. Nieman iv Table of Contents Cover Page ............................................................................................................... i Abstract .................................................................................................................. ii Acknowledgement ................................................................................................. iii List of Tables ......................................................................................................... iv Statement of Purpose ...............................................................................................1 Introduction ..............................................................................................................2 Method/Procedure ....................................................................................................9 Results... .........................................................................................................13 Analysis/Conclusion ..............................................................................................19 Reflection ...............................................................................................................23 References ..............................................................................................................24 Appendices .............................................................................................................26 Appendix A: Candidate Bios .....................................................................26 Appendix B: Coding Rules ........................................................................28 Appendix C: CITI Training .......................................................................33 H. Nieman 1 Statement of Purpose The purpose of this study was to analyze the elements of political candidates social media use within the context of Twitter by categorizing tweets based on content and the use of technical conventions. This helped clarify characteristic differences in Twitter use between candidates in Midwest elections. Candidates tweets from a U.S. Senate race, a U.S. House race, a couple Kentucky Senate races, and a few Kentucky House races were all analyzed to determine how many tweets mentioned certain campaign-related categories and used certain technical conventions. The results of this study helped highlight the idea that different characteristics can impact how candidates tweet. H. Nieman 2 Twitter in Politics: The Content and Conventions Behind Candidates Tweets Introduction Context Each day, individuals from all over the world go online and log into Twitter, gaining access to content from different individuals with unique backgrounds; all the user has to do is choose to follow another. This relatively new communication medium provides an interesting opportunity for politicians and candidates. Not only can they reach a wide audience and expand word-of-mouth campaigning, but they can connect with their constituents and voters with more personal messages. Furthermore, this can be done with a minimal cost. While campaign advertising on media such as television can be a financial drain, using a Twitter account simply requires a device and Internet access. Justification of study. After the emergence of television, the use of political ads has been a source of numerous studies. However, research on the use of Twitter in the political realm has been slow. Studies considering candidates use of Twitter, such as the ones cited in this study, usually consider the amount of tweets, how long the candidate has had a profile, and the number of followers, but few studies seek to determine what messages the candidates send to those followers. Considering this aspect of candidates using Twitter is important if researchers are to determine the potential influence and impact of a campaign on Twitter. President Barack Obama received attention for his online campaign strategy in 2008 and 2012 with some crediting his election to the success of that initiative. If such influence can stem H. Nieman 3 from applications on the Internet such as Twitter, understanding how candidates tweet is essential to determining what makes an online campaign successful. Statement of problem. This study set out to find further results regarding this innovative campaign strategy. The study was designed to address the following question: What characterizes the tweets from candidates for political office? Review of Literature Numerous studies have explored the realms of politics, analyzing the content and effects of media coverage and advertisements. However, a whole new area has emerged as Internet advertising and social media campaigns have increased. Drew and Weaver (2006) recognized the significance of the Internet and decided to incorporate it into their study on the importance of media in the 2004 presidential election. Expanding upon their previous research, the authors sought to measure attention and exposure to media to find correlations between these and knowledge, interest, and intention to vote. They found that those who searched for and paid attention to campaign information on the Internet were more knowledgeable about the candidates issue positions. This combination of Internet exposure and attention also was correlated with campaign interest and served as a predictor of knowledge. Drew and Weaver also found that this study was the first of theirs, since 1988, to show a significant direct relationship of exposure and attention to Internet campaign information with knowledge of candidate issue positions or interest in the campaign (p. 33). With Twitter having been introduced in 2006, one wonders whether this added to an increased opportunity for potential voters to connect to politics. H. Nieman 4 Some studies such as one conducted by Groshek and Al-Rawi (2013) have analyzed the content of politicians' Facebook pages, media that could connect to voters, but have only considered tweets with a specific political hashtag from various users. While Facebook is still a popular social networking site, politicians can use Twitter to reach more potential voters. Vergeer, Hermans, and Sams (2011) sought to determine this possible significance of Twitter in connecting voters with politicians. Within their multifaceted study, the researchers sought to determine whether disadvantaged candidates, such as those running on a third party ticket or those in a party that lost seats in the previous election, were more active on Twitter, connecting with the idea that exposure to information can assist with knowledge of candidates. They also set out to determine whether the frequency of tweets or amount of followers corresponded to votes, relating to the idea that attention to this information impacts voters. Their results mostly demonstrated that the more disadvantaged or struggling candidates were more active and had larger networks. However, more followers did not significantly correspond to more votes. The authors suggest that those most active on Twitter are those who have lost seats or need to garner more support. Therefore, Twitter is an effective tool for directly connecting to voters in order to establish recognition and build a base for a campaign. Similar to this article and the authors further studies, many researchers focus on political Twitter use in regards to voters connection to the candidates. Therefore, the studies incorporate voters impressions and candidates activity and network size in relation to votes. However, as Drew and Weaver (2006) mention, communication measures such as frequency of interpersonal discussion of elections and exposure to H. Nieman 5 differing viewpoints might help predict knowledgeand interest in a campaign (p. 38). Twitters personalized feel and ability to easily reach out to others may play a role in knowledge and interest during campaigns, but this may be dependent on the way candidates use Twitter and communicate with constituents and voters. This concept shows that determining the ways in which candidates tweet is important. To understand how candidates may be using Twitter, one must understand what users look for and communicate when logging on to Twitter, since a candidate must connect with voters. In a study considering medical tweets, Sullivan et al. (2011) sought to determine what users are seeking or intending to communicate when they tweet about concussions, a condition resulting from head trauma. The authors found that users predominantly tweet about concussions by sharing news followed by personal information or situations. They suggest that Twitter has the potential to be an influential broadcast medium. This conclusion as well as their solid content coding categories can be applied to the political realm. Their categories, including personal information, news, and advertising, can be connected to categories used in another study. Golbeck, Grimes, and Rogers (2010) studied everyday Twitter use by U.S. Congress members, focusing on the content they communicate to the public. They found that most tweets were informative with 72 percent including links. These types of tweets were followed by tweets that discussed the persons unofficial activities and location. The authors studied Congress Twitter use when adoption was in its early stages. Therefore, they speculate that Twitter is a medium for sharing known information and promoting positions, ideas, and events that also allows opportunities for communication innovation H. Nieman 6 (Golbeck, Grimes, & Rogers, 2010, p. 1610). Similarly, when Glassman, Straus, and Shogan (2011) analyzed tweets from U.S. Congress members, they found that most tweets concerned policy, a category included in informational tweets by Golbeck, Grimes, and Rogers. However, the types of tweets politicians use may vary depending on whether they are campaigning or currently in office. For example, Golbeck, Grimes, and Rogers found that only 2.9 percent of tweets requested action and only 7 tweets mentioned fundraising. If a politician is campaigning, these types of tweets would be expected more frequently. Therefore, it is necessary to differentiate between campaign tweeting and tweeting while in office. While the tweets analyzed in those studies concerned politicians in office, Evans, Cordova, and Sipole (2014) analyzed tweets from those campaigning for the U.S. House of Representatives. They coded tweets into eight categories, finding that factors such as incumbency, party affiliation, and gender influence tweet content. Tweets were more often placed in the personal category with campaign tweets coming in second. Campaign tweets were considered to be those linking to campaign videos and referencing speeches and events. The authors assert that their analysis shows most candidates used Twitter to campaign. However, their other findings differ from a study analyzing how presidential candidates use Twitter, suggesting that Twitter use may vary depending on the level of office sought. Conway, Kenski, and Wang (2013) studied the content of tweets and activity levels during the 2012 presidential primary elections. They adapted the content categories used by Golbeck, Grimes, and Rogers to campaign-related tweets. They found that many H. Nieman 7 tweets utilized links, hashtags, and the convention of mentioning other users. Most tweets fell into the elections issues category, followed by those tweets referencing campaign support. This shows that there is a difference in Twitter use during an election versus while in office. The authors suggest that politicians could use Twitter to draw attention to their candidacy and attract news media; however, the researchers believe that politicians may not be at this point, choosing to follow instead of lead (Conway, Kenski, & Wang, 2013, p. 1607). These results are similar to those obtained in a study by Adams and McCorkindale (2013). However, their study was conducted early in the campaign, focusing on the primaries as well. This leaves room for more analysis in Twitter use during the months leading up to the general election, like that of Evans, Cordova, and Sipole. Many studies have been conducted to analyze the connection between the media and politics. Recently, as Twitter has emerged as a solid medium, research has expanded into this area, mainly focusing on network size, frequency of tweets, and impact on voters. Few studies have considered the content of tweets; however, this area may strongly influence voters. As Adams and McCorkindale (2013) state, Twitter can help individuals, such as candidates for political office, engage and build relationships with potential voters (p. 357). President Obama, one considered to have run a successful social media campaign, currently has 72.7 million followers. Ted Cruz, Donald Trump, Hillary Clinton, and Bernie Sanders, candidates for the 2016 presidential election have one million, 7.5 million, 5.9 million, and 1.9 million followers respectively. This provides these political candidates with the ability to transmit a message directly to numerous H. Nieman 8 individuals with minimal cost. Therefore, it is important to explore the realm of political content in candidates tweets. Statement of Research Questions After a review of previous studies and their results, the researcher sought answers to the following research questions: RQ1: Do candidates use Twitter primarily to communicate issues, share campaign media, to promote campaign events, or to call followers to act? RQ2: Do candidates use Twitter's structure to post personal tweets or interact with followers? RQ3: Are most campaign-related tweets native to the candidate and his/her campaign or retweets/modified tweets? RQ4: How often do candidates use technical conventions such as @ and # on Twitter? RQ5: How often do candidates include links, photos, graphics, audio, or video? RQ6: What is the relationship between: RQ6a: candidates age and the number of tweets sent? RQ6b: candidates gender and the number of tweets sent? RQ6c: candidates party affiliation and the number of tweets sent? RQ6d: candidates incumbency and the number of tweets sent? RQ6e: level of office sought and the number of tweets sent? H. Nieman 9 Method Tweets posted from September 1 to November 4, 2014, of 10 candidates running in the state of Kentucky were included in this study for a total of 1347 tweets. Races were selected by considering the margin of victory as well as whether the candidates on either side had a Twitter account. Official Twitter accounts for those already in office were excluded. Candidates from the U.S. Senate, one U.S. House district, two Kentucky Senate, and three Kentucky House races were considered. All candidates in the U.S. Congress races had Twitter accounts during the 2014 campaign. One candidate in the considered Kentucky Senate races did not have Twitter accounts during the campaign while three candidates in the Kentucky House races did not have accounts. Three of the candidates were female, and two were of minorities. Detailed biographical information on the candidates in the selected races can be found in Appendix A. Coding Categories Using adaptations of content categories developed by Conway, Kenski, and Wang (2013) and Evans, Cordova, and Sipole (2014), analyzed tweets were sorted into the following categories. The complete coding rules can be viewed in Appendix B. Content and Keyword Categories. Campaign Issue: Any reference to important election issues such as the economy, health care, or foreign affairs; does not include references to different groups of people. Campaign-Related Media: Any reference to campaign-related media including advertisements, endorsements, news stories, and public opinion polls. H. Nieman 10 Campaign Event: Any reference to a campaign event including rallies, speeches, or debates; excludes simple references to crowds or presence in a location. Call to Act: Any reference to support given or needed including donations, volunteers, votes, or retweets. Office-Related: Any reference to events, votes, or other items native to the office. User Interaction: Any reference to events, votes, or other items native to the office. Personal: Tweets like those one might see on a Facebook page including family photos, comments about heading to church services or family events, references to national holidays or memorials, spiritual or inspirational messages, quotes or other matters not political in nature. Obama: Any mention of Obama, Barack, the president, @POTUS, or @BarackObama. Democrats: Any reference to Democrats, the Democratic Party, or liberals. Republicans: Any reference to Republicans, the Republican Party, or conservatives. Opponent: Any reference to the candidates opponent. Other: Any reference to another political figure. Technical Categories. Photo: The inclusion of a still photograph. Audio: The inclusion of a stand-alone audio clip; excludes audio that also accompanies a video clip. H. Nieman 11 Video: The inclusion of a video clip including or not including audio. Graphic: The inclusion of a static graphic image, including a photo altered to have text, objects, or other images. Link: The inclusion of a live link to a web site, not including the link that references the tweet itself. Hashtag: The inclusion of a hashtag used as a Twitter content organizer. At: A reference to a specific Twitter user using the @ convention Retweet: Indicated by RT at the beginning of the tweet. Modified Tweet: Indicated by @...... in tweet, usually preceded by text and MT or RT Procedures Tweets were downloaded using a Python script with a tweepy plug-in. According to Pythons website, the program is a programming language that lets you work quickly and integrate systems more effectively (Python). By using the language to type commands in a script, one can run the script to complete a task or achieve a specific result. An initial Google search yielded results for a website with a script template to download all of one Twitter users tweets (yanofsky). In the early lines of the script, a plug-in called tweepy was mentioned along with the site for download. After both tweepy and Python were downloaded, the script had to be adapted and personalized. Reading through the instructional documents on tweepy.org identified the next steps. This involved obtaining a consumer key and secret from the Twitter API. Once the information was obtained, it was plugged into the script. Also, directions to call H. Nieman 12 for the system path to import tweepy had to be added into the script. To download tweets, the users Twitter handle was typed into the relevant section of the script, and the program was ran. This was done for each candidate. To begin analysis of our data, simple percentages were calculated from the coded tweets to answer the research questions. Furthermore, while coding the tweets, the researcher took note of qualitative differences between the candidates tweets overall, focusing on the unique nature of Julie Raque Adams tweets. H. Nieman 13 Results RQ1: Do candidates use Twitter primarily to communicate issues, share campaign media, to promote campaign events, or to call followers to act? Out of the 1347 total tweets, 10.91 percent mentioned campaign issues, 10.62 percent shared campaign media, 13.36 percent promoted campaign events, and 21.23 percent called followers to act. Alison Lundergan Grimes focused on calls to act in her Twitter campaign with 31.85 percent of her tweets including a call to act. Events comprised 16.31 percent of Grimes tweets. Campaign media shares comprised 8.92 percent of her tweets, and issues were mentioned in 10 percent of her tweets. Similarly, Mitch McConnell included calls to act in 23.29 percent of his tweets. Issues were in 10.27 percent, media were in 7.53 percent, and events were in 9.25 percent of his tweets. Ron Leach mentioned issues, media, events, and calls to act in 9.76 percent, 29.27 percent, 24.39 percent, and 1.22 percent of his tweets respectively. Several of the candidates did not include any tweets in specific categories. Brett Guthrie and Dean Schamore did not mention issues, Siddique Malik did not promote any campaign events, Jason Steffen did not call followers to act, and Joe Choate only promoted events, not including issues, media, or calls to act. Of these candidates, 63.16 percent of Guthries tweets mentioned events, 46.43 percent of Maliks tweets mentioned issues, and 57.14 percent of Choates tweets provided event information. Steffen mentioned issues in 41.18 percent of his tweets and media in 47.06 percent of his tweets. Jenean Hamptons tweet content composition was as follows: issues 3.33 percent, media 10 percent, events 13.33 percent, and calls to act 6.67 percent. Schamore tweeted H. Nieman 14 about media and events equally with only one call to act. Julie Raque Adams focused on issue in 5.52 percent of tweets, media in 3.31 percent, events in 1.66 percent, and calls to act in 3.31 percent of tweets. RQ2: Do candidates use Twitter's structure to post personal tweets or interact with followers? Overall, 7.57 percent of tweets were personal, and 7.5 percent involved user interaction. Six of the candidates did not interact with users in their tweets, while one candidate did not post any personal tweets. Percentages for each candidate can be seen below in Table 1. H. Nieman 15 RQ3: Are most campaign-related tweets native to the candidate and his/her campaign or retweets/modified tweets? Of all the combined tweets, 38.23 percent were not purely native to the campaign; 33.85 percent were retweets, and 4.38 percent were modified tweets. The percentage of non-native tweets for each candidate using Twitter can be found in Table 2. RQ4: How often do candidates use technical conventions such as @ and # on Twitter? The symbol #, known on Twitter as a hashtag, was included in 60.73 percent of all tweets. The majority of these tweets were sent by Grimes and McConnell. Percentages of hashtags and at symbols used by the candidates can be found in Table 3. H. Nieman 16 RQ5: How often do candidates include links, photos, graphics, audio, or video? Links were included in 28.88 percent of the tweets. Percentages of the tweets for each link category can be found in Table 4. Graphics were in 19.97 percent of the tweets, and photos were posted with 17.45 percent of the tweets sent. None of the candidates included audio in their tweets, and only Adams and McConnell included videos, with Adams posting one and McConnell posting two. H. Nieman 17 RQ6: What is the relationship between candidate characteristics and the number of tweets sent? Table 5 contains candidate characteristics and the number of tweets sent. The reference to candidate type considers whether the candidate is an incumbent (I), a challenger (C), or a participant in an open-seat race (O). H. Nieman 18 H. Nieman 19 Analysis/Conclusion Interpretation of Results In response to the first research question, candidates tweeted to call followers to act and to promote events more than they tweeted about issues and shared campaignrelated media. To get ones message to reach individuals using Twitter, those individuals much choose to follow the person. Therefore, Twitters main benefit for political candidates is the engagement of supporters. By calling followers to act, the campaign is asking those who believe in the candidate to support his or her campaign in some way or to spread the individuals message. Promoting events on Twitter is also a viable option because the tweets are reaching those who would be interested in attending. The candidate or his or her campaign can write a brief statement asking followers to donate or promoting the next campaign rally. This makes sense for Twitter where each post can only be 140 characters. If a candidate is trying to appeal to a skeptical audience, they most likely will not be able to sway them with an issue position communicated through an application with a restraining character limit. However, candidates should not completely avoid mentioning campaign issues on Twitter. Tweeting about a candidates stance on an issue allows for a dialogue between the candidate and potential voters. Using Twitters structure, a user can easily reply to a tweet. If a candidate responds to concerns from potential voters, the Twitter user may feel as though the candidate is truly running for office to serve the people. Yet, the results for the second research question show that candidates do not utilize this function of Twitter often. Potential voters have few opportunities to communicate with political candidates H. Nieman 20 without some type of barrier. They must take the time to call and talk to someone with the campaign; if they want to talk to the candidate, they may have scheduling issues. If they write a letter, it may take several days or weeks to get a response. While individuals may be able to talk to candidates at events, they are sacrificing time waiting for others to have conversations. On the other hand, a potential voter can easily type a reply to a candidate on Twitter. If the candidate then takes advantage of this, he or she will be able to engage with more possible constituents. This is similar to the idea behind the use of personal tweets; the candidate appears to be a normal person that can relate to the voters. However, candidates in this study, with the exception of Adams, do not use these often. Another benefit of Twitter is the concept of a retweet which allows a user to reach people outside of his or her group of followers. This is useful for political candidates who have their followers retweet calls to act or event information. When a candidate is the one retweeting, there needs to be balance. Individuals choose to follow a candidate to see content from them. If the candidate constantly retweets other people, followers may become irritated. Of the tweets in this study, 38.23 percent were retweets. For a few of the candidates, retweets were nearly the majority; for Adams, they were the majority. Candidates need to ensure that retweets do not overwhelm their own voices. The candidates in the present study rarely used modified tweets, but they are a better option than retweets. Using a modified tweet, one can share a tweet while commenting on it, maintaining the presence of the candidates voice. While the use of retweets and modified tweets propose knowledge of Twitter, hashtags and the @ symbol suggest a sophisticated Twitter user. Based on the results of H. Nieman 21 the tweet analysis, Grimes and McConnell know Twitter well. However, both were competing for the highest level of office included in the study. This may be connected with more funding and a larger staff rather than the candidates knowledge of Twitter. Twitter sophistication can also be demonstrated through the inclusion of photos, graphics, links, audio, and video. Based on previous Twitter use by the researcher, video seems to be a more recent feature that is slowly adopted. Only Adams and McConnell posted videos; this seems to mean that they or their campaigns have more Twitter knowledge than the other candidates. Links may seem to indicate knowledge, but the type of link could show otherwise. Leach almost always linked to Facebook in his tweets; he posted on Facebook and just shared the posts on Twitter. This alludes to the idea that he or his campaign do not know much about Twitter. Not many conclusions can be drawn in response to the sixth research question. While some trends, such as the idea that females tweet more, are present, other elements do not have enough data. Age may be a predictor, but other factors, such as level of office would need to be controlled. This is not the only validity issue in this study. Since all of the tweets were coded by one individual, fatigue may have impacted analysis of the tweets. Without multiple coders, no intercoder reliability was established, and no numerical predictors can provide insight into possible deviations in interpretations of the coding rules. Also, using total percentages of all the tweets may create a skewed perception since some candidates sent up to 650 tweets while others tweeted as little as seven times. Finally, the sample size is too small and localized to make general conclusions. A larger sample size could be considered in future studies. H. Nieman 22 When coding the tweets, Adams style appeared to differ greatly from the styles of the others. She was the only candidate to retweet cat photos, and only 3.31 percent of her tweets called followers to act. To determine the potential reasoning behind this difference, one would need to analyze the circumstances of the race. Further studies should consider the competitiveness of the race when analyzing the differences in Twitter use. Ultimately, candidates use Twitter in different ways. The results of this study seem to suggest that biographical characteristics are related to the number of tweets, and content and technical categories can serve as an indicator of funding and staff size as well as knowledge of the application. Further research is needed to determine the nature of these relationships and statistical evidence is needed to find correlations. H. Nieman 23 Reflection This research project was an individual effort similar to a project I completed as a part of a class. While I enjoy research, conducting a study independently was a challenge, especially when balancing internships, school work, and management in my major. Through the research, I found that several theories I formed about social media throughout my internships are supported in the literature. Twitter and other forms of social media have the potential to change elections. All of this research has connected into my courses in political science as well, specifically in regard to political behavior and engagement. H. Nieman 24 References Adams, A., & McCorkindale, T. (2013). Dialogue and transparency: A content analysis of how the 2012 presidential candidates used twitter. Public Relations Review, 39(4), 357-359. doi:10.1016/j.pubrev.2013.07.016 Carlson, T., Djupsund, G., & Strandberg, K. (2014). Taking risks in social media campaigning: The early adoption of blogging by candidates. Scandinavian Political Studies, 37(1), 21-40. doi:10.1111/1467-9477.12011 Conway, B.A., Kenski, K., & Wang, D. (2013). Twitter use by presidential primary candidates during the 2012 campaign. American Behavioral Scientist, 57(11), 1596-1610. Drew, D. & Weaver, D. (2006). Voter learning in the 2004 presidential election: Did the media matter? Journalism & Mass Communication Quarterly, 83(1), 25-42. Evans, H.K., Cordova, V., & Sipole, S. (2014). Twitter style: An analysis of how House candidates used Twitter in their 2012 campaigns. American Political Science Association, 454-462. doi:10.1017/S1049096514000389 Glassman, M.E., Straus, J.R., & Shogan, C.J. (2011). Social networking and constituent communications: Member use of Twitter during a two-month period in the 111th Congress. Journal of Communications Research, 2(2-3), 219-233. Golbeck, J., Grimes, J., & Rogers, A. (2010). Twitter use by the US Congress. Journal of the American Society for Information Science and Technology, 61(8), 1612-1621. H. Nieman 25 Groshek, J., & Al-Rawi, A. (2013). Public sentiment and critical framing in social media content during the 2012 U.S. Presidential campaign. Social Science Computer Review, 31(5), 563-576. doi:10.1177/0894439313490401 Python. (2016). Python homepage. Python. Retrieved from python.org Sullivan, S.J., Schneiders, A.G., Cheang, C., Kitto, E., Lee, H., Redhead, J., Ward, S., Ahmed, O.H., & McCrory, P.R. (2012). Whats happening? A content analysis of concussion-related traffic on Twitter. British Journal of Sports Medicine, 46, 258-263 Vergeer, M., Hermans, L., & Sams, S. (2011). Is the voter only a tweet away? Microblogging during the 2009 European Parliament election campaign in the Netherlands. First Monday, 16(8). yanofsky. (n.d.). A script to download all of a user's tweets into a csv. Message posted to https://gist.github.com/yanofsky/5436496#file-tweet_dumper-py H. Nieman 26 Appendices Appendix A: Candidate Bios Alison Lundergan Grimes Race: US Senate for Kentucky Birthday: November 23, 1978 Gender: Female Challenger, Democrat Total Votes: 584,698 # of Tweets: 650 Brett Guthrie Race: US House Kentucky District 2 Birthday: February 18, 1964 Gender: Male Incumbent, Republican Total Votes: 156,936 # of Tweets: 19 Jody Richards Race: Kentucky House District 20 Birthday: 02/20/1938 Gender: Male Incumbent, Democrat Total Votes: 6,237 Got Twitter on January 29, 2015 Siddique Malik Race: Kentucky Senate District 36 Birthday: ? Age: 592 Gender: Male Open seat, Democrat Total Votes: 16,011 # of Tweets: 56 Jason Michael Steffen Race: Kentucky Senate District 24 Birthday: ? Age: 393 Gender: Male Open seat, Democrat Total Votes: 13,547 # of Tweets: 17 Joe Choate Race: Kentucky House District 21 Birthday: ? Age: ? Gender: Male Challenger, Democrat Mitch McConnell Race: US Senate for Kentucky Birthday: February 20, 1942 Gender: Male Incumbent, Republican Total Votes: 806,787 # of Tweets: 292 Ron Leach Race: US House Kentucky District 2 Birthday: ? Age: 501 Gender: Male Challenger, Democrat Total Votes: 69,898 # of Tweets: 82 Jenean Hampton Race: Kentucky House District 20 Birthday: May 12, 1958 Gender: Female Challenger, Republican Total Votes: 3,610 # of Tweets: 30 Julie Raque Adams Race: Kentucky Senate District 36 Birthday: June 11, 1969 Gender: Female Open seat, Republican Total Votes: 31,623 # of Tweets: 181 Will Schroder Race: Kentucky Senate District 24 Birthday: June 29, 1982 Gender: Male Open seat, Republican Total Votes: 21,792 Does not have Twitter Bart Rowland Race: Kentucky House District 21 Birthday: April 11, 1977 Gender: Male Incumbent, Republican H. Nieman 27 Total Votes: 6,391 # of Tweets: 7 Dean Schamore Race: Kentucky House District 10 Birthday: August 19, 1968 Gender: Male Open seat, Democrat Total Votes: 8,099 # of Tweets: 13 Total Votes: 8,613 Does not have Twitter Alan Claypool Race: Kentucky House District 10 Birthday: ? Age: ? Gender: Male Open seat, Republican Total Votes: 7,002 Does not have Twitter H. Nieman 28 Appendix B: Coding Rules Non-Content Categories A. CANDIDATE a. 1 = Lundergan Grimes b. 2 = McConnell c. 3 = Leach d. 4 = Guthrie e. 5 = Hampton f. 6 = Malik g. 7 = Adams h. 8 = Steffen i. 9 = Choate j. 10 = Schamore B. GENDER a. 1 = Female b. 2 = Male C. PARTY AFFILIATION a. 1 = Democrat b. 2 = Republican D. CANDIDATE TYPE a. 1 = Incumbent b. 2 = Challenger c. 3 = Open Seat Race Participant E. BRANCH OF OFFICE a. 1 = United States Senate b. 2 = United States House of Representatives c. 3 = Kentucky Senate d. 4 = Kentucky House of Representatives F. AGE: The candidates age at the time of the election a. 1 = 25-35 b. 2 = 36-45 c. 3 = 46-55 d. 4 = 56-65 e. 5 = 66+ f. 6 = Could Not Be Determined G. TWEET ID: Tweet number (provided in spreadsheet) H. Nieman 29 H. DATE: Date and time of the tweet (from candidates' tweet database) I. TWEET: The tweet itself (from candidates' tweet database) Content Categories (J-M Must relate to the users own campaign) J. CAMPISSUE (Campaign Issue) a. Any reference to important election issues such as the economy, health care, or foreign affairs; does not include references to different groups of people b. Must refer to a specific issue, not generality c. 1 = Present d. 2 = Not Present K. CAMPMEDIA (Campaign-Related Media): Any reference to campaignrelated media including advertisements, endorsements, news stories, and public opinion polls a. 1 = Present b. 2 = Not Present L. CAMPEVENT (Campaign Event): Any reference to a campaign event including rallies, speeches, or debates; excludes simple references to crowds or presence in a location a. 1 = Present b. 2 = Not Present M. CALL TO ACT: Any reference to support given or needed including donations, volunteers, votes, or retweets a. 1 = Present b. 2 = Not Present N. OFFICE-RELATED: Any reference to events, votes, or other items native to the office a. 1 = Present b. 2 = Not Present O. USER INTERACTION: Any tweet involving a conversation, usually replying to an individual; does not include a simple retweet a. 1 = Present b. 2 = Not Present P. PERSONAL: Tweets like those one might see on a Facebook page including family photos, comments about heading to church services or H. Nieman 30 family events, references to national holidays or memorials, spiritual or inspirational messages, quotes or other matters not political in nature a. 1 = Present b. 2 = Not Present Technical Categories Q. PHOTO: The inclusion of a still photograph a. Does not include images with text, objects, or other photos overlay b. Includes picture collages or Pic Stitch c. 1 = Still photograph present d. 2 = Picture collage/stitch present e. 3 = Not Present f. 4 = Could Not Be Determined R. AUDIO: The inclusion of a stand-alone audio clip; excludes audio that also accompanies a video clip a. 1 = Present b. 2 = Not Present S. VIDEO: The inclusion of a video clip including or not including audio a. 1 = Present b. 2 = Not Present T. GRAPHIC: The inclusion of a static graphic image, including a photo altered to have text, objects, or other images a. 1 = Present b. 2 = Not Present U. LINK a. The inclusion of a live link to a web site, not including the link that references the tweet itself b. A link that is distorted in the download from Twitter API ("http://" or "http://t.co/0FGc" for example) should be coded Could Not Be Determined" c. 1 = Not Present d. 2 = Facebook e. 3 = YouTube f. 4 = Instagram g. 5 = Campaign Website h. 6 = News Site i. 7 = Crowd-Funding Site j. 8 = Other Site k. 9 = Could Not Be Determined H. Nieman 31 V. HASHTAG: The inclusion of a hashtag used as a Twitter content organizer a. 1 = Present b. 2 = Not Present W. AT: A reference to a specific Twitter user using the @ convention a. 1 = Present b. 2 = Not Present X. RETWEET: Indicated by RT at the beginning of the tweet a. 1 = Present b. 2 = Not Present Y. MODTWEET (Modified Tweet): Indicated by @...... in tweet, usually preceded by text and MT or RT a. 1 = Present b. 2 = Not Present Keyword Categories (for a positive or negative rating, the tweet must be explicit; neutral will include statements of fact that could be interpreted based on ideology) Z. OBAMA: Any mention of Obama, Barack, the president, @POTUS, or @BarackObama a. 1 = Present Positive b. 2 = Present Negative c. 3 = Present Neutral d. 4 = Not Present AA. DEMOCRATS: Any reference to Democrats, the Democratic party, or liberals a. 1 = Present Positive b. 2 = Present Negative c. 3 = Present Neutral d. 4 = Not Present BB. REPUBLICANS: Any reference to Republicans, the Republican party, or conservatives a. 1 = Present Positive b. 2 = Present Negative c. 3 = Present Neutral d. 4 = Not Present CC. OPPONENT: Any reference to the candidates opponent a. 1 = Present Positive H. Nieman 32 b. 2 = Present Negative c. 3 = Present Neutral d. 4 = Not Present DD. a. b. c. d. OTHER: Any reference to another political figure 1 = Present Positive 2 = Present Negative 3 = Present Neutral 4 = Not Present H. Nieman 33 Appendix C: CITI Training  ...

... Translational Practice: Outcome Tool Implementation in an Inpatient Rehabilitation Facility Sarah Humbird May, 2018 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. Brenda Howard, DHSc, OTR A Capstone Project Entitled Translational Practice: Outcome Tool Implementation in an Inpatient Rehabilitation Facility Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Sarah Humbird Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION Translational Practice: Outcome Tool Implementation in an Inpatient Rehabilitation Facility Sarah Humbird, OTS University of Indianapolis 2018 1 TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION Abstract The purpose of this Doctoral Capstone Experience (DCE) was to provide the Rehabilitation Hospital of Indiana (RHI) with an outcome measure to better quantify upper extremity recovery following a stroke or brain injury. This need was identified as a result of conversations with physicians, payer sources, and community partners that requested additional information to justify the need of services for the patients served at RHI. As a result of this need, the FuglMeyer Assessment for the Upper Extremity (FMA-UE) was identified as the most appropriate assessment to implement. The Knowledge to Action (KTA) framework provided a sequence of steps that aided in the implementation of this outcome measure. Utilizing the KTA framework over the course of 16 weeks, therapists were educated on the purpose of the DCE and FMA-UE, and practiced the FMA-UE with patients. At the conclusion of the DCE, it was determined that the FMA-UE was beneficial and provided additional information to further strengthen the profession within this setting. The result of this DCE is better use of evidence-based practice through implementation of the FMA-UE, therefore resulting in better care for patients receiving inpatient rehabilitation and outpatient services at RHI. Keywords: Implementation science, translational practice, Fugl-Meyer, inpatient rehabilitation 2 TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 3 Translational Practice: Outcome Tool Implementation in an Inpatient Rehabilitation Facility. In the field of occupational therapy, there is a large gap between the time research is performed and the time effective interventions are put into practice. Evidence shows that the gap between publication of evidence-based intervention and implementation into practice is approximately a 20-year period (Brekke, Ell, & Palinkas, 2007; Glasgow & Emmons, 2007). It is often a misconception that new research practices are being implemented among practitioners (Malec & Swan, 2017). As a result of practitioners not utilizing research-based interventions, patients do not receive evidence-based care 30-45% of the time (Clark, Park, & Burke, 2013). Even more concerning is that patients may receive care that is not necessary or even potentially harmful (Clark, Park, & Burke, 2013). In an effort to bring evidence-based research into practice, the term implementation science has developed. Implementation science is defined as the scientific study of methods to promote systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care (Eccles & Mittman, 2006). Using implementation science, new and effective research can be translated into practice, which in turn provides patients with better care and more individualized treatments (L. Swan & K. Ruggles, personal communication, January 8, 2018). Implementation science, also known as translational science, has become a top priority for the National Institutes of Health (NIH; Brekke, Ell, & Palinkas, 2007). Implementation science has helped with application of evidence-based practice (EBP; Bauer et al., 2015). The need for implementation science is great, particularly in health care settings, but often there is no formula or protocol for implementation of these EBP (Brekke, Ell, & Palinkas, 2007). The TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 4 purpose of implementation science is to assist with the dissemination and implementation of EBP into everyday practice (Brekke, Ell, & Palinkas, 2007). A planned action model is also necessary so that information is presented in a systematic approach rather than just relying on diffusion of information (Metzler & Metz, 2010). The process of implementation science requires a thorough understanding of the individual, institutional, and systematic factors that will either facilitate or obstruct these processes (Brekke, Ell, & Palinkas, 2007). The individual factors include those on the frontline that may assist or obstruct the implementation of research into practice. Individual factors also include the frontline individuals commitment to change. The institutional factors can include stakeholders or individuals in positions of authority that help to drive the translation of research into practice. For example, if therapists are not on-board with implementation of a certain type of research then the carryover is likely to be poor. Systemic factors may be those relating to the facility or outside factors that impact knowledge translation (Brekke, Ell, & Palinkas, 2007). Communication, collaboration, and consensus are all necessary for effective implementation of EBP (Brekke, Ell, & Palinkas, 2007). At the Rehabilitation Hospital of Indiana (RHI), the leadership team has a desire to enhance their current evaluation process completed by occupational therapists (OTs, L. Swan & K. Ruggles, personal communication, January 8, 2018). The hospital currently utilizes the Functional Independence Measure (FIM) and Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) as their primary outcome measures (L. Swan & K. Ruggles, personal communication, January 8, 2018). The OTs also utilize other standardized assessments such as grip and pinch strength dynamometer, 9-hole peg test, and box and blocks. While these assessments provide normative data, they do not always provide a true depiction of upper extremity recovery (L. Swan & K. Ruggles, personal communication, January 8, 2018). In a TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 5 study by Klein & Hopper (2013), it was determined that the FIM did not demonstrate functional change of upper extremity (UE) from admission to discharge. Tietjen-Smith et al. (2006) determined that grip strength is not always a true predictor of functional capacity. Therefore, it is important that OTs complete outcome measures that reflect true progress of the individual. In an effort to remain evidence-based and to be a primary provider for individuals requiring rehabilitation, RHI has determined that an additional outcome measure for upper extremity recovery needs implemented (L. Swan & K. Ruggles, personal communication, January 8, 2018). A majority of the population at RHI are individuals recovering from various types cerebrovascular accidents (CVAs), or strokes (L. Swan & K. Ruggles, personal communication, January 8, 2018). As a result of a CVA, individuals often lose function in one or both upper extremities (Gladstone, Danells, & Black, 2002). Nearly 70-80% of individuals postCVA have hemiparesis, which is the most common deficit among CVA survivors (Gladstone et al., 2002). While the FIM looks at function, OTs do not currently utilize an outcome measure that specifically assesses motor recovery of the upper extremity. The Fugl-Meyer (FMA) is an assessment developed in 1975 by Alex Fugl-Meyer that assesses the motor recovery of an individual following a stroke (Gladstone et al., 2002). At the time the FMA was developed, most assessments focused on measuring disability and ones capacity to complete activities of daily living (ADL) independently (Gladstone et al., 2002). The authors of the FMA identified that there was not an assessment that looked at motor recovery in a standardized manner (Gladstone et al., 2002). Other assessments that are more objective in nature, such as the Barthel Index (BI) and FIM, do not adequately portray the dynamic process of motor recovery and are therefore less likely to identify change (Gladstone et al., 2002). Authors recognized that the motor recovery in both the upper and lower extremity typically proceeds in a TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 6 predictable manner (Gladstone et al., 2002). For example, in regard to the upper extremity, movement returns in a proximal to distal manner: shoulder, elbow, wrist, hand (Gladstone et al., 2002). The observed manner of recovery is based on the Brunnstom stages of motor recovery (Gladstone et al., 2002). The FMA upper extremity (FMA-UE) is a shortened version of the larger FMA which contains categories including: motor function, sensory function, balance, joint range of motion, and joint pain. The FMA-UE only includes the motor function category with the upper extremities (Shirley Ryan Ability Lab, n.d.). Based on recent research, the FMA-UE is a valid and reliable measure to use for individuals in the rehabilitation setting after a CVA (Kim et al., 2012). The FMA-UE is a free, observation-based assessment that quantifies motor recovery following a CVA (Gladstone et al., 2002). The FMA-UE contains subsections including: reflexes, movement observation, grasp and coordination (Gebruers, Truijen, Engelborghs, and De Deyn, 2014). Although there are numerous types of CVAs, and everyone progresses differently, the FMA-UE gives a map for expected recovery (Velozo & Woodbury, 2011). The FMA-UE is considered a comprehensive, quantitative assessment of motor impairment after a CVA (Gladstone et al., 2002). Though this assessment was designed for CVAs, some research has also shown that it is effective with diagnoses such as Multiple Sclerosis and traumatic brain injury (Platz et al., 2005). This assessment allows therapists to develop their treatments around expected recovery to help the patient progress in the best way possible (Velozo & Woodbury, 2011). The FMA-UE has been shown to be highly sensitive as well as a reliable predictor of upper extremity recovery and general disability (Gebruers, Truijen, Engelborghs, & De Deyn, 2014). The FMA-UE also demonstrates high levels of construct validity, and responsivity (Thompson-Butel, Lin, Shiner, & McNulty, 2015; Gladstone et al., 2002). In addition, it TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION demonstrates efficacy with individuals recovering from a CVA (McDonnell, Hillier, & Esterman, 2013). For these reasons, the FMA-UE was determined to be an effective outcome measure to implement during evaluations. Although the FMA-UE is an excellent tool to implement into evaluations, the translation of this research into practice is difficult. The uptake of EBP is often impeded due to several barriers including: lack of funding, time, technology, the requirement of a controlled environment, and/or burden on therapists (Bauer, Damschroder, Hagedorn, Smith, and Kilbourne, 2015). Therapists are encouraged to read peer-reviewed journals to stay up to date with EBP which is important, however the information gained is not easily implemented, according to research (Grol & Grimshaw, 2003). It is often stated that peer-reviewed articles contain the highest level of evidence; however, these publications do not always provide practical ways of implementation and instead focus solely on the research context (Metzler & Metz, 2010). Research is more likely to be implemented when a planned action model, such as the Knowledge to Action (KTA) framework, is utilized (Metzler & Metz, 2010). In conjunction with the OT manager and executive director of therapies, the priority of this DCE was to implement the FMA-UE and educate the therapists on proper administration. This occurred through meetings and one-on-one interaction. The final steps of the needs assessment, evaluating and identifying alternative solutions, and creating a plan of action included multiple discussions with the OT manager and executive director of therapies that identified how to carry out the implementation of this assessment. We determined that I should first implement the tool myself as a way to identify any major obstacles, followed by the therapists on the outcome committee, and finally by the remaining therapists. This included the continued identification of the problem along with the review of knowledge in regards to the 7 TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 8 problem. The information gathered at this point of the KTA framework is then utilized to help with the adaptation to local context which occurs during the implementation phase. Occupational therapists are taught that the top-down approach to treatment places the patient at the center of the entire OT process (Doucet & Gutman, 2013). The bottom-up approach is opposite in that it focuses more so on deficits and impairments and how those impact daily function (Doucet & Gutman, 2013). In this era where healthcare is constantly changing, it is important that we demonstrate the importance of our profession. Reimbursement agencies and insurance companies want objective measurements for how a patient is progressing (Doucet & Gutman, 2013). Objective measurements allow these agencies to understand patient progression without having to fully understand occupational therapy and the meaning of the occupationbased language that we know so well (Doucet & Gutman, 2013). Due to lack of knowledge, individuals and parties involved in reimbursement may not understand the distinct value of our profession (Doucet & Gutman, 2013). While we should continuously advocate and educate about our profession, we must also ensure that our services are able to be reimbursed. While the FMAUE and inpatient rehabilitation are well established within the OT profession, the need for objective measures to demonstrate progress is not widely implemented and therefore considered emerging (Kroll & Fisher, 2017). It is also important for hospitals and outpatient centers to utilize comprehensive assessments that demonstrate patient progress from the time an individual is in the hospital to the time they are discharged from outpatient therapy, which is attainable with the FMA-UE (Jongbloed & Wendland, 2002). Therefore, objective values allow both parties to meet in the middle, which is why RHI has deemed this DCE so important. RHI is a traditional practice setting of inpatient rehabilitation and outpatient therapy. One of the biggest reasons for implementing a new outcome measure, specifically among the CVA TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 9 population, is that it provides numeric data that indicates a patients progress toward projected outcomes (Levine, 2009). This score is then translated to recovery potential for an individual (L. Swan & K. Ruggles, personal communication, January 8, 2018). With UE recovery after a CVA, it is easy to see a plateau in function after approximately three months (Levine, 2009). However, the FMA-UE is able to capture small, incremental changes in UE use (Levine, 2009). In the first month of the DCE, it became apparent that the physicians want to know what changes are happening with their patients, especially those small changes that may not be noticed through functional measures. The Knowledge to Action (KTA) framework can be used for implementation of evidence-based research into practice, and therefore is a beneficial theoretical background for this project (Field, Booth, Ilott, & Gerrish, 2014). The KTA consists of two factors: knowledge creation and the action cycle, both of which contain their own specific components (see Figure 1; Field, Booth, Ilott, & Gerrish, 2014). The knowledge creation factor is funnel shaped and consists of three components. The top portion of the funnel contains the knowledge inquiry component which is considered first generation knowledge (Graham et al., 2006, p. 18). This includes all the accessible and non-accessible information in regards to the topic of interest (Graham et al., 2006). The second portion of the funnel is the knowledge synthesis component, which is second generation knowledge (Graham et al., 2006, p. 19). This part of the process involves the utilization of reproducible methods to identify, appraise, and synthesize relevant studies or information to the specific question (Graham et al., 2006, p. 19). The final component of the knowledge creation funnel, knowledge tools/product (also called third generation knowledge) is utilized to display found knowledge in a format that is clear, concise, and easy to TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 10 use (Graham et al., 2006, p. 19). This portion also provides recommendations for stakeholders on what change should occur (Graham et al., 2006). The second factor of the KTA framework consists of the action cycle. Within this cycle there are seven steps for implementation of knowledge into practice (Graham et al., 2006). The first step is to identify a problem that needs addressing and identify, review, and select the knowledge or research relevant to the problem (Graham et al., 2006, p. 20). This step includes determining a problem and analyzing the problem while reviewing relevant research (Graham et al., 2006). The second step includes adapting the identified knowledge or research to the local context (Graham et al., 2006, p. 20). At this step individuals or groups involved take the information obtained and adjust it to their own environment and/or setting (Graham et al., 2006). The third step is to assess barriers to using the knowledge, which involves assessing for any obstacles or barriers that may prevent acceptance of knowledge (Graham et al., 2006, p. 20). The fourth step is select, tailor, and implement interventions to promote the use of knowledge (i.e. implement the change; Graham et al., 2006, p. 20-21). This phase involves applying the information into the specific practice setting (Graham et al., 2006). The fifth step includes monitoring knowledge use which involves assessing and measuring changes in knowledge (Graham et al., 2006, p. 21). The sixth step is to evaluate the outcomes of using the knowledge at which point it should be determined if the intervention chosen has brought about the desired change or if it is time to reevaluate (Graham et al., 2006, p. 21). The final step is to sustain ongoing knowledge use which involves maintenance of the new, implemented knowledge (Graham et al., 2006, p. 21). In Canada, the KTA framework has been utilized with cancer patients. A team of individuals comprised of physicians, therapists, and researchers utilized the framework to TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 11 implement new guidelines for patients with breast cancer (Munce et al., 2013). Similarly to this DCE, the KTA framework assisted with implementation and evaluation of a new tool. These authors implemented a screening tool in a similar manner to the implementation of the FMA-UE. The authors found that this framework is beneficial for dissemination of new information in the healthcare setting which further demonstrates the use of the KTA framework for this DCE (Munce et al., 2013). The process of translating knowledge to practice is overwhelming and daunting. However, Graham et al. (2006), provides a step-by-step guide that yields a foundation for implementing knowledge into everyday practice. The purpose of this DCE is to assist with implementation of the FMA-UE at RHI. Therefore, this theoretical base of the KTA framework is ideal for this project as the focus is the application of research to occupational therapy evaluations. Screening and Evaluation In order to fully identify a problem, a needs assessment must first be completed. A needs assessment includes: collecting relevant data, analyzing and synthesizing data, completing a strengths, weaknesses, opportunities, threats (SWOT) analysis, determining priorities, evaluating and identifying alternative solutions, and creating a plan of action (AOTA, n.d.; Brownson, 2001). The beginning of a needs assessment, collection of relevant data, should include discussion with those involved to identify where the problem lies (Brownson, 2001). In regards to the KTA, the needs assessment falls under the identify and review of knowledge step in the action cycle of the framework. At RHI, the data collection portion occurred prior to the beginning of this DCE. The leadership team explained several months prior to the start of the DCE that the evaluation system needed to be enhanced through implementation of an additional TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 12 assessment tool that targeted the post-CVA population. At the start of the DCE, the leadership team determined that an assessment to quantify upper extremity recovery would be beneficial in addition to the assessments already utilized. Previously, the evaluation process did not include a standardized assessment to address recovery of the upper extremity post-CVA (L. Swan & K. Ruggles, personal communication, January 8, 2018). After discussion regarding the focus of the DCE, the leadership team determined that the FMA-UE would be most applicable to RHI as a majority of patients are in rehabilitation for deficits after a CVA (L. Swan & K. Ruggles, personal communication, January 8, 2018). Analyzing and synthesizing the data was the next step of the needs assessment. This included understanding RHIs current OT evaluation process. From observing, it was reinforced that an assessment to focus on upper extremity recovery would add value to the current OT evaluation process. Based on observations, physicians appreciate receiving information from assessments that quantify recovery because it is an easy way to see if patients are progressing. This observation supports the use of the FMA-UE as an additional outcome tool because it allows OT to quantify an individuals recovery post-CVA (Woytowicz et al., 2017). During the first few weeks of this DCE, I observed several OT evaluations. From observation, I noticed that the focus is very much on an individuals functional status. While functional status is extremely important to OT, and sets our profession apart, it can be difficult to demonstrate measurable patient progress (L. Swan & K. Ruggles, personal communication, January 8, 2018). Demonstrating measurable patient progress can be difficult to do, because while it is easy for therapists to see small changes, standardized assessments often do not capture those small changes in the recovery process (Levine, 2009). The FMA-UE provides numeric values to recovery of the upper extremity after a CVA (Woytowicz et al., 2017). The numeric values help demonstrate to TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 13 physicians, insurance companies, and community partners that the treatment provided at RHI is efficacious in assisting with recovery following a CVA (L. Swan & K. Ruggles, personal communication, January 8, 2018). Along with observing evaluations, I also met with the outcomes committee. This committee consists of an OT from each of the four units (complex medical, spinal cord injury, stroke, and brain injury), two outpatient OTs, the executive director of therapies, and the OT manager. During the meeting, therapists voiced their concerns and suggestions regarding implementation of a new outcome tool. For example, the therapists were concerned that this tool cannot be used across all units; however, after discussion it was determined that it is not possible to find an outcome measure that is suitable for the wide variety of populations therapists treat. The next step of the needs assessment includes a SWOT analysis (see Figure 2), which identifies strengths, weaknesses, opportunities and threats. Some strengths are that the FMA-UE will allow therapists to demonstrate patient progress in quantitative, concrete way. The FMA-UE also is backed by literature stating its practical use in a multitude of settings (Asher, 2014). A weakness of the FMA-UE is that it is only applicable to a few populations including CVA, brain injury, and Multiple Sclerosis (Shirley Ryan Ability Lab, n.d.). An opportunity is that the implementation of this new outcome measure will allow RHI to participate in research with other institutions and hospitals (L. Swan & K. Ruggles, personal communication, January 8, 2018). Research is highly emphasized at RHI and is constantly being completed. Some of the therapists at RHI complete research full time, in an effort to increase the value of various disciplines. The hospital often collaborates with other hospitals and universities such as the Shirley Ryan AbilityLab (formerly the Rehabilitation Institute of Chicago), Mary Free Bed Rehabilitation Hospital, and Washington University in St. Louis (L. Swan & K. Ruggles, personal TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 14 communication, January 8, 2018). Therefore adoption of this assessment would allow for collaboration with other therapists and hospitals. The FMA-UE also encourages therapists to be more evidence-based in how they treat their patients, which is considered another opportunity. A threat with the implementation of this outcome tool is that there could be push back from therapists with the addition of another component to the evaluation process. Therapists are concerned that there already is not enough time in an evaluation to complete all necessary steps and that this assessment will be more work. The results of the SWOT analysis were then discussed with the OT manager and the executive director of therapies who provided input and direction on how to manage the concerns and promote the strengths and opportunities. Implementation The implementation phase of this project includes application of the FMA-UE to practice. Utilizing the KTA framework, I first identified that I was in the adapt to local context phase (Graham et al., 2006). I began by taking steps to prepare for implementation of the FMAUE. This planning and preparation included watching videos on appropriate administration, reading research articles, development of a thorough understanding of the FMA-UE manual, and continuous practice of the assessment. The most difficult aspect was practicing the assessment. In inpatient rehabilitation, patients receive three hours of therapy per day, along with time blocks for nurses, physicians, psychologists, psychiatrists, chaplains, and recreational therapists. Therefore, it was difficult to find time to practice the FMA-UE as the patient was often resting or meeting with another hospital employee. It was also difficult to find a standardized approach to administration of the FMA-UE. A large majority of the videos and resources all administer the FMA-UE in a variety of ways. Therefore, I had to develop a thorough understanding of the TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 15 manual for the FMA-UE, and then find a video or other resources that aligned with appropriate administration After I developed a comprehensive understanding of the FMA-UE I brought it to the outcomes committee. At this meeting, the FMA-UE was presented along with a demonstration on how it is to be administered. The program planning piece comes into play in regards to the preparation for this meeting. The planning included development of a handout with quick facts as well as additional information to provide foundational knowledge of the assessment. This helped to answer some of the therapists initial questions about the assessment, such as: who is it for, when should it be administered, why is this tool being utilized, etc. A manual with step-bystep instructions was also provided to each therapist to assist with administration and scoring. In addition, pictures for positioning were included in the handouts. During a weekly meeting with my site supervisors, we discussed some concerns with how receptive the staff will be to implementation of a new assessment. My site supervisors encouraged me to develop a SWOT analysis specifically for the outcomes meeting that I presented to the therapists on the committee. This preemptively identified barriers and developed support for the assessment before it was implemented with the rest of the team. I also provided articles and research prepared that served as supplemental resources for the outcome committee if they desired to dive into the research themselves. Information regarding clinically important statistics for measured progress was also brought to the therapists. For example, a statistically significant increase in score on the FMA-UE is 4.25-7.25 points for a chronic CVA, and 9-10 points for an acute CVA (Page, Fulk, & Boyne, 2012). Following the meeting, I continued to implement the assessment, however it was alongside the OTs that will implement it during their evaluations, initial treatments, and discharges. The therapists were allotted a couple weeks to TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 16 trial the assessment, with my guidance, so that they became comfortable with knowing when and how to administer it. During this trial time, the therapists were asked to identify any additional obstacles that were addressed and resolved prior to educating the remaining group of OTs. The bulk of the implementation phase occurred with working one-on-one with the therapists to help develop an understanding of the FMA-UE. However, to be successful with implementation, certain leadership qualities were required. For example, during the planning phase I had to advocate for myself and for the entire DCE. Many therapists did not fully understand my role, so when possible, I would engage in conversation and explain my project. This allowed me to develop some rapport with the therapists, as well as prepare them for what was to come. I also observed several evaluations during the first 6 weeks, which helped me develop an understanding of how therapists complete evaluations. This allowed me to see how the FMA-UE could be implemented into what they already do without creating extra burden on the OTs. The direct service provision model guided my interaction with both the therapists and patients. I worked directly with both parties while using this model to guide my DCE. During the DCE, I also attended several meetings. These meetings were with therapists, physicians, and leadership teams. I was often asked to provide information regarding my project and my role at RHI. This allowed me to explain my purpose and help develop a team mindset between myself as a student and other parties involved. During outcome committee meetings, I also created the agenda and facilitated conversation regarding the DCE and implementation of the FMA-UE. This aspect of the DCE required public speaking skills and the ability to explain my role, as well as the reason for the FMA-UE, which is another leadership quality. Another aspect of my responsibility was to identify patients who were candidates for the FMA-UE and determine appropriate times to see them. Clinical reasoning was required to recognize which TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 17 patients were appropriate and which were not. I would often coordinate with therapists and nursing staff to ensure that everyone was on board with my project. I also discussed the status of patients with the OTs to determine if they were appropriate for an FMA-UE assessment. Because the DCE is self-directed, I created timelines for myself and came to meetings organized and prepared, all of which are qualities required for a leadership role. This experience often brought me out of my comfort zone and required me to demonstrate leadership qualities in how I interacted with therapists and other individuals. The overall focus of my DCE was to assist with implementation of FMA-UE as a new outcome measure at RHI. Staff development coincides perfectly with the purpose of my project. I was in charge of educating the staff and ensuring that they developed an in-depth understanding of what all is entailed within the FMA-UE. The education was important to ensure that the therapists correctly administer the assessment. Professional development is incredibly important at RHI as the staff are required to set professional development goals (L. Swan & K. Ruggles, personal communication, February 8, 2018). Therapists are encouraged to attend continuing education courses, collaborate with other disciplines, pursue specializations, and participate in research (L. Swan & K. Ruggles, personal communication, February 8, 2018). At RHI, the leadership team is constantly striving to be a frontrunner for inpatient rehabilitation in the Indianapolis area. In this community, participating in research is considered essential to leadership because it ensures the best care possible. Therefore, through staff education and training with the FMA-UE, I assisted with staff development and facilitation of quality care for the patients served at RHI. TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 18 Discontinuation The discontinuation phase of this project occurred during the last four weeks of the Capstone experience. At that point in time, the OTs received education regarding the FMA-UE and instruction for its implementation. The discontinuation aspect focused on passing the information to the OTs at RHI and allowing them the opportunity to regularly implement the FMA-UE into their evaluations, initial treatments, and discharges. The process of discontinuation contained a multitude of steps. Prior to discontinuation, the OTs on the outcome committee agreed that the assessment was ready to be introduced to the remaining therapists. Then an educational meeting occurred in which the information was presented to the remaining OTs who then began implementing the assessment. The first part of the implementation phase occurred with just the outcome committee. During this second part of the implementation phase I worked with the therapists to ensure appropriate administration. I also began utilizing a fidelity measure that I created to initiate the discontinuation process. A fidelity measure is a tool used to ensure that a change is implemented appropriately and accurately (Malec & Swan, 2017). In the case of this DCE, the fidelity measure was utilized to ensure that therapists were administering the FMA-UE in the correct, standardized manner, ultimately striving for continuous quality improvement. From that point, I then worked with the therapists to correct any changes that needed to be made during administration. The last four weeks of my DCE included finalizing implementation and ensuring that a continuation plan was in place. Continuation focuses on sustainability, which is essential for this outcome measure so that it is continued to be utilized beyond the completion of this DCE. Sustainability is needed to ensure that RHI is continuously meeting the needs of both society and their patients. The FMA-UE meets the needs of society by further justifying the need TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 19 for OT with the patients that are served. As healthcare continuously changes, it becomes more and more important for therapists to show that the treatment they provide is beneficial to their patients. In regards to the FMA-UE, this assessment provides quantitative data that demonstrates patient progress, therefore showing the extensive need for OTs among these populations. Along with meeting the needs of society, the need of the patient is the main priority. This assessment allows the patient to see progress from the time they are an inpatient, to when they go home, and all the way through outpatient therapy. The therapists and leadership team have stated that the responsibility of ensuring sustainability, will fall to them upon completion of this DCE. Outcome The outcome of this DCE is continued use of the FMA-UE during evaluations and discharges. The purpose is to provide better care to the patients that are served by RHI. The outcome of providing better patient care will not be identified during the time of the DCE because an important piece is sustainability. Sustainability of this outcome measure cannot be established in 16 weeks (L. Swan & K. Ruggles, personal communication, January 8, 2018). It is estimated that this project will take a minimum of six months to complete, which is beyond the timeframe for the DCE (L. Swan & K. Ruggles, personal communication, January 8, 2018). There is a possibility for another DCE student to continue in this project; otherwise, it will become the responsibility of the site mentors and outcome committee (L. Swan & K. Ruggles, personal communication, January 8, 2018). The KTA framework was utilized to ensure that the outcomes have been met. The goal was to reach the select, tailor, implement interventions phase. If that phase was met, then the goal of this DCE will have been accomplished. This phase included the use of the FMA-UE by therapists across all units, among patients with specific neurological conditions. The final stage TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 20 of the FMA-UE is monitor knowledge use. Because this DCE is only 16 weeks, this will occur past the completion of this DCE. As noted, the outcome committee has stated that they will take ownership upon completion of the DCE to ensure sustainability of this FMA-UE. Overall Learning Throughout the DCE, it was my responsibility to maintain open communication not only with my site mentors, but also therapists, patients, nurses, and my faculty mentor. I communicated both verbally and non-face to face. With my site mentors I learned that e-mail communication was most effective as they are both in managerial positions and not always available to discuss topics, in person, related to my experience. I found that with therapists the opposite was true. Few therapists are able to check their email regularly throughout the day; therefore, I would try and catch them in the mornings or at lunch time when I knew they would not be on their way to see a patient. This proved most effective and also allowed me to build rapport with the therapists as that is easier to accomplish through conversation than through written communication. I also communicated verbally with patients in order to build rapport. With the purpose of my DCE, I only saw patients typically during their first or second day and then the day before their discharge. However, the initial meeting still allowed me to get to know them briefly and explain the purpose of the assessment I was administering. The various styles of communication I utilized will be extremely beneficial when I enter practice. As a student, I have observed the most effective way to communicate with a multitude of people, and I have learned how to identify the most effective communication style. It is likely that this will change from setting to setting and facility to facility, however I now have the tools to quickly identify what form of communication is the most effective. TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 21 The team at RHI does a fantastic job of working together to provide the best care possible to their patients. Throughout the day, therapists are continuously discussing how patients are progressing. They coordinate treatment plans and collaborate on what they can do to make the patient as safe and independent as possible. The therapists work together to come up with new treatment ideas to remain evidence-based. The managers also demonstrate teamwork, but in a slightly different capacity. They each manage their own units and departments; however, they meet together on a weekly basis to collaborate on ways to better the workplace. Each manager also possesses a multitude of leadership skills. One of the most prominent skills I observed is communication, both among therapists and managers. The managers are continuously finding ways to improve communication with their employees. As a result of input from therapists, the leadership team determined they want to continue striving for better communication. It was determined that an action plan needed to be created with input from the therapists so that they are meeting their needs. Throughout this planning process, the team utilized Lean Six Sigma to guide their development of an effective and efficient quality improvement process. As a DCE student, I was often placed in the middle and saw both sides of conflict. I worked very closely with managers and the leadership team, while also communicating and being in the vicinity of therapists on a daily basis. I would often hear of growth areas from both sides and how each group of individuals (managers and therapists) believed things should be improved. This allowed me to observe the process for conflict resolution. During my time at RHI, an issue arose that created tension between the therapists and leadership team. During weekly leadership meetings, I listened to conversations regarding this issue and how those in positions of power were working to resolve the issue. Over the course of a few months, I saw how even though it was not always evident to the therapists, the managers were working with TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 22 individuals higher up in the RHI management team to advocate for them and their profession. Once the therapists were made aware of the resolution to their problem, they were able to see, that though it is a slow process, the managers do their best to fight for the therapists wants and needs. Personally, I further developed leadership skills such as: organization, time management, communication, resourcefulness, and project management. During my first meeting with my site mentors, they told me that project management would be the biggest focus of my DCE. They left it up to me to determine timelines, such as implementation, education, and discontinuation. They were there to guide if needed but encouraged me to take ownership and only utilize them as a resource. As a result, I continuously had to advocate for my project and why it was important, through how I communicated with others. Culture changes can be difficult, so I had to learn the balance of implementing a new assessment without creating an extra burden on both the therapists and managers. I also had to advocate for myself with other professionals. I often explained my role as a student to physicians, nurses, and other disciplines in a way that differed from that of a typical student role. Throughout this experience, I gained all of these qualities and skills which will in turn assist me in becoming a successful occupational therapist. In conclusion, I gained a multitude of skills and experiences throughout my DCE. The purpose was to provide the Rehabilitation Hospital of Indiana (RHI) with an outcome measure to better quantify upper extremity recovery following a stroke or brain injury. I accomplished this goal through implementing the FMA-UE into the evaluation and discharge process. As a result of this new assessment, RHI is better equipped to treat individuals after a CVA or brain injury, as well as participate in research to further advance the profession. TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 23 References American Occupational Therapy Association. (n.d.). AOTA program development resource toolkit [Online forum]. Retrieved from https://www.aota.org//media/corporate/files/practice/aging/driving/assessments/needs.pdf Asher, I.E. (Ed.) (2014). Asher's occupational therapy assessment tools: An annotated index (4th ed.). Bethesda, MD: AOTA Press Bauer, M. S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A. M. (2015). An introduction to implementation science for the non-specialist. Biomed Central, 3(32), 112. doi: 10.1186/s40359-015-0089-9 Brekke, J. S., Ell, K., & Palinkas, L. A. (2007). Translational science at the National Institute of Mental Health: can social work take its rightful place? Research on Social Work Practice, 17(1), 123-133. doi: 10.1177/1049731506293693 Brownson, C. (2001). Program development for community health: Planning, implementation, and evaluating strategies. In M. Scaffa, (Ed.), Occupational therapy in community-based practice settings (pp.95-118) Philadelphia: F.A. Davis. Clark, F., Park, D. J., & Burke, J. P. (2013). Dissemination: bringing translational research to completion. American Journal of Occupational Therapy, 67, 185-193. doi: 10.5014/ajot.2013.006148 Doucet, B. M., & Gutman, S. A. (2013). Quantifying function: the rest of the measurement story. American Journal of Occupational Therapy, 67(1), 7-9. Eccles, M. P., & Mittman, B. S. (2006). Welcome to implementation science. Implementation Science, 1(1), 1-3. doi: 10.1186/1748-5908-1-1 TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 24 Field, B., Booth, A., Ilott, I., & Gerrish, K. (2014). Using the knowledge to action framework in practice: a citation analysis and systematic review. Implementation Science, 9(172), 1-14. doi: 10.1186/s13012-014-0172-2 Gebruers, N., Truijen, S., Engelborghs, S., & De Deyn, P. P. (2014). Prediction of upper limb recovery, general disability, and rehabilitation status by activity measurements assessed by accelerometers or the Fugl-Meyer score in acute stroke. American Journal of Physical Medicine and Rehabilitation, 93(3), 245-252. doi: 10.1097/PHM.0000000000000045 Gladstone, D. J., Danells, C. J., & Black, S. E. (2002). The Fugl-Meyer Assessment of motor recovery after stroke: a critical review of its measurement properties. The American Society of Neurorehabilitation, 16(3), 232-240. Glasgow, R. E. & Emmons, K. M. (2007). How can we increase translation of research into practice? Types of evidence needed. Annual Review of Public Health, 28, 413-433. doi: 10.1146/annurev.publhealth.28.021406.144145 Graham, I. D., Logan, J., Harrison, M. B., Strauss, S., Tetroe, J., Caswell, W., & Robinson, W. (2006). Lost in knowledge translation: time for a map? The Journal of Continuing Education in the Health Professions, 26, 13-24. Grol, R. & Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients care. The Lancet, 362, 1225-1230. Jongbloed, L. & Wendland, T. (2002). The impact of reimbursement systems on occupational therapy practice in Canada and the United States of America. The Canadian Journal of Occupational Therapy, 69(3), 143-152. TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 25 Kim, H., Her, J., Ko, J., Park, D. S., Woo, J. H., You, Y., & Choi, Y. (2012). Reliability, concurrent validity, and responsiveness of the Fugl-Meyer Assessment (FMA) for hemiplegic patients. Journal of Physical Therapy Science, 24(9), 893-899. Klein, J. & Hopper, T. (2013). Restructuring a rehabilitation program for older adults: effects on patient outcomes and staff perspectives. Canadian Journal on Aging, 32(2), 185-194. doi: 10.1017/S0714980812000402 Kroll, C. & Fisher, T. (2017). Justifying rehabilitation intensity through functional performance measures in postacute care. American Journal of Occupational Therapy, 72(1), 1-6. doi: 10.5014/ajot.2018.721002 Levine, P. G. (2009). Upper-extremity, stroke-specific testing: are lab-tested, stroke-specific outcome measures ready for clinical prime time? American Occupational Therapy Association, 32(3), 1-4. Malec, J. F. & Swan, L. (2017). Research to practice: a step-by-step guide to clinical implementation. Unpublished manuscript, Rehabilitation Hospital of Indiana, Indianapolis, Indiana. McDonnell, M. N., Hillier, S. L. & Esterman, A. J. (2013). Standardizing the approach to evidence-based upper limb rehabilitation after stroke. Topics in Stroke Rehabilitation, 20(5), 432-440. doi: 10.1310/tsr2005-432 Metzler, M. J. & Metz, G. A. (2010). Translating knowledge to practice: an occupational therapy perspective. Australian Occupational Therapy Journal 57, 373-379. doi: 10.1111/j.14401630.2010.00873.x Munce, S., Kastner, M., Cramm, H., Lal, S., Deschene, S. M., Auais, M., Stacey, D., & Brouwers, M. (2013). Applying the Knowledge to Action framework to plan a strategy TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 26 for implementing breast cancer screening guidelines: an interprofessional perspective. Journal of Cancer Education, 28, 481-487. doi: 10.1007/s13187-013-0490-0 Page, S. J., Fulk, G. D., & Boyne, P. (2012). Clinically important differences for the upperextremity Fugl-Meyer scale in people with minimal to moderate impairment due to chronic stroke. American Physical Therapy Association, 92(6), 791-798. doi: 10.2522/ptj.20110009 Platz, T., Pinkowski, C., Van Wijck, F., Kim, I. H., Bella, P. D., & Johnson, G. (2005). Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test, and Box and Block Test: a multicentre study. Clinical Rehabilitation, 19, 404-411. doi: 10.1I191/0269215505cr832oa Shirley Ryan Ability Lab. (n.d.). Fugl-Meyer assessment of motor recovery after stroke [Online forum]. Retrieved from https://www.sralab.org/rehabilitation-measures/fugl-meyerassessment-motor-recovery-after-stroke Thompson-Butel, A. G., Lin, G., Shiner, C. T., & McNulty, P. A. (2015). Comparison of three tools to measure improvements in upper-limb function with poststroke therapy. Neurorehabilitation and Neural Repair, 29(4), 341-348. doi: 10.1177/1545968314547766 Tietjen-Smith, T., Smith, S. W., Martin, M., Henry, R., Weeks, S., & Bryant, A. (2006). Grip strength in relation to overall strength and functional capacity in very old and oldest old females. Physical & Occupational Therapy in Geriatrics, 24(4), 63-78. doi: 10.1080/J148v24n04_05 Woytowicz, E. J., Rietschel, J. C., Goodman, R. N., Conroy, S. S., Sorkin, J. D., Whitall, J., & Waller, S. M. (2017). Determining levels of upper extremity movement impairment by TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION applying a cluster analysis to the Fugl-Meyer assessment of the upper extremity in chronic stroke. Archives of Physical Medicine and Rehabilitation, 98, 456-472. doi: 10.1016/j.apmr.2016.06.023 27 TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION 28 Figure 1. Knowledge to Action Wheel demonstrates how evidence-based practices can be implemented through a step-by-step process (Field et al, 2014). TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION Strengths Highly skilled therapists Strong committee Excellent facility Evidence based assessment Helpful for a high percentage of the patients at RHI (CVA, brain injury, neuro conditions) Provides quantitative data to physicians, payers, and community partners for benefits of OT and potential recovery Widely used and internationally accepted assessment Weaknesses Opportunities Participation in research Utilization of EBP Allows for greater communication between therapists and physicians Stand out from other surrounding rehab centers 29 Does not apply to all populations May be difficult to administer as many patients are lethargic or confused Deficit/impairment focused May not demonstrate improvements in patients with higher level hand function Threats Long-term use/sustainability Push back/culture change Timeline Competition from other local healthcare organizations Figure 2. The SWOT analysis demonstrates various aspects involved with implementing change (AOTA, n.d.; Brownson, 2001). TRANSLATIONAL PRACTICE: OUTCOME TOOL IMPLEMENTATION Figure 3. A fidelity measure ensures that change is implemented appropriately and allows for the monitoring of knowledge use (Malec & Swan, 2017). 30  ...

... Running Head: THA AND TKA OUTCOMES 1 Total Joint Arthroplasty Outcomes Using Short Musculoskeletal Function Assessment and University of California, Los Angeles Activity Score Shelby Allen, Melanie Browne, Curtis Clem, Taylor Millar, Shannon Nale, and Zachary Selby December 2017 A research 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 research advisor: Lucinda Dale EdD, OTR, CHT, FAOTA THA AND TKA OUTCOMES 2 A Research Project Entitled Title: Total Joint Arthroplasty Outcomes Using Short Musculoskeletal Function Assessment and University of California, Los Angeles Activity Score Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Shelby Allen, Melanie Browne, Curtis Clem, Taylor Millar, Shannon Nale, and Zachary Selby Occupational Therapy Students Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTR Chair, School of Occupational Therapy Date THA AND TKA OUTCOMES 3 Total Joint Arthroplasty Outcomes Using Short Musculoskeletal Function Assessment and University of California, Los Angeles Activity Score Shelby Allen, Melanie Browne, Curtis Clem, Taylor Millar, Shannon Nale, Zachary Selby, and Lucinda Dale EdD, OTR, CHT, FAOTA University of Indianapolis Author Note Shelby Allen, School of Occupational Therapy, University of Indianapolis; Melanie Browne, School of Occupational Therapy, University of Indianapolis; Curtis Clem, School of Occupational Therapy, University of Indianapolis; Taylor Millar, School of Occupational Therapy, University of Indianapolis; Shannon Nale, School of Occupational Therapy, University of Indianapolis; Zachary Selby, School of Occupational Therapy, University of Indianapolis and Lucinda Dale EdD, OTR, CHT, FAOTA, School of Occupational Therapy, University of Indianapolis THA AND TKA OUTCOMES 4 Abstract Objectives: The purpose of this study was to explore the impact of total hip arthroplasties (THA) and total knee arthroplasties (TKA) through measurement of functional outcome via the Short Musculoskeletal Function Assessment (SMFA) and activity level using the University of California, Los Angeles (UCLA) Activity Score for patients with elective, primary THA or TKA. Method: Patients scheduled for THA or TKA completed the SMFA and UCLA Activity Score during routine assessment and intervention sessions preoperatively, and at 1-month, 3-month, 6month, and 12-month follow-up visits. Hospital personnel de-identified and entered SMFA, UCLA Activity Score, and demographic data from a convenience sample into an Excel spreadsheet. Researchers entered data into Statistical Package for the Social Sciences (SPSS) for analysis. Results: From a sample of 490 patients, complete data for patients with THA (n = 27) and TKA (n = 21) could be used for analysis. Insufficient data prevented analysis of 6-month and 12month THA, and 12-month TKA time frames. An independent t-test and independent samples test confirmed similarities of SMFA and UCLA Activity Score for THA and TKA, allowing the two populations to be combined for analysis. Total SMFA and all subcategories showed more disability than normative values at pre-operation. Results from a paired t-test indicated significant improvements in total SMFA scores from pre-operation to 1 month, and from 1 to 3 months. Arm and hand, mobility, and emotional subcategories of the SMFA showed significant improvements from pre-operation to 1 month; the activities of daily living subcategory showed a significant improvement from 1 to 3 months. Total SMFA, activities of daily living, emotional status, and mobility subcategory mean scores were statistically similar to normative values by 6 THA AND TKA OUTCOMES 5 months, whereas arm and hand mean score was better than normative value by 1 month. Results from a Wilcoxon Signed-Rank test indicated a significant improvement in UCLA Activity Score from 1 to 3 months. Conclusion: THA and TKA impact multiple areas of occupational performance and nonoperative areas of the body. Researchers and clinicians can use the SMFA and UCLA Activity Score to measure multidimensional outcomes for THA or TKA. Keywords: total hip arthroplasty; total knee arthroplasty; occupational therapy; physical therapy; Short Musculoskeletal Function Assessment; University of California, Los Angeles Activity Score; activities of daily living THA AND TKA OUTCOMES 6 Total Joint Arthroplasty Outcomes Using Short Musculoskeletal Function Assessment and University of California, Los Angeles Activity Score More than seven million Americans are living with total hip arthroplasties (THA) and total knee arthroplasties (TKA) (Maradit-Kremers, Crowson, Larson, Jiranek, & Berry, 2014). The annual number of TKA doubled from 300,000 surgeries in 1991 to 600,000 in 2010 (Martin, Thornhill, & Katz, 2015). Researchers estimate that demand for primary THA and TKA in the United States will increase by 174% and 673% respectively between 2005 and 2030 (Patel, Pavlou, Mjica-Mota, & Toms, 2015). Increases in the incidence of osteoarthritis (OA) and in the aging population are two contributing factors for the rise of THA and TKA in the United States (Allen & Golightly, 2015; Yan & Pogoda, 2013). OA is the most frequently diagnosed joint disease in adults and is the principal cause of pain and disability for older adults (Harding, Holland, Delany, & Hinman, 2014; Simmons & Smith, 2013). OA can be associated with poor physical function and is the most common reason for THA/TKA (Davison, Ioannidis, Maly, Adachi, & Beattie, 2014; Harding et al., 2014). Occupational therapy (OT) and physical therapy (PT) services are often prescribed for patients who have undergone THA or TKA to improve occupational performance and physical function, with an emphasis on lower extremity function (American Occupational Therapy Association [AOTA], 2011; Reicherter, 2017; Sathe, 2013; Singh & Lewallen, 2013b; Umpierres et al., 2014). OT and PT practitioners evaluate patients and provide interventions, pre- and postoperatively that focus on education regarding precautions, pain management, engagement in occupations to increase quality of life (QOL), exercise programs, and appropriate adaptive and mobility devices (AOTA, 2011; Reicherter, 2017; Sathe, 2013). Patients typically spend 1 to 3 THA AND TKA OUTCOMES 7 days in the hospital after THA/TKA, and full recovery is expected to occur 6 to 12 months after surgery (American Association of Hip and Knee Surgeons, n.d.). Researchers have focused on lower extremity function, muscle strength, and joint mobility, and have rarely used the Short Musculoskeletal Function Assessment (SMFA) and University of California, Los Angeles (UCLA) Activity Score outcome tools for individuals with THA/TKA (Herbold et al., 2014; Simmons & Smith, 2013; Wimmer, Nechtow, Schwenke, & Moisio, 2015). In the reviewed literature there has been a greater focus on PT interventions than OT interventions after THA/TKA (Harding et al., 2014; Heiberg, Ekeland, & Mengshoel, 2013; Huber, Roos, Meichtry, de Bie, & Bischoff-Ferrari, 2015). However, according to AOTA (2014), OT practitioners provide services using a client-centered, multidimensional approach to improve QOL, function, safety, and independence in work, play, leisure, activities of daily living (ADL), and instrumental activities of daily living (IADL). Outcomes are the end result of the OT process; they describe what clients can achieve through OT intervention, (AOTA, 2014, p. S16). Outcome measures are chosen based on client goals and psychometric properties of the tool (AOTA, 2014). Due to their assessment of multiple factors contributing to occupational performance, the outcome tools used in this study were the SMFA and UCLA Activity Score. The SMFA is a patient-reported assessment tool that supports a holistic, multidimensional approach through its inclusion of ADL, arm and hand, mobility, and emotional areas of daily function, allowing practitioners to gather patient-reported information relevant to daily living (Swiontkowski, Engelberg, Martin, & Agel, 1999). The UCLA Activity Score is also a patient-reported assessment tool that is used to measure an individuals activity level, and has been shown to be the most useful tool to measure physical THA AND TKA OUTCOMES 8 activity in individuals diagnosed with OA in the hip and/or knee (Terwee, Bouwmeester, van Elsland, de Vet, & Dekker, 2011). The purpose of this study was to measure functional outcome via the SMFA and activity level using the UCLA Activity Score for patients with elective, primary THA or TKA. The research question for this study was: For patients who undergo THA or TKA and participate in OT and PT, what are the outcomes as measured by the SMFA and UCLA Activity Score? Literature Review Patient-rated outcome tools are used to measure patients perceptions of their recovery of function after THA or TKA. Researchers have used the Western-Ontario McMaster Universities (WOMAC) Osteoarthritis Index, Oxford Hip Score, Oxford Knee Score, 36-Item Short Form Health Survey (SF-36), Hospital for Special Surgery (HSS) Knee Rating Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Hip Injury and Osteoarthritis Outcome Score (HOOS), Functional Independence Measure (FIM), Short Questionnaire to Assess Physical Activity (SQUASH), 12-Item Short Form Health Survey (SF-12), UCLA Activity Score, and internally developed questionnaires to report outcomes after THA or TKA (Andrawis et al., 2015; Harding et al., 2014; Herbold et al., 2014; Huber et al., 2015; Judd et al., 2014a; Judd, Thomas, Dayton, & Stevens-Lapsley, 2014b; Mandzuk, McMillan, & Bohm, 2015; Monticone et al., 2014; Peter et al., 2015; Terwee et al., 2011; Umpierres et al., 2014). These outcome measures included ways to assess effectiveness of pre- and postoperative PT and OT rehabilitation, patient function, pain levels, ADL, QOL, and community reintegration (Fujita, Xia, Liu, Mawatari, & Makimoto, 2014; Harding et al., 2014; Herbold et al., 2014; Peter et al., 2015; Poortinga, van den AkkerScheek, Bulstra, Stewart, & Stevens, 2014; Singh & Lewallen, 2013a; Singh & Lewallen, 2013b; Stergiou-Kita & Grigorovich, 2014). THA AND TKA OUTCOMES 9 Most researchers in the reviewed literature focused on PT intervention after THA/TKA with an emphasis on strength, functional activity, range of motion (ROM) exercises, mobility training, and stretching; however, most researchers did not address nonoperative areas of the body that may also be impacted by THA/TKA (Judd et al., 2014a; Poortinga et al., 2014; Simmons & Smith, 2013; Umpierres et al., 2014). Fewer researchers addressed a combination of OT and PT intervention in regards to joint mobility and function in ADL (Herbold et al., 2014; Yan & Pagoda, 2013). General trends in the reviewed literature indicate preoperative education interventions alone were equally effective as a combination of preoperative education and PT interventions (Huber et al., 2015). Additionally, participation in OT and PT post-THA/TKA resulted in improved QOL, pain, physical function, ADL performance, and community reintegration (Harding et al., 2014; Mandzuk et al., 2015; Peter et al., 2015; Singh & Lewallen, 2013b; Stergiou-Kita & Grigorovich, 2014). To assess physical function, researchers have used general health status measures, outcome tools for lower extremity function, and outcome tools designed for individuals with arthritis, which have yielded mixed results (Harding et al., 2014; Poortinga et al., 2014; Schotanus, Bemelmans, Grimm, Heyligers, & Kort, 2016; Simmons & Smith, 2013). In addition to these tools and measures, researchers have commonly used performance-focused outcome tools in combination with patient-reported outcome tools (Andrawis et al., 2015; Harding et al., 2014; Maxwell et al., 2013). Results from studies that include both types of outcome tools indicate that patient-reported outcome tools have more consistently detected improvements in function, physical activity, pain, and QOL, whereas performance-focused outcome tools yielded mixed results (Andrawis et al., 2015; Harding et al., 2014; Maxwell et al., 2013). Objective, performance-based measures may not represent patients perceptions of functional status. THA AND TKA OUTCOMES 10 Researchers have found that patients who have undergone THA/TKA generally experience an increase in QOL (Dailiana et al., 2015; Harding et al., 2014; Keurentjes et al., 2013; Mandzuk et al., 2015). Harding et al. (2014) reported that pain was inversely related to function and QOL after THA/TKA. Furthermore, Singh & Lewallen (2013a; 2013b) showed that decreased pain was associated with improved ADL and functional mobility post-THA/TKA. Dailiana et al. (2015) found that approximately 50% of patients who planned to undergo THA or TKA experienced depressive symptoms. Researchers identified a significant improvement in patient-reported QOL and reduction of depressive symptoms after THA and TKA (Dailiana et al., 2015; Harding et al., 2014). Although individuals planning to undergo THA have reported impaired sexual activity, only one study in the reviewed literature included this topic. Lavernia and Villa (2016) used an internally developed questionnaire and found that THA was effective in decreasing pain and increasing mobility for sexual activity. Using outcome tools that include sexual activity as part of ADL could help practitioners identify and address concerns about meaningful activities that otherwise may not be addressed (Lavernia & Villa, 2016). Reports of research have shown that patients value their performance in meaningful activities and engagement in their communities (Stergiou-Kita & Grigorovich, 2014). Participants who experienced significant pain relief expressed satisfaction with community engagement because decreased pain allowed them to participate in meaningful activities. This concept is essential for practitioners to consider when measuring IADL (driving, community mobility, meal preparation, and care of others/pets) that are meaningful to individuals planning to undergo THA or TKA (AOTA, 2014; Stergiou-Kita & Grigorovich, 2014). THA AND TKA OUTCOMES 11 Although outcomes after THA and TKA have been extensively reported in the literature, there are gaps that need to be addressed. Outcome measurement has rarely included OT interventions for this population (Poortinga et al., 2014; Simmons & Smith, 2013, Singh & Lewallen, 2013b; Umpierres et al., 2014). Despite usefulness, validity, and reliability of the SMFA and UCLA Activity Score (Swiontkowski et al., 1999; Terwee et al., 2011), researchers have rarely used these outcome tools with THA or TKA. Other limitations in the reviewed literature consisted of: limited sample sizes, incomplete data, compromised external validity, and a limited focus on participants function (Andrawis et al., 2015; Harding et al., 2014; Heiberg et al., 2013; Judd et al., 2014a; Judd et al., 2014b; Maxwell et al., 2013; Singh & Lewallen, 2013b). Researchers in the current study chose the SMFA and UCLA Activity Score to measure outcomes for patients after THA or TKA. Patients participated in OT and PT prior to and after surgery. The current study methodology serves to fill some of the gaps identified in the reviewed literature. Method Study Design The researchers in this study used a quantitative, repeated measures design with retrospective data. A regional healthcare organization, which included one hospital-based and three satellite outpatient OT and PT locations, partnered with a university for the purpose of measuring outcomes for THA and TKA. In this study, the independent variables were THA and TKA and the dependent variables were outcome scores for the SMFA and UCLA Activity Score. In this study, three surgeons performed elective, primary TKA and one of the three surgeons also performed elective, primary THA using an anterior approach. The primary investigator (PI) of this study is an OT practitioner, faculty of the university, and advisor of six THA AND TKA OUTCOMES 12 student researchers. The SMFA and UCLA Activity Score assessment tools were collaboratively selected by the PI, healthcare organization administrators, surgeons, and OT and PT practitioners at the organizations facilities. Researchers completed this study to fulfill an academic requirement to earn a doctoral degree in OT. Instruments SMFA. The Musculoskeletal Function Assessment (MFA) is a health status instrument with 101 self-rated health items, designed for patients with a wide variety of musculoskeletal diseases (Engelberg, 1996). The MFA is used to assess patient function including upper and lower extremity function, daily activities, recreational functioning, emotional adjustment, and overall functioning as well as standard clinical measures such as ROM, grip strength, walking speed, fine motor skills, and knee and elbow strength (Engelberg, 1996). The SMFA is a shortened version of the MFA that contains two parts: the dysfunction index and the bother index (Swiontkowski et al., 1999). A five-point Likert scale is used for each of the 46 items that comprise the dysfunction and bother indices. The dysfunction index is a 34-item questionnaire that assesses ones daily activities, emotional status, arm and hand function, and mobility. A score of 1 shows good function and a score of 5 shows poor function. The bother index is a 12-item questionnaire that addresses how bothered patients feel about problems related to their condition and how these problems affect performance (score of 1 shows not bothered at all to a score of 5 extremely bothered). For the SMFA, both indices are standardized and have normative data. To score the SMFA results in a specific category, the first step is to calculate the sum of the scores for that category; this sum is the raw score. Then, the lowest possible sum from the category is subtracted from the raw score. The difference obtained THA AND TKA OUTCOMES 13 is then divided by the maximum possible sum from the category. Finally, this value is multiplied by 100 to obtain the standardized score. The standardized scores give a measure of patient disability; lower scores indicate higher function, and higher scores indicate lower function. Standardized scores can also be calculated for a SMFA index, using the same rules. The lowest possible raw score total for the dysfunction index is 34, and the highest possible score is 170. The range of possible standardized scores for the dysfunction index is 0 to 100 (Swiontkowski et al., 1999). Swiontkowski et al. (1999) found that both SMFA indices were shown to have internal consistency and stability, with most values more than 90 percent. In the same study, significant correlations were found between the SMFA indices and physicians ratings of patient function (e.g. emotional function and ADL) (r .40). Correlations of similar significance were found between both indices and standard clinical measures (e.g. grip strength and walking speed) (r .40). These correlations demonstrated convergent validity for both SMFA indices. Convergent and discriminant construct validity of both SMFA indices was demonstrated (p < 0.01) when the indices were compared to clinical, demographic, SF-36 Health Survey, and life-change data. Content validity was demonstrated for both indices, with very little skew (less than 1.00), few ceiling effects (less than 5 percent), and no floor effects. Responsiveness of both SMFA indices was demonstrated with standardized response means that ranged from moderate (0.76) to large (1.140) for patients whose health status changed (Swiontkowski et al., 1999). The SMFA is a valuable outcome tool for patients who have undergone THA/TKA because it allows them to rate daily activities, arm and hand function, emotional status, and mobility. For this study, researchers used the the SMFA dysfunction index. Patients were THA AND TKA OUTCOMES 14 administered the SMFA five times: preoperatively, and at 1-month, 3-month, 6-month, and 12month follow-up visits. UCLA Activity Score. The UCLA Activity Score is a non-normative and nonstandardized self-assessment questionnaire that can be used to measure the activity level of patients who have undergone joint arthroplasties (Terwee et al., 2011; Zahiri, Schmalzried, Szuszczewicz, & Amstutz, 1998). To complete the assessment, respondents rate their activity levels using the 10-point UCLA Activity Score rating scale. This score indicates their current participation in activities, regardless of intensity or frequency. The assessment tool includes activity level ratings ranging from 1 to 10. Level 1 is defined as wholly inactive, dependent on others, and cannot leave their residence, and level 10 is defined as regularly participates in impact sports (Zahiri et al., 1998). The UCLA Activity Score was found to be useful for measuring physical activity levels of populations including lower extremity joint replacement, osteoarthritis, and healthy individuals (Judd et al., 2014b; Terwee et al., 2011; Zahiri et al., 1998). Content validity and reliability of the UCLA Activity Score have been established (Terwee et al., 2011). Zahiri et al. (1998) found a significant correlation (p < 0.05) between pedometer data and the UCLA Activity Score, bringing validity to the rating scale. Patients were administered the UCLA Activity Score five times: preoperatively, and at 1-month, 3-month, 6month, and 12-month follow-up visits. Procedures IRB. The Institutional Review Board of the university approved this study as exempt. Training. The PI trained OT and PT practitioners on scoring procedures and interpretation of scores for the SMFA and UCLA Activity Score. The practitioners were also educated on the normative data of the SMFA. Student researchers received the same training at THA AND TKA OUTCOMES 15 a university. Aides and office staff were trained to administer tools and to collect and scan tools for electronic retrieval. Researchers completed the Collaborative Institutional Training Initiative to ensure ethical standards were fulfilled . Patient sample. Patients who underwent elective, primary unilateral or bilateral THA or TKA were included in the study. Patients were excluded if they had either of the following: a fractured bone which required a THA or TKA or revision of a THA or TKA. Preoperative intervention. As a part of routine assessments and interventions, all individuals who planned to undergo THA or TKA were scheduled to attend a pre-operation clinic. OT and PT practitioners administered and collected the SMFA and UCLA Activity Score during the pre-operation clinic. Additionally, the practitioners completed routine assessments including: ADL performance, ROM and manual muscle testing of upper and lower extremities, a grind test of the first carpometacarpal (CMC) joint, and functional mobility. Occupational and physical therapists prescribed upper and lower extremity exercises, educated patients on environmental modifications and adaptive devices, and described routine postoperative OT and PT interventions. Postoperative intervention. Patients who underwent THA or TKA were referred to OT and PT immediately post-operation. OT practitioners focused on increasing patients independence in toileting, bathing, and dressing. PT practitioners focused on ambulation, stair climbing, lower extremity ROM, and functional mobility. OT and PT practitioners collaborated with surgeons, nurses, and family to make recommendations for discharge to home, to a rehabilitation facility, or to a skilled nursing facility. All patients were referred to PT for THA AND TKA OUTCOMES 16 continued rehabilitation after discharge. During hospitalization, aides administered and collected the SMFA and UCLA Activity Score. Data Collection Data were collected by OT and PT practitioners, aides, and office staff as part of routine assessments and interventions for patients with THA and TKA. Hospital personnel de-identified the patient information before it was made available to the researchers. Data Analysis De-identified data from an Excel spreadsheet were copied and pasted into International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) version 23.0 software for data analysis. In order to reduce chance of human error, data were entered by pairs of researchers. One researcher entered data as another oversaw the data input process to check for errors. Independent t-test and independent samples test were conducted to determine if unilateral THA and TKA outcome scores for the SMFA and UCLA Activity Score were the same at pre-operation and could be combined for a single sample. A repeated measures ANOVA test and an equivalent nonparametric test were used to analyze the SMFA outcome score and UCLA Activity Score data for each of the five administered times to determine statistical change. Paired t-test and Wilcoxon Signed-Rank test were completed to determine statistical change between each sequential time frame. Descriptive statistics were utilized to analyze the demographic data. Researchers established p < .05 to identify statistical significance. Results Of the 490 patients who underwent THA or TKA from 2010 to 2016, data from 442 patients were removed prior to analysis due to incomplete data. At pre-operation, the sample included 30 patients who underwent bilateral TKA. However, data from only 15 of these THA AND TKA OUTCOMES 17 patients were completed 1 month after surgery, which was too few for an accurate analysis and resulted in removal from the data set. Of the 48 patients that had complete data, 27 underwent THA and 21 underwent TKA; 20 percent had a positive grind test of the first CMC joint; and 97.9 percent were overweight or obese (Table 1). Patients who underwent more than one primary THA or TKA were recorded as separate patients for the data set. Scores of the 6-month THA, 12-month THA, and 12-month TKA data were not included in the data set due to insufficient data. If patients were missing scores on fewer than half the items within any of the four SMFA subcategories, researchers replaced the missing data with the mean scores of available data from the remaining sample. The means for the SMFA subcategories did not change when missing data were replaced. Data entries were removed if missing more than two subcategories of the SMFA, or more than one time frame of the UCLA Activity Score. If patients were missing only one UCLA Activity Score time frame, it was replaced with the median score of the available data from the remaining sample. If patients chose more than one answer on the UCLA Activity Score, researchers recorded the higher score. Data of the SMFA scores showed normal distribution (p > .05), which allowed researchers to use parametric tests. Because The UCLA Activity Score data did not meet assumptions for normal distribution, nonparametric tests were used for analysis. At preoperation, results of independent t-tests and independent samples test for nonparametric tests were not significantly different (p > .05) when scores of the SMFA and UCLA Activity Score were compared, which allowed researchers to analyze THA and TKA data as a single sample. THA and TKA means and median scores remained the same on the SMFA and UCLA Activity Score respectively, at 1- and 3-month post-operation time frames. THA AND TKA OUTCOMES 18 Repeated measures ANOVA for the SMFA showed significant differences (p < .05) across means over the separate points in time. Paired t-tests indicated significant improvements for the total SMFA score from pre-operation to 1 month after, and 1 to 3 months post-THA/TKA (Table 2). Table 2 shows the mean differences and significance level for each subcategory on the SMFA at the various time frames. Figure 1 shows a comparison of the total SMFA and subcategory means and normative data for each time frame. The SMFA total and all subcategory scores at pre-operation showed more disability than the normative value. Improvements in total SMFA, and subcategories of ADL and emotional status achieved statistical similarity with normative values by 3 months; similarity with normative value was reached at 6 months for the mobility subcategory (Table 3). The preoperative score for the arm/hand subcategory was worse than, but not significantly different than, the normative value. The mean score for arm/hand became significantly better than normative data at 1 and 3 months, which indicated reduced disability. Arm/hand mean score indicated a slight increase in disability at 6 months but, though not statistically significant, remained better than the normative value. Results of a Friedman ANOVA for repeated measures showed significant difference (p < .05) in UCLA Activity Score across separate points in time. Follow-up Wilcoxon Signed-Rank test showed significant improvements in scores only for the 1-to-3 month time frame (Table 2). Patients maintained activity levels from pre-operation to 1 month, and made additional improvements 3 to 6 months (Figure 2), though these improvements were not statistically significant (p > .05) (Table 2). THA AND TKA OUTCOMES 19 Discussion Research results in this study reflected patients progress after PT and OT interventions post-THA/TKA. This interdisciplinary approach, which could influence the outcome scores, is in contrast and contributes to the literature in which researchers have primarily reported outcomes for patients receiving PT (Harding et al., 2014; Heiberg et al., 2013; Huber et al., 2015). The SMFA allowed researchers to address function of operative and nonoperative extremities that contributed to the patients overall levels of function in daily living (walking, shopping, community mobility, driving, leisure activities, sexual activity, home management, yardwork, work, toileting, dressing, bathing, self-care, and sleeping) impacted by THA or TKA. Use of the SMFA in measuring outcomes for the current study enabled researchers to address a gap in the literature in which most researchers have focused on impairments of the operative extremity or tasks that primarily rely on the operative extremity (George, Hu, & Sloan, 2014; Huber et al., 2015; Stergiou-Kita & Grigorovich, 2014; Umpierres et al., 2014). Use of the UCLA Activity Score allowed researchers to determine change in activity levels between measured time frames (pre-THA/TKA to 1 month post-operation, 1 month to 3 months postoperation, and 3 months to 6 months post-operation), and to determine whether activity levels increased preoperatively to 6 months post-operation. SMFA Total SMFA. At pre-operation, the total SMFA score showed a higher level of disability when compared to normative data. This score indicates, but cannot confirm that osteoarthritic conditions resulting in elective, primary THA or TKA could affect operative and non-operative parts of the body, and multiple areas of occupational performance that are reflected by all items of the SMFA. THA AND TKA OUTCOMES 20 The total SMFA score at the 1-month time frame showed less disability than preoperation, but remained significantly worse than normative data. One possible explanation for results of the total SMFA score at 1 month could be patients restrictions suggested by surgeons. Patients may have just begun, or had not yet started IADL performance and mobility tasks at this time frame, depending on surgeons orders for duration of restrictions. Limited performance in occupations could have affected the emotional status subcategory mean, in turn contributing to the total SMFA score. Mobility. The average score at pre-operation was significantly worse than the normative value. One explanation for this finding is that patients may have been self-limiting mobility tasks at pre-operation due to pain. The mobility score improved nearly 50 percent from preoperation to the 3-month time frame, but still remained significantly worse than the normative value. This result could be partly attributed to the time frame for discontinuation of postoperative restrictions for community mobility that were required by surgeons. Only indirect comparisons can be made of the mobility score to others findings as the items in the SMFA subcategory focus more on quality of mobility than ambulatory speed or distance. Researchers who have reported change in mobility for THA and TKA have used measurements of speed or distance during ambulation, and found mixed results at 1-month, 3-month, 6-month, 12-month, and 2-year time frames (George et al., 2014; Judd et al., 2014a). Arm/hand function. Arm/hand score was worse than normative value preoperatively, but improved to be better than the normative value at 1 month, and remained better through the 6-month time frame. Although Peter et al. (2015), did not specifically use a grind test to confirm that pain in the hand was attributed to OA, they were the only researchers in the reviewed literature that addressed the relationship between upper extremity (elbow and distal joints) THA AND TKA OUTCOMES 21 function and THA/TKA. Arm/hand disability could be attributed to overuse of and increased pressure on the hands preoperatively with the use of assistive devices for functional mobility. By 1 month post-operation, improvement in lower extremity joint mobility and pain may have been attributed to less reliance on ambulatory devices and upper extremities for functional mobility due to decreased lower extremity function. This possible explanation could also be applied to 3month score for the arm/hand function subcategory. Despite a significant improvement in arm/hand function at the 3-month time frame, the average score at the 6-month time frame showed an increase in disability for this subcategory. This trend could be attributed to individuals resuming activities that had ceased because of lower extremity joint pain, and that also required more aggressive use of the arms and hands, such as leisure, sports, or IADL. Researchers in a previous study found similar results (Dale et al., n.d.). Merritt, Roddey, Costello, and Olson (2010) suggested that outcomes of the grind test of the first CMC joint are influenced by performance of activity prior to test administration. In the current study, OT practitioners administered a grind test during the preoperative evaluation, and these results were used to guide intervention during the postoperative time frame. The grind test was not repeated post-operation. It could be that patients with negative grind tests pre-operation became symptomatic after surgery due to the increased physical demands on the arms and hands with use of mobility devices and functional mobility prior to discharge from the hospital. With no inpatient data, the results may imply that patients arm and hand function improved continuously from pre-operation to 1-month post-operation. However, data from Dale et al. (n.d.) suggest that arm and hand performance initially decreases after THA and TKA, and then improves by 1 month post-THA/TKA. Results from this study indicate hand function is important in initial and ongoing assessments because it can impact intervention plans. In this THA AND TKA OUTCOMES 22 study, 20 percent of patients had a positive grind test at the first CMC joint, which affected postoperative intervention plans. Those with a positive grind test received padding on walker handles post-operation to reduce stress on joints in the hands, as well as education on methods to pursue conservative management of CMC OA through OT services. ADL. Similar to the mobility score, the average ADL subcategory score improved nearly 50 percent from pre-operation to 3 months post-operation. Patients reasons for lack of ADL performance preoperatively, such as comorbidities and reliance on caregiver, were not provided in the data set. The average ADL score improved between all time frames, with the least amount of change from pre-operation to 1 month. This could be explained by the demands of the activities included in this subcategory (shopping, driving, physical recreation, leisure activities, sexual activity, yard work, and work). Patients received restrictions for physical activities that risked injury or improper healing; restrictions differed among surgeons. These restrictions may have resulted in patients avoiding activities within the 1-month time frame. The ADL score showed the largest functional improvement at the 3-month time frame when compared to average ADL scores of other measured time frames, and was no longer significantly different than the normative value. It is possible that patients experienced improved ADL function from 1 month to 3 months because restrictions were either reduced or discontinued, and pain levels may have decreased. George et al. (2014) also found that patients who underwent TKA had fewer ADL limitations, better health, and experienced less pain and fewer deficits in physical function than patients who did not undergo TKA. In this study, although functional improvement at the 6-month time frame was not significantly better, similar explanations for decreased disability may apply. The decrease in disability in ADL at 3 months post-operation coincided with improved activity level indicated by the UCLA Activity Score at 3 THA AND TKA OUTCOMES 23 months post-operation (5.03), which is defined as, sometimes participate in moderate activities, (Zahiri et al., 1998, p. 891). Similarly, the decrease in disability at the 6-month time frame in the SMFA (13.53) matched the 6-month activity level in the UCLA Activity Score (6.00), which is defined as, regularly participate in moderate activities, such as swimming and unlimited housework or shopping, (Zahiri et al., 1998, p. 891). Naal, Impellizzeri, & Leunig (2009) found that the UCLA Activity Score may be the most appropriate subjective physical activity assessment [for patients who have undergone THA or TKA] (p. 958). Emotional Status. Although others have not used the SMFA, researchers have recognized the impact of emotional status and pain for patients who have undergone THA/TKA and found improvement after surgery (George et al., 2014; Harding et al., 2014; Keurentjes et al., 2013; Stergiou-Kita & Grigorovich, 2014). In the current study, the SMFA emotional status score included patient-rated pain, sleep and fatigue levels, concentration, self-limitation, and emotions such as anger and frustration. Comparison of average mobility status scores at 1-, 3-, and 6-month time frames indicated the significant improvement for this subcategory occurred from pre-operation to 1 month. This may indicate that elective, primary THA/TKA can make the largest impact within 1 month after surgery on areas of occupational performance that may be indirectly related to the operative hip or knee. Because the data were given to the researchers in aggregate, it is not possible to know which of the items in this subcategory showed the most improvement. However, with pain as one of the items, it may be that lower levels of pain typically reported after THA/TKA could explain the change in this subcategory. Less pain may have resulted in better quality of sleep, less frustration, and increased participation in meaningful occupations and, therefore, an improvement in overall emotional status. The SMFA emotional status score possibly improved as a result of increased mobility, ADL, and arm and hand THA AND TKA OUTCOMES 24 function. Patients improvement in emotional status could have resulted from an increase in activity level as measured by the UCLA Activity Score, as well as participation in daily occupations measured by the SMFA. UCLA Activity Score Naal et al. (2009) found that, unlike other assessment tools, the UCLA Activity Score [showed discrimination between] insufficiently and sufficiently active patients [who underwent THA or TKA] (p. 958). In this study, researchers found that UCLA Activity Score results showed continuous improvement through the 6-month time frame. Patients may have shown additional increases in activity level after 6 months, however, insufficient data prevented analysis. The UCLA Activity Score median result did not significantly change from pre-operation to 1 month. This finding was different from Judd et al. (2014a), who found that the UCLA Activity Score significantly decreased from pre-operation to 1 month. Dale et al. (n.d.) found significant improvements in the UCLA Activity Score at this time frame. The results in this study could be partially explained by effective preoperative education and postoperative intervention that prevented a decrease in reported activity levels. These results could also be explained by patients lower activity levels at pre-operation due to pain or other self-limitations, and continued low levels of activity at 1 month post-operation due to prescribed postoperative restrictions. The UCLA Activity Score indicates overall activity level of the patient, which may or may not reflect hip or knee OA symptoms. Therefore, postoperative scores could also be explained by patients having a sedentary lifestyle, rather than functional limitations. Of the total sample, 97.9 percent were overweight or obese, with a mean body mass index (BMI) of 32.35 THA AND TKA OUTCOMES 25 kg/m2. This is a similar finding to Harding et al. (2014), whose patients had an average BMI of 31.10 kg/m2. Both of these BMI means are classified as obese, which could impact ones OA symptoms as well as participation. Preoperative and 1-month scores showed a median of 4.00, which is defined as Regularly participate in mild activities, such as walking, limited housework, and limited shopping" (Zahiri, 1998, p. 891). The median score at the 3-month (5.03) to 6-month (6.00) time frame on the UCLA Activity Score showed a continued increase in activity compared to the preoperative score. However, the 6-month time frame only included patients who underwent TKA. This is important for future patients and practitioners to consider because evidence supports that activity levels can improve after THA and TKA. For example, Harding et al. (2014) found that the UCLA Activity Score significantly improved from baseline to 6 months postoperatively for THA and TKA. Andrawis et al. (2015) also found improvements in the UCLA Activity Score from pre-operation to post-operation at 6- and 12-month time frames for THA and TKA. Limitations The researchers analyzed the data that healthcare providers in the organization were able to collect. The study had a small sample size due to incomplete data in the majority of patient charts. Researchers were informed that reasons for missing data included: outcome tool incompletion, patients not returning for appointments, patients leaving item 22 (sexual activity) of the SMFA unanswered, and inconsistencies in distribution or collection of outcome tool by the hospital staff. THA AND TKA OUTCOMES 26 The SMFA scores were calculated and entered into the computer manually; this could have led to human error in reporting scores. Although data were entered by pairs of researchers to reduce chance of human error, the possibility of error remains. Another limitation is that due to de-identified data, researchers were unaware of how many of the patients had more than one joint replacement. With varying time frames between the replacements, scores may have been influenced by patients still recuperating after one joint replacement at the same time they were undergoing a second replacement. Recommendations A larger sample of patients who undergo elective, primary THA or TKA is recommended to improve generalizability. Implementation of an electronic method that reduces data input and handling errors, and permits easier access for patients to complete the UCLA Activity Score and SMFA may yield complete data for more patients. An electronic method of data input and calculation would lessen the administrative burden for outcome tool completion and interpretation. Additionally, the sample size of patients who underwent THA only includes the anterior approach. It is recommended for future research to analyze outcomes of patients with anterior and posterior approaches for THA in facilities where both procedures are performed routinely. It is also recommended for researchers to utilize a longer follow-up time frame in the study design. The UCLA Activity Score and SMFA scores, except for the arm/hand subcategory, showed continued improvement at the 6-month time frame for TKA; gathering data past the 6-month time frame for THA and TKA could show more accurate levels of function and activity post-operation. The retrospective design does not allow researchers to explain why patients improved in the UCLA Activity Score and SMFA scores. Future research could include THA AND TKA OUTCOMES 27 established benchmarks found in this study to evaluate interventions and determine reasons for improvements in the UCLA Activity Score and SMFA scores for THA and TKA in this facility. A grind test of the first CMC joint is recommended for any future study in which postTHA/TKA patient function is measured. Use of mobility devices with, and increased reliance on, arms and hands prior to and after lower extremity joint replacement, may exacerbate CMC OA. Therefore, this test should be performed at more than one time frame to accurately determine if patient activity levels are affected due to increased use of arms and hands, rather than limitations in physical activity being attributed to the operative extremity. Patients who may benefit from conservative management of OA in the hand could be identified and educated in OT services for this condition. A grind test at the first CMC joint has been shown to have high specificity and moderate sensitivity for identifying OA (Merritt et al., 2010). Conclusion THA and TKA influence multiple areas of occupational performance, as well as nonoperative areas of the body. Using outcome measures that reflect many areas of patient function, including occupational performance, emotional status, and QOL, is important for researchers and OT practitioners to consider when assessing the impact THA and TKA have on patients. OT practitioners should be aware of a potential impact on nonoperative areas such as hand function for patients before and after THA and TKA, as OA generally affects multiple areas of the body. Researchers can use the SMFA and UCLA Activity Score to measure outcomes for THA or TKA that address occupational performance beyond lower extremity function. THA AND TKA OUTCOMES 28 References Allen, K. D. & Golightly, Y. M. (2015). Epidemiology of osteoarthritis: State of the evidence. Current Opinion in Rheumatology, 27(3), 276-283. doi: 10.1097/BOR.0000000000000161 American Association of Hip and Knee Surgeons. (n.d.). Total hip replacement. Retrieved from http://www.aahks.org/care-for-hips-and-knees/do-i-need-a-joint-replacement/total-hipreplacement/ American Occupational Therapy Association. (2011). Definition of occupational therapy practice of the AOTA model practice act. Retrieved from https://www.aota.org//media/Corporate/Files/Advocacy/State/Resources/PracticeAct/Model%20Definition%20 of%20OT%20Practice%20%20Adopted%2041411.ashx American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain & process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Andrawis, J., Akhavan, S., Chan, V., Lehil, M., Pong, D., & Bozic, K. (2015). Higher preoperative patient activation associated with better patient-reported outcomes after total joint arthroplasty. Clinical Orthopaedics and Related Research, 473(8), 2688-2697. doi:10.1007/s11999-015-4247-4 Dailiana, Z. H., Papakostidou, I., Varitimidis, S., Liaropoulos, L., Zintzaras, E., Karachalios, T., Malizos, K. (2015). Patient-reported quality of life after primary major joint arthroplasty: A prospective comparison of hip and knee arthroplasty. BMC Musculoskeletal Disorders, 16(366), 1-8. doi: 10.1186/s12891-015-0814-9 THA AND TKA OUTCOMES 29 Dale, L., Cooley, M., Hickman, A., Lecher, C., Lockhart, K., Mauk, E., & Slayback, K. (2015). Outcomes after occupational therapy and physical therapy interventions for patients after a total knee or total hip arthroplasty. Unpublished manuscript, Department of Occupational Therapy, University of Indianapolis, Indianapolis, Indiana. Davison, M. J., Ioannidis, G., Maly, M. R., Adachi, J. D., & Beattie, K. A. (2014). Intermittent and constant pain and physical function or performance in men and women with knee osteoarthritis: Data from the osteoarthritis initiative. Clinical Rheumatology, 35(2). doi: 10.1007/s10067-014-2810-0 Engelberg, R. (1996). Musculoskeletal function assessment instrument: Criterion and construct validity. The Journal of Orthopaedic Research, 14(2), 182-192. doi: 10.1002/jor.1100140204 Fujita, K., Xia, Z., Liu, X., Mawatari, M., & Makimoto, K. (2014). Lifestyle and health-related quality of life in Asian patients with total hip arthroplasties. Nursing & Health Sciences, 16(3), 365-372 8p. doi:10.1111/nhs.12114 George, L. K., Hu, L., & Sloan, F. A. (2014). The effects of total knee arthroplasty on physical functioning and health among the under age 65 population. Value in Health, 17(5), 605610. doi: 10.1016/j.jval.2014.04.004 Harding, P., Holland, A., Delany, C., & Hinman, R. (2014). Do activity levels increase after total hip and knee arthroplasty? Clinical Orthopaedics and Related Research, 472(5), 1502-1511. doi:10.1007/s11999-013-3427-3 Heiberg, K. E., Ekeland, A., & Mengshoel, A. M. (2013). Functional improvements desired by patients before and in the first year after total hip arthroplasty. BMC Musculoskeletal Disorders, 14(1), 1-8. doi:10.1186/1471-2474-14-243 THA AND TKA OUTCOMES 30 Herbold, J. A., Bonistall, K., Blackburn, M., Agolli, J., Gaston, S., Gross, C., & ... Babyar, S. (2014). Randomized controlled trial of the effectiveness of continuous passive motion after total knee replacement. Archives of Physical Medicine & Rehabilitation, 95(7), 1240-1245. doi:10.1016/j.apmr.2014.03.012 Huber, E. O., Roos, E. W., Meichtry, A., de Bie, R. A., & Bischoff-Ferrari, H. A. (2015). Effect of preoperative neuromuscular training (NEMEX-TJR) on functional outcomes after total knee replacement: An assessor-blind randomized controlled trial. BMC Musculoskeletal Disorders, 16(101), 1-14. doi: 10.1186/s12891-015-0556-8 Judd, D. L., Dennis, D. A., Thomas, A. C., Wolfe, P., Dayton, M. R., & Stevens-Lapsley, J. E. (2014a). Muscle strength and functional recovery during the first year after THA. Clinical Orthopaedics and Related Research, 472(2), 654-664. doi:10.1007/s11999-0133136-y Judd, D. L., Thomas, A. C., Dayton, M. R., & Stevens-Lapsley, J. E. (2014b). Strength and functional deficits in individuals with hip osteoarthritis compared to healthy, older adults. Disability & Rehabilitation, 36(4), 307-312. doi: 10.3109/09638288.2013.790491 Keurentjes, J. C., Fiocco, M., So-Osman, C., Onstenk, R., Koopman-Van Gemert, A. M., Pll, R. G., & ... Nelissen, R. G. (2013). Patients with severe radiographic osteoarthritis have a better prognosis in physical functioning after hip and knee replacement: A cohort-study. Plos One, 8(4), e59500. doi:10.1371/journal.pone.0059500 Lavernia, C. J., & Villa, J. M. (2016). High rates of interest in sex in patients with hip arthritis. Clinical Orthopaedics and Related Research, 474(2), 293-299. doi:10.1007/s11999-0154421-8. Mandzuk, L. L., McMillan, D. E., & Bohm, E. R. (2015). A longitudinal study of quality of THA AND TKA OUTCOMES 31 life and functional status in total hip and total knee replacement patients. International Journal of Orthopaedic and Trauma Nursing, 19(2), 102-113. doi:10.1016/j.ijotn.2014.07.001 Maradit-Kremers, H., Crowson, C., Larson, D., Jiranek, W., & Berry, D. (2014). First nationwide prevalence study of hip and knee arthroplasty shows 7.2 million Americans living with implants. Retrieved from http://www.mayoclinic.org/medical-professionals/clinical-updates/orthopedicsurgery/study-hip-knee-arthroplasty-shows-7-2-million-americans-living-with-implants Martin, G. M., Thornhill, T. S., & Katz J. N. (2015). Total knee arthroplasty. Retrieved from http://www.uptodate.com/contents/total-knee-arthroplasty Maxwell, J., Keysor, J., Niu, J., Singh, J., Wise, B., Frey-Law, L., & Felson, D. (2013). Participation following knee replacement: The MOST cohort study. Physical Therapy, 93(11), 1467-1474. doi: 10.2522/ptj.20130109 Merritt, M. M., Roddey, T. S., Costello, C., & Olson, S. (2010). Diagnostic value of clinical grind test for carpometacarpal osteoarthritis of the thumb. Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists, 23(3), 261-267. doi:10.1016/j.jht.2010.02.001 Monticone, M., Ambrosini, E., Rocca, B., Lorenzon, C., Ferrante, S., & Zatti, G. (2014). Task-oriented exercises and early full weight-bearing contribute to improving disability after total hip replacement: A randomized controlled trial. Clinical Rehabilitation, 28(7), 658-668. doi:10.1177/0269215513519342 Naal, F. D., Impellizzeri, F. M., & Leunig, M. (2009). Which is the best activity rating scale THA AND TKA OUTCOMES 32 for patients undergoing total joint arthroplasty? Clinical Orthopedics and Related Research, 467(4), 958-965. doi: 10.1007/s11999-008-0358-5 Patel, A., Pavlou, G., Mjica-Mota, R. E., & Toms, A. D. (2015). The epidemiology of revision total knee and hip arthroplasty in England and Wales: A comparative analysis with projections for the United States. The Bone Joint Journal, 97(B), 1076-1081. doi: 10.1302/0301-620X.97B8.35170 Peter, W. F., Dekker, J., Tilbury, C., Tordoir, R. L., Verdegaal, S. H. M., Onstenk, R., & Vlieland, T. P. M. V. (2015). The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty. Rheumatology International, 35, 1233-1241. doi: 10.1007/s00296-015-3211-7 Poortinga, S., van den Akker-Scheek, I., Bulstra, S. K., Stewart, R. E., & Stevens, M. (2014). Preoperative physical activity level has no relationship to the degree of recovery one year after primary total hip or knee arthroplasty: A cohort study. Plos ONE, 9(12), 1-9. doi:10.1371/journal.pone.0115559 Reicherter, A. (2017). Physical therapists guide to total knee replacement (arthroplasty). Retrieved from http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=aba13452-8eec4fcb-adb8-53e3a5456e3f Sathe, P. (2013). Physical therapists guide to total hip replacement (arthroplasty). Retrieved from http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=1f495c5a08cc-4e59-9fdd-8640fc2c0 Schotanus, M. M., Bemelmans, Y. L., Grimm, B., Heyligers, I. C., & Kort, N. P. (2016). THA AND TKA OUTCOMES 33 Physical activity after outpatient surgery and enhanced recovery for total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 25(11), 3366-3371. doi: 10.1007/s00167-016-4256-1 Simmons, L., & Smith, T. (2013). Effectiveness of pre-operative physiotherapy-based programmes on outcomes following total knee arthroplasty: A systematic review and meta-analysis. Physical Therapy Reviews, 18(1), 1-10 10p. doi:10.1179/1743288X12Y.0000000035 Singh, J. A., & Lewallen, D. G. (2013a). Patient-level improvements in activities of daily living and pain after total hip arthroplasty: Data from a large U.S. institutional registry. Rheumatology, 52(6), 1109-1118. doi: 10.1093/rheumatology/kes416 Singh, J. A., & Lewallen, D. G. (2013b). Patient-level improvements in pain and activities of daily living after total knee arthroplasty. Rheumatology, 53(2), 313-320. doi: 10.1093/rheumatology/ket325 Stergiou-Kita, M., & Grigorovich, A. (2014). Community reintegration following a total joint replacement: A pilot study. Musculoskeletal Care, 12(2), 103-113. doi:10.1002/msc.1065 Swiontkowski, M. F., Engelberg, R., Martin, D. P., & Agel, J. (1999). Short musculoskeletal function assessment questionnaire: Validity, reliability, and responsiveness. The Journal of Bone and Joint Surgery, 8, 1245-60. Terwee, C. B., Bouwmeester, W., van Elsland, S. L. de Vet, H. C. W., & Dekker, J. (2011). Instruments to assess physical activity in patients with osteoarthritis of the hip or knee: A systematic review of measurement properties. Osteoarthritis and Cartilage, 19(6), 620-633. doi:10.1016/j.joca.2011.01.002 THA AND TKA OUTCOMES 34 Umpierres, C. S., Ribeiro, T. A., Marchisio, . E., Galvo, L., Borges, . K., de Souza Macedo, C. A., & Galia, C. R. (2014). Rehabilitation following total hip arthroplasty evaluation over short follow-up time: Randomized clinical trial. Journal of Rehabilitation Research & Development, 51(10), 1567-1578. doi:10.1682/JRRD.2014.05.0132 Wimmer, M. A., Nechtow, W., Schwenke, T., & Moisio, K. C. (2015). Knee flexion and daily activities in patients following total knee replacement: A comparison with ISO standard 14243. BioMed Research International, 2015, 1-7. doi: 10.1155/2015/157541 Yan, K., & Pagoda, T. (2013). Orthopaedic patient outcomes following interdisciplinary inpatient rehabilitation. International Journal of Therapy and Rehabilitation, 20(7), 361366. doi: 10.12968/ijtr.2013.20.7.361 Zahiri, C. A., Schmalzried, T. P., Szuszczewicz, E. S., & Amstutz, H. C. (1998). Assessing activity in joint replacement patients. The Journal of Arthroplasty, 13(8), 890-895. THA AND TKA OUTCOMES 35 Table 1 Demographic Characteristics Characteristic M (n = 48) SD Age 63.81 10.11 BMI 32.35 6.15 Frequency (n = 48) % Male 21 43.8 Female 27 56.3 THA 27 56.3 TKA 21 43.8 Both positive 4 8.3 Left positive 2 4.2 Right positive 4 8.3 Both negative 27 56.3 Missing 11 22.9 Normal (18.5-29.4 kg) 1 2.1 Overweight (25-29.9 kg) 18 37.5 Obese (30 kg and over) 29 60.4 Characteristic Sex Diagnosis 1st CMC Grind Test BMI Note. BMI = body mass index. THA AND TKA OUTCOMES 36 Table 2 Results Time Frame Pre-op to 1-month 1-month to 3-month 3-month to 6-month M difference (SD) p M difference (SD) p M difference (SD) p SMFA total 9.02 (13.35) .00* 6.09 (9.61) .00* 1.65 (7.75) .34 Mobility 18.81(17.78) .00* 2.78 (11.27) .09 3.84 (8.81) .06 Arm/hand 3.32 (8.11) .01* .70 (4.28) .26 -3.03 (8.03) .10 ADL 1.67 (19.46) .56 14.85 (19.08) .00* 2.48 (15.81) .48 Emotional 12.69 (15.89) .00* 2.49 .19 3.23 .23 .33 .19 1.04 .00* .57 .08 UCLA * p < .05 THA AND TKA OUTCOMES Figure 1. SMFA scores compared to established normative values; higher scores reflect greater disability. 37 THA AND TKA OUTCOMES 38 Table 3 SMFA Results Compared to the Normative Values SMFA Normative M (n = 48) Values Total SMFA Significance (p < .05) Pre-op 30.85 12.70 .00* 1-month 21.83 12.70 .00* 3-month 15.74 12.70 .11 6-month 13.02 12.70 .91 Pre-op 43.69 13.61 .00* 1-month 24.89 13.61 .00* 3-month 22.11 13.61 .00* 6-month 17.73 13.61 .20 Pre-op 7.00 6.02 .42 1-month 3.65 6.02 .02* 3-month 2.95 6.02 .00* 6-month 5.60 6.02 .87 Pre-op 32.32 11.85 .00* 1-month 30.65 11.85 .00* 3-month 15.8 11.85 .17 6-month 13.53 11.85 .70 Pre-op 39.85 20.54 .00* 1-month 27.16 20.54 .00* 3-month 24.67 20.54 .09 6-month 21.09 20.54 .88 Mobility Arm/Hand ADL Emotional * p < .05 THA AND TKA OUTCOMES Figure 2. Median UCLA scores. 39  ...

... McCormick 1 THROUGH SPACE: A SHORT STORY COLLECTION ABOUT FAMILY DYNAMICS AFTER THE APOCALYPSE By Dani McCormick An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Kevin McKelvey. 27 March 2016 Approved by: _______________________________________________________________________ Kevin McKelvey, Faculty Advisor _______________________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College _______________________________________________________________________ First Reader _______________________________________________________________________ Second Reader McCormick 2 Abstract To try to present the topic of family dysfunction in a new light, families dealing with death, addiction, sickness, cheating, and divorce were written into a fictional postapocalyptic world. This suspension of reality revealed the usual dysfunctions in a new light and so made them interesting again. The collection of short stories created contains interrelated stories that each individually followed a character through a pivotal moment in their life. During the collections creation the author learned about the writing process extolled in multiple craft books as well as what worked best for herself. The finished product could be submitted as a collection or as individual stories to literary journals and competitions for publication. 2 McCormick 3 Table of Contents Cover Page i Abstract ii Statement of Purpose 1 Introduction 3 Method 5 Conclusion 23 Reflection 27 Works Referenced 31 Appendices 32 Appendix A: Product Produced 32 Earthshock 32 Apanthropy 41 Radiate 58 Shadow Dances 68 Cygnet Song 93 3 McCormick 4 Statement of Purpose Using three stories that were already drafted and two that would be written for the project, I endeavored to recreate familiar family dysfunction in a short story collection set in a post-apocalyptic Chicago. The stories (Appendix A) follow five characters through pivotal moments of their lives that lead to the potential dissolution of their families. The foci of the stories are illness, death, addiction, infidelity, and divorce, which translates into the focus of the collection as a whole, or how the aforementioned problems affect the families and the character reactions in the stories. By setting familiar stories, like those of family dysfunction, in an unfamiliar setting I was hoping to reenergize archetypal stories and make them more interesting. To open readers eyes to the problems in the world around them, I placed my stories in a distant future world. As a culture, we have been desensitized to too much of the violence, death, poverty, and pain around us because it is so common in our world. By putting my characters in positions that highlight the problems facing our own culture, I hope to give my readers a new way of looking at the various problems and give them the tools to make their own decisions about the causes and effects. While each story has a specific family dysfunction at its core, I included other important issues in the world of the collection as well like feminism, poverty, and classism to name a few, which I discuss in the Method section. No event exists in isolation so it was important to create an entire 4 McCormick 5 cohesive world behind the five stories in my collection including societal upheaval and negative cultural histories. The purpose of the short story collection as a whole was to make a social commentary on the world we live in while also creating something representative of myself as an author. When finished, the collection was ready to be submitted to chapbook competitions, publishing houses, as well as submitting the individual stories to literary magazines for publication. The individual stories were harder to place in literary magazines due to their length, but at the time of this writing, I was still on the hunt for a proper home for them. The collection, however, will be submitted to Dzanc Books Short Story Collection Competition, Iowa Presss John Simmons Short Fiction Award competition, and Black River Chapbook Competition when their submissions open for the 2016 editions. 5 McCormick 6 Introduction Growing up, I devoured books. The person I knew the best in my elementary school was my librarian, Mrs. Oakes. She, along with my teachers, encouraged a voracious appetite for the written word that carried me along through high school and directly into an English degree in college. I read everything from the Magic Treehouse series to Watership Down to The Diary of a Young Girl. Through all my reading, though I found that not all books were interesting, just like not all stories were interesting. I gravitated towards books of the surreal, the fantastical, the imaginative. In college, I learned that was called speculative fiction, but at the time all I knew was that this type of book could take me places I had never been to experience things I could never have experienced in the comfort of middle class suburbia. I began reading authors like Garth Nix and Scott Westerfield, leaving behind Sarah Dessen, whose large sans serif covers called out for girls like me. I denied the romance hiding within the pages of the girl books as my male classmates called them, and instead dove headfirst into adventure. Looking back, I now realize that this early predilection for fantasy and science fiction over realism formed the fiction I would write. I have wanted to be an author since the third grade when, for a class assignment, I concocted my first book, complete with pictures, about a unicorn and a chess board. Creating a world and a plot for my fellow classmates to read filled me with such joy that I decided right then and there to renounce my goal of becoming a doctor in favor of a future in the literary arts. In all honesty, this really was the best choice, I found in high school that I didnt react well to blood and that fictional blood was much less bothersome. 6 McCormick 7 When deciding on my honors project, I toyed around with a few different ideas that would utilize what I had learned in my majors, Creative Writing and Professional Writing, as well as my minors and honors college to the greatest advantage. I began with a service project with the Garfield Park Farmers Market, but decided that did not apply to my majors so much as it did my general passions, and reconsidered. I ended up writing a short story collection of interrelated stories because I had already written two stories to be included in the collection and thoroughly enjoyed the idea of intermingling storylines and characters. The post-apocalyptic setting began as a way of distancing myself from a story whose elements I was using, I am the Messenger by Markus Zusak. Though written completely realistically, and therefore not in my preferred genre, it had compelling characters that I wanted to try to emulate. To prevent myself from stealing completely from Zusak, I changed the world around the character into a post-apocalyptic version of the city I knew best, Chicago. I suppose it could be said that my catalyst into post-apocalyptic fiction began with the rise of dystopian young adult novels. I was spellbound by Uglies by Scott Westerfield when it debuted, and subsequently stunned by The Hunger Games, Maze Runner, The City of Ember, and many others. The characters, mostly strong females, always surprised me with their ingenuity and bravery, but also with how they dealt with the crumbling societies around them. Post-apocalyptic fiction taught me to question the world that people before me built and remember that it had faults like the seemingly perfect societies in the books. I began to see social issues through the lenses of my favorite novels and learned about compassion and social justice through the characters. My view 7 McCormick 8 of the world was formed through the broken eyes of the narrators but I learned more from them than any teacher could have taught me in class. Since then, I have always viewed reading, and fiction in particular, as a vehicle for social commentary and social change, which was, in part, why I wanted to write a short story collection for my project instead of doing a more academic but possibly less impactful research study or public action project. To make my collection accomplish my social justice goals, I read many different books by a variety of authors to see how they empowered their short stories and novels with the ability to challenge their readers. Since my stories were interrelated, I thought it important to read authors that successfully wrote interrelated short story collections, such as Tim OBriens The Things They Carried and Cathy Days Circus in Winter, who exemplify the format of a novel-in-short-stories, as it has come to be known. I also read other science fiction novels, like Oryx and Crake by Margaret Atwood, which is a postapocalyptic novel as well, and The Martian Chronicles by Ray Bradbury. To help with revision, books on craft like The Art of Fiction: Notes for Young Writers by John Gardner and Jerome Sterns Making Shapely Fiction helped me identify areas that needed rewritten. All of the books affected my writing in different ways because, besides being written by authors of different ages and genders, which does affect their viewpoints somewhat, they all have different ways of viewing the short story as a vehicle for social commentary, or even simply a way of producing emotion in the reader. The differing views made them all instrumental in constructing a well-integrated short story collection that accomplished my goal of providing a social commentary on family dysfunction. 8 McCormick 9 I can submit the completed short story collection to publishers whole, or edit it into a shorter collection for chapbook competitions. My advisor, Kevin McKelvey, helped me edit my book and create a publishable finished document. 9 McCormick 10 Method I began my project with three short stories that I had already written in previous fiction workshop classes with Professor Sal Pane. During one of his classes during my sophomore year Professor Pane brought in a list of writing prompts that he thought would help I and the other students through a problem we were having as a class. None of us seemed to be able to form coherent, three-dimensional characters that were believable and could carry a story. The prompt led us through a series of questions to create a character that was more than just a tool to push the plot of the stories along. We were tasked with imagining what the character looked like in detail: eyes, skin color, hand shape, hair length, scars, etc. Then we were directed to give them a job and imagine a usual day in the life of their job. I had just read I Am the Messenger by Markus Zusak which was about a taxi driver and thought that a job as a taxi driver could lead to many interesting stories. Originally, I was thinking my character could be a window into the lives of the people he gave rides to, but then the third leg of the prompt was given. I had to create a backstory for my character. I usually get bored when I read stories that are too realistic so I decided that the backstory of my character should be post-apocalyptic without venturing too far from what I knew. He lived in Chicago, a city I know well, with a flirty sister, a quiet and weak-willed mother, and a father with thyroid cancer, something for which I have a family predisposition and a generous amount of knowledge. 10 McCormick 11 Combining these, I created a new world and new scenarios without leaving my realm of knowledge. I wrote the first story in my collection from the prompt Professor Pane gave in class that day. The first draft was just about a son trying to hold together his family as his father died of cancer. I submitted it for workshop and got many critiques from my classmates and professor for how to make the short story more publishable. I applied those critiques and came out with a story I loved. When we were given a prompt the next semester in a different fiction workshop class with Professor Pane, I was given the chance to work with that character again. The prompt was supposed to help the revision process by fleshing out the world around the characters. We were directed to take a secondary character from one of our stories and write their backstory. I chose the best friend of the main character of the story I had written the semester before, March. He ended up with an addict mother, missing father, and terminally ill brother. His story followed his discovery of his mothers addiction through her selling his brothers medicine for drugs to a finale of her death where he wrestles with the idea of being the sole caretaker of his little brother. I submitted this story to workshop in class as well and got great feedback, which solidified my desire to keep writing stories in this world. I realized two things while writing the second story: that I really enjoyed writing stories in the post-apocalyptic Chicago I had created, and that my stories seemed to be fixated on family dysfunctions and how people deal with different dysfunctions in different ways. I wrote a third story to test the world and see if it really could carry multiple stories without breaking down or becoming melodramatic by writing a story 11 McCormick 12 about the sister from the first story, Sali. To enlarge the world and give her somewhere new to explore, I built a new culture on a different planet. I decided that, since she was so close to the subject of the first story, if I had placed her in Chicago I would have ended up with a rewritten version of the first story only from a female perspective instead. While having a separate perspective of the events of the first story could have been interesting, I decided that it was time to broaden the horizons of my world and created life on other planets. Placing Sali on Venus gave me the chance to create a culture completely different from what I know as well, which tested both my skill as a writer, and my skill as a researcher. I tried to create a culture that was unlike any on Earth while still having an obviously negative view of misogyny. The Venusian culture I created centers around the idea that women are second class citizens whose only value is in their marriageability. Female babies are married off to male toddlers as soon as possible and given to the husbands parents to raise where they are brought up with the knowledge of exactly how they are expected to behave and what their husband likes in every aspect of his life. If the parents cannot marry a female baby off, she joins the ranks of the Unmarrieds, a caste of women without husbands that work as secretaries, ticket salesmen, and various other jobs that the Venusian men find demeaning. While this would have been misogynistic enough for my story, I decided to add in one more layer, which was, incidentally, also how Sali got access to this very exclusive Venusian world. Infidelity on Venus is not a sin; it isnt even frowned upon, as long as the one committing it is male. Men are allowed to cheat all they want as long as their wives bear their children. Women, on the other hand, are not 12 McCormick 13 allowed to cheat simply because how would the husband know it was their child afterwards? So, if a man is unfaithful, it cannot be with another mans wife; it must be with an Unmarried woman, or a foreigner. Sali is the foreign mistress who doesnt realize her lover is married and Yely is the Venusian wife who tragically loves her husband though he doesnt return her affection. This set up enabled me to examine not only the relationship between husband and wife, but also husband and mistress and mistress and wife. I used the last relationship to invert the power dynamics present in the Venusian culture to give the power back to Yely and Sali, who use it to plan an escape from the misogyny around them. I submitted this story to a class second semester of last year and received good feedback that made me sure that the post-apocalyptic Chicago collection was what I wanted to do for my honors project. I decided that there were really two more stories that needed written before I could really call the collection completed. I needed to finish the storyline that had begun with Sali and Yely, and I needed to tell the story of Dilly, the dreamy little brother from the second story. In completing these two pieces, I felt that the loose ends would be wrapped up and my characters arcs would come gracefully to a close. While I do not allow any of my characters to have fairytale happy endings in a desire to keep some sense of realism to my dark and dismal world, the endings of each of their personal narratives carried finality and a sense of conclusion that I believe put to rest any questions the readers might have had throughout the stories. The project started with a substantial reading list which I pared down to a cursory reading of the post-apocalyptic books I loved in high school, as well as an in-depth 13 McCormick 14 reading and analysis of two books each of interconnected short story collections similar to what I was creating, science fiction novels set in worlds similar to mine, and craft books would be helpful in the formation of the other two stories as well as the substantial revision needed in all five stories. The six books worked together to inform my writing in general concepts I would need to include as well as problems I would face along the way. I read the short story collections Circus in Winter by Cathy Day and The Things They Carried by Tim OBrien. Both were composed of interconnected short stories similar to the structure of my collection, however they were significantly different compared to each other as well as compared to my collection. The Things They Carried is a short story collection about the authors time in the Vietnam War, though the specific situations and characters are fictionalized. This was useful to me because I was taking situations from real life and putting them in a fictional world to see how the characters would react. Thought OBriens collection is not science fiction, it is very similar in format in that the stories themselves are character driven narratives. I paid special attention to how he referenced one event in a few of his stories. OBrien speaks multiple times about a situation in which he had to kill someone, a trauma that scarred him emotionally if not physically. This event is referenced in a couple stories before being explicitly explained about three-quarters of the way through the book. While my stories did not repeat the emotionally scarring parts of the narratives because they were told from multiple perspectives instead of one like OBriens, they did repeat scenes between the stories. I wanted to keep the emotion captured in individual stories, but to interlink them, I used The Things They Carried as a touchstone on how to 14 McCormick 15 have the same scene in multiple stories without it being repetitive or going stagnant. OBrien shows a different side of the scene, a moment where he shoots a Vietnamese boy, each time he writes about it, either using a different characters perspective or by telling part of the scene that was not mentioned in a prior description of the scene. One such scene in my collection was when three characters, Cal, Sali, and March, were playing war together as children. Following OBriens example, I briefly mentioned it in the stories of two of the characters as a passing memory to use as a connecting point but reveal the entire scene in the first story through Cal. This repetition also worked to stitch the stories together into a collection instead of leaving them as five individual stories that were arbitrarily put together. Cathy Days influence on my writing was much more structural than Tim OBriens was. Circus in Winter as a collection is formatted almost exactly like how I wanted my collection to be formatted. The biggest difference in her formatting and mine was that Circus in Winter was a book-length short story collection that encompasses almost all of the secondary characters involved in the circus central to the books narrative. My collection was only five stories and the central narrative of the series of stories was the family dysfunctions that are linked to the Thill family: Cal, and his sister Sali. Day explored the characters surrounding the circus as it progresses through time, showing the children growing up and the adults aging into grandparents. While my collection doesnt move through nearly as much time as Days, I paid close attention to her time markers between and during stories. For example, Jennie Dixianna, a story set up very similar to my opening story, has a nonlinear plot line that goes from present to 15 McCormick 16 past to present again, following Jennie, the main character, through a character development arc from emotional and sexual abuse by her father in the past through her revenge to her self-empowerment in the present of the story. Jennie then played a minor role in several of the other stories, showing up as a performer and a lover, similar to some of my secondary characters. In a way, reading Circus in Winter, though the story structures were similar to mine, was more of a clinic on how to advance my pieces through time without getting lost in a timeless void in the stories. Days handle on the dynamics of time in her collection and how her characters react to time passing and memories being referenced was instrumental in my own structuring of time in my collection. I tried to emulate her control of the passage of time, though on a smaller scale, with how my stories related to one another on a timeline, as well as how the timeline of my characters related to the timeline of the solar system as a whole with the macrohistorical events that had happened. Days iron solid understanding of when each event happened in relation to everything else led me to nail down my timeline and ensure that nothing was mistimed. Outside of the short story realm, I read two science fiction novels to see how other authors in the genre were creating worlds and how they worked. The first science fiction novel I read was The Martian Chronicles by Ray Bradbury, a very imaginative novel about a possible future where Earth has colonized Mars, because its subject matter is similar to mine in that it also deals with interplanetary travel and multiple cultures. In the book, interactions between Earthlings and Martians have become strained and the book examined the different ways that they reacted to each other which varied from violence to 16 McCormick 17 disease to acceptance. This novel, though longer than my chosen form, did an excellent job at one of the most difficult parts of writing fiction that is not realistic: creating a realistic setting. Settings require space, time, and culture and in Bradburys novel these things merged together seamlessly so that the reader never questioned the logic of the story or the reality of the world. I examined the setting in The Martian Chronicles so see how he expanded and defined the rules of his world and if I could apply that to the world I had already created in the previously written stories. By looking at the pieces of culture that Bradbury chose to change, like the physical appearance of the Martians versus the Earthlings, a reader could infer what issues are important to Bradbury. For example, he did not change the way people relate to each other, so it could be inferred that Bradbury was at least partially interested in interpersonal relationships. I used this theory to help highlight certain topics that I was concerned with in my stories, like the strife of the impoverished or the feminist battle against misogyny. The novel also progressed through time similar to Cathy Days collection only Bradbury accomplished this in one narrative instead of multiple. Watching how Bradbury negotiated the time dynamics was an interesting comparison to Days version in that Bradbury used a little more distance to allow him to adjust to time while Day was much closer to her subjects and accounted for the passing of time in the switching of stories. I decided that in my stories I should employ a mix of the two, using the Day technique to show the passage of time between stories, while using Bradburys slightly more distant narrative strategy to show the passage of time within individual stories. 17 McCormick 18 The other novel I read was by renowned post-apocalyptic novelist Margaret Atwood, Oryx and Crake. Oryx and Crake was a novel of science fiction, that was placed in a post-apocalyptic world not entirely unlike the world that my stories are set in. Margaret Atwood was an excellent creator of setting and character and I learned the most from her book by the way she weaved the two together to form a compelling story while also not neglecting plot. The character development of the main character, Snowman, followed the novels plot arc without distracting from the story of the world as a whole. Even reading as a writer and trying to analyze the way Atwood used different techniques in her work, I was extremely impressed by the story as a whole and how each part works to make the novel a well-tuned machine. I truly believed this story benefits best from a holistic reading which led me to the realization that I needed to edit my work at the end of the writing process so that not only would the stories be able to stand alone as short stories, but also have the cohesiveness necessary to work together as a connected connection. The central conceit of my collection was that the stories would be connected and placed in the same world and use some of the same characters. After reading Oryx and Crake, though, I realized that my collection should also work as a novel in itself, with a larger arc composed of the storylines pulled through all five stories. This was accomplished in revision when I reshuffled my stories to make the collections plot more cohesive, as I discuss later, and work through each piece to ensure that threads that appear in the first story are either tied up or carried through the other stories. The most difficult part of this revision was identifying what themes needed to be included in each 18 McCormick 19 story to prevent them from disappearing from the readers minds without taking over the other stories either. The last set of books I read were not in the same vein as the first four; they were craft books. I read The Art of Fiction: Notes on Craft for Young Writers by John Gardner and Making Shapely Fiction by Jerome Stern which was probably the most recommended craft book Ive encountered. In this seminal writing craft book, Gardner advocated the idea that fiction should be like a dream with nothing to wake one up from the dream. He claims that the biggest mistakes that young writers made was breaking the dream, or in other words doing something that popped the reader out of the story. He listed many different mistakes that could do this to the reader and I made sure to go through my stories with the list and a fine tooth comb to ensure that I had not made any of them in my writing. He denies the adage I was taught of write what you know, meaning write about people, places, and situations you know, and instead advocates writing the kind and type of story that you know the best, like what you enjoy reading and are most familiar with. His advocation for genre fiction supported the type of writing I did in my project which bridged the gap between genre fiction and literary fiction. He discussed plot as well in connection to genre and how a well formed plot could passively support or actively improve a story by making it work better within its own structure. I applied these three very different credos to my stories by ensuring that the world I created was complete and held up by the plot structures of my stories, writing them in science fiction, one of my favorite genres, and ensuring that nothing broke through the dream of the story with careful reading. 19 McCormick 20 The other craft book I read, Making Shapely Fiction by Jerome Stern, was a book detailing the different shapes plots and stories can take. The different story formats outlined in this book helped to restructure my stories to make them easier to read and flow better. My advisor actually helped Jessi, my revision partner, and I to identify different structures from the book that could be beneficial for each story. I revised them each multiple times to see if the new structures worked better than what I currently had as individual pieces as well as within the collection. In the end, I usually chose the structure the most similar to the one I began with, but experimenting with the different structures helped me better define my scenes and character reactions. Actually, rewriting the stories and experimenting with different plot shapes and structures helped me better understand how the stories all work together and how to better utilize the scene placement within the timelines as well as which archetypal scenes were missing from my pieces and which scenes were included too much. Making Shapely Fiction was also helpful because it had a glossary of terms and symbols as well as how they are usually used in literature of different forms. I used this to help me define my scenes and make sure they were not stereotypical while also ensuring that they were recognizable which gave readers something familiar to connect with. Sterns book was the most helpful in the revision process because I could link the themes, symbols, and shapes of my stories to how other authors had used them and how they operated within the larger literary canon. After the reading came the main action of my project, writing, which was not the most difficult part of the project. Before I could start revising and putting my stories into a collection, I had to draft the other two stories to complete my quota of five. I sketched 20 McCormick 21 out a couple stories for secondary characters from the three already-written stories to see which ones could form complex characters that would fit my goal for the project. I ended up choosing the wife of Salis lover and Marchs little brother from the initial sketches and had to then decide what direction I wanted to go with the collection as a whole as well as with the stories individually. After deciding that Yely, the wife, needed to liberate herself in her story and that Dilly, the brother, needed to die, whether in the story or outside of it, I wrote a rough draft of the stories. It took multiple tries to get it quite right. Originally, I had also written a third story about Salis lover and Yelys husband, but when I began writing, I realized that his story and Yelys story overlapped too much and could not reconcile the two as separate stories. Instead, I merged the two, eliminating the presence of Olli, the lover and husband, and combined the events into one larger story. I also had to toy around with Dillys death, figuring out how it should happen and whether or not it needed to be shown or not. I finally settled on a grim setting, a hospital in the middle of a broken city, with a lighter story, two children exploring their surroundings, which ended with the knowledge of Dillys death without dwelling on it. After the combination of the stories of Yely and Olli and the chosen death of Dilly, my five stories were written and ready to workshop with my workshopping partner, Jessica Tillman, and my faculty advisor Kevin McKelvey. During the first round of workshops, my partner and I both had very rough drafts to start with. We read through each others pieces and then met to offer suggestions for plot, character development, and story arrangement as well as story structure and plot holes. Professor McKelvey showed us his favorite way to revise which involved multiple 21 McCormick 22 colors of post-it notes as well as a rainbows worth of pen colors and scissors. After our round-table discussion, he sat us down with our stories spread out over multiple tables and we covered our stories with sticky notes. Different colors denoted different revisions needed: index-sized sticky notes meant a scene needed to be added, green meant motivation was lacking, blue signified that repetition was needed for theme or metaphor, pink showed a lack of interiority or reflection. Any notations in pen were minor revisions like grammar mistakes, misspellings, or spots where paragraphs needed rearranged. We were sent away from the workshop with many neon post-it revisions to make. We were still in the phase of revision where we were working on the individual stories, not the collection as a whole, so I did not need to worry as much about the overarching plotline of the collection yet. I started revising the first story I had written, Earth-shock, and moved through the revisions in chronological order of formation. Earth-shock had already been through numerous revisions as an individual story and so did not need that many edits in the first round. As the story that laid the groundwork for the rest of the collection, I needed to build the relationships shown more while also giving the rules of the world and the apocalypse that happened to create it. Since the story is in a non-linear format, adding in scenes that made sense to the plot was not hard. I added a scene about three of the main characters in the collection, Cal, March, and Sali, playing war as little kids which simultaneously gave me the chance to explain the Venusian War while also allowing me to characterize the three more and explain their relationship a little better. A similar effect was achieved in revising a scene already included in the story where Cal attends a Take Your Kid to Work Day with his father. I expanded the scene to show how 22 McCormick 23 Cal is being pressured into becoming the man of the family while also showing how unready he is to accept that role, even as an adult. The second story, Apanthropy, has a title that literally means an aversion to the company of men. I thought it an appropriate title since the basic plotline of the story entails two women abandoning their respective lover and husband to escape the confines of a patriarchal, misogynist culture. This story needed much more revision than the last one because it bleeds into the fourth story. The ending of this one was the beginning of the other. The hardest part of revision was separating the two into two distinct stories. I started by changing the main character, originally Sali, into Yely because while I was writing the story I noticed that the most symbols and metaphors fell on her. She had the most conflict in the story and the most to lose while Sali was really just transitioning from one phase of her life to the next. In making it Yelys story, though, there were a few scenes that I had to shift perspectives on or delete entirely. I also added a new ending to the second story so that the fourth story, Shadow Dances, which almost serves as a continuation of Apanthropy, could start smoother and include more motivation and interiority. Originally Apanthropy ended with Sali being arrested on the way to her childhood home and Yely forcibly returned to her husband. This did not work very well for the world I was trying to build as well as being rather boring and without motivation. Instead, I had Sali successfully take Yely home with her. Yely learned what it was like to be poor and chose to return to her husband instead of being forced there. This gave her a more complete transformation and character arc. 23 McCormick 24 Third, Radiate, also entered the project rather complete already. In my fiction workshop, my classmates voiced concerns about the ending, so I played around with various other endings, attempting to achieve the right balance of addiction and abandonment. Originally, the mother died of a drug related illness, leaving the two sons to figure out how to take care of each other in a world that seemed determined to bring them down. Instead, now the mom leaves the two to follow her addiction and March gives her an ultimatum of the drugs or the family. This worked better for the continuation of the brothers dynamics into the fifth story which centered around Dilly. I also had to change the way the family related to each other and to the world around them, specifically the drugs in the world by showing more of the mothers addiction before she got admitted to the hospital. Shadow Dances, a continuation of Apanthropy, originally was set from Yelys perspective but I changed it to be from Salis perspective instead because Yely had already dominated Apanthropy. Sali was established in the second story as the wandering soul of the pair, and since the story entails them traveling across the solar system, Sali seemed the logical focalizer for the story. I expanded the middle of the story and included more vignettes from their travels than I had in the original. Before, the two went to Jupiter on a social justice crusade, confronted Yelys ex-husband, and succeeded in helping the homeless of Marius, the capitol city of Jupiter. While the story was very satisfying as a writer with this turn of events, as a reader, it read as a cop out on what the reader could feel or what the characters could do at the end of the story. Instead, I took the husband out of the story all together and made it a story about the two women finding 24 McCormick 25 their power in a society that had disenfranchised them both in different ways. In the end, they do succeed in helping the homeless, but have more influence on the turn of events. Also, by lengthening the central travel sections, I could show the parts of the world I created that the middle and upper classes ignored, the underbelly where the poor and forgotten lived. While the point of the project is to highlight the things that can pull families apart, I also wanted to include more than that. Showing the darker parts of the civilization not only rounded out the world but also created new situations that my other characters had not been exposed to. I was also able to include some of my other social concerns through the vignettes like feminism, homelessness, poverty, and hunger. The last story, Cygnet Song, broke from the tone of the other stories because it followed two innocent children instead of a complicated, confused adult. A cygnet is a baby swan and, since the story serves as the two childrens swan song, the last thing they get to do before they die, I thought Cygnet Song to be an appropriate title. The story came to me pretty whole cloth after a little bit of floundering to find the proper setting for Dillys story. I only needed minimal story revisions like cutting one characters dialogue down to make him seem younger as well as masking some of the more overt metaphors so that they were not too strong. I seemed to want this to be a brother story and layered in so many different metaphors and symbols of brotherhood that it distracted from the actual story. I did not notice the heavy-handed symbolism until it was pointed out to me in workshop. After the first round of revisions, Jessi and I resubmitted our stories to each other and did another round of workshops in a twelve hour write-a-thon. Professor McKelvey 25 McCormick 26 brought us lunch and a large roll of paper. I claimed a fifteen-foot piece and taped it to the wall to layout my stories and my world. I began by outlining the stories scenes and then figuring out the chronology of the collection as a whole. Professor McKelvey and Jessi helped me identify the themes of the stories and gave me the assignment of making sure that each scene helped further the theme. For example, the theme of the third story is abandonment so it was important that each scene showed abandonment or gave context to abandonment. This led to some restructuring and scene additions or deletions to help tie together the themes. This theme threading also gave me a chance to look at my stories with a little more distance so that I could see how the five stories worked together as a collection on a macro scale. While outlining the stories, I also noticed that I had five stories and my last story had five scenes. Professor McKelvey mentioned that with a little bit of tweaking I could make my collection into a five story, five act structure and my last story could mirror the collections structure as a whole. Each scene in the fifth story takes place on a different floor of the hospital and I linked each to a previous story in the collection. Earthshock has a central theme of coming of age, which linked with the trauma and cancer center at the beginning of the story where Dilly takes control of his own care. Apanthropy links with the maternity ward because of Yelys youth. The addiction and psychiatric ward connects to Radiate and gives Dilly a reason to talk about his own mortality. The gritty underbelly of civilization shown in Shadow Dances rears its head again in the Free Clinic on the first floor of the hospital. The last act in Cygnet Song represents itself and 26 McCormick 27 takes place on the roof. The structural mirror works well to tie up the loose ends of the collection in the final story without leaving the reader with nothing left to ponder. Another great advancement on my project was the substantial world building I did. Probably half of my fifteen-foot paper was cultural and technical definitions of how the world worked. I began by writing down exactly what happened between Earth and Venus that led to the conflict and the War. Though most of the details do not actually make it into the stories, it was important that I knew what happened so that I could more accurately display the ramifications of it through my characters eyes. In short, Earth colonized Mars and turned it into an agricultural planet then moved on to colonize Venus. Due to the beauty and convenience of living on Venus, the upper class slowly immigrated there. The cultures of Venus and Earth grew apart until they were almost unrecognizably different. Finally, Venus wanted independence from Earth, which they considered to be a lower-class planet. Instead of using diplomacy, they declared war, wiping out the agricultural fields on Mars and targeting the nuclear reactors on Earth. This turned Mars into a desert wasteland again that was only really valuable for the minerals that could be mined. Earth became a broken world of urban wreckage and rural emptiness. Venus is secure in its position as the place to live in the solar system. I also worked out all of the kinks of the Venusian culture as it opposed its Earth counterpart. I had written it into the original version of Apanthropy in some detail but it came off too complex for a fiction story which, as John Gardner warns, popped the reader out of the story. I wanted to include some sort of feminist leaning in my story, but I 27 McCormick 28 thought it would be too much to have my characters talking about it overtly so I created a misogynistic culture for one of my characters to escape from as I mentioned earlier. The last thing that I figured out (which took the most time because I am moderately bad at math) was the travel times between the different planets and the different speeds of space vehicle that would be available to my characters. I ended up choosing scaled-up versions of the shuttles we have now: Ion A, Ion B, Shuttle, and Solar Sail. Since about one-thousand years has passed, I upgraded their speeds and attributed them each to a different type of vehicle. The Ion M is the fastest mode of transportation and replaces the sports car and luxury cars we have now and are reserved for upper-class people and car rental services. Other Ion cars, like J, K, or L, are slower and used by more middle-class people. An industrial ferry carries people and things across the asteroid belt and goes about the same speed as the shuttle between planets, which is significantly slower than the Ion cars and is based off of the speed of our manned space ships. The last option, a solar sail, is only a little slower than the Ion M but much more dangerous and unstable; I let the hippies drive it in Shadow Dances. I also laid out the roles of the different planets in the economy of the solar system as a whole. Since the planets really are not inhabitable past the asteroid belt, I made only Jupiter inhabited as a concession that technology will have advanced and it could be possible. Saturn, Uranus, and Neptune were all only used for mining for precious gasses. Jupiter had one metropolitan center, Marius, which was named after one of the astronomers that discovered Jupiters moons. Galileo was credited to discovering the moons so I gave Marius a little credit in the citys name. The city itself descended into 28 McCormick 29 the upper layers of Jupiters surface with layers of the city built one on top of another. The asteroid belt got mined as well for choice metals that are used to build the cloud colonies on Venus. A ferry carried the mined materials from the outer planets into the inner planets while Jupiter was in other parts of its orbit. When Jupiter was nearby, the ferry was converted into a passenger ferry. Mars was an agricultural planet before the War and devolved into a desert planet of mines afterwards. Earth was a wreck with no resources to speak of besides its housing capabilities. Venus was the rich suburbs of the solar system, where the wealthy lived and worked in colonies that were anchored to the ground but floated above the surface. Mercury was too hot to colonize and so was only used for emergency resources when necessary due to how much work it would take for a ship to stay on the planet and not melt. The final revision included all the larger bits that I hashed out in my workshop. I put in the backstory of the way the solar system worked as well as how the War came about. I hinted more at the way the Venusian world worked as well as the times needed for travel and the modes of transportation used. Most of my revision dealt with structural corrections and rearranging the scenes within the stories so that they better worked within the themes. Reshaping the stories was probably the hardest part of the revision because it meant changing the underlying form of my stories. Without sounding trite, the large revisions where I rearrange scenes and change the format of the stories almost hurts. This type of revision is necessary though if I want the collection to work as a whole as well as the individual stories to succeed on their own. These revisions are far harder to describe as the smaller ones but no less important. 29 McCormick 30 When the macro revisions were done, my collection was complete. I put it away for a few days and waited to clear my head of what I had been filling it with for weeks. I read through it and corrected any minor details that did not connect from one story to another while also checking for spelling and grammar mistakes. I was originally planning on laying out my collection in InDesign to create an actual book file, but found it superfluous when I discovered that most of the contests prefer to get their submissions in .doc or .docx format. 30 McCormick 31 Conclusion My completed project goal was to create a collection about the dissolution of families, but many people have written on that topic already. In order to attract and keep the attention of my readers, I decided that I would write my stories in an unrealistic, science fiction setting. The realm of science fiction is more accessible in novel form simply because of the difficulty of creating a believable world in a short format like the short stories in my collection. This difficulty is subverted by connecting my short stories together and therefore giving me the option of spreading my world building out amongst all five stories instead of trying to distill it all down into the first one. By creating a series of interconnected stories, I also open up the ability to look at my characters from multiple angles, showing more of them than I would otherwise be able to with one story per world. The characters have their own developmental arcs to follow that are separate from the plot arcs of the individual stories but since my characters exist in stories outside their own, they continue to develop past the end of their individual stories. For example, the main character of the first story, Cal, exists in every other story in various contexts. In his own story he goes through the death of his father and his familys reaction to it. In the second and fourth story, he is a protective son trying to keep his sister from breaking his mothers heart. The third and fifth stories paint him as a generous man helping his best friend through hard times. The reader gets to see many different sides of the same character from the different ways the other characters perceive him in their own stories. 31 McCormick 32 The structure of my collection follows a five act structure similar to Shakespeare and Greek dramas. Each story in the collection serves as an act with the final story, Cygnet Song, also having a five act structure itself with each act reflecting on the themes of one of the former stories as I mentioned in the Method section. For example, Radiate deals with addiction and the theme of abandonment. When Dilly and Zaba go to the psychiatric ward in Cygnet Song, they confront their own abandonment and reflect on the addiction and neurosis they are seeing in the patients around them. Putting the collection in a five act structure places it within a literary tradition and helps to ground my speculative, science fiction genre piece in more classical style. Doing this helps to ground the piece and keep a familiarity to it without discounting the postapocalyptic setting or futuristic world. The stories could be thematically analyzed individually as well. Earth-shock centered on Cal Thill, a driver of a car company that drove wealthy businessmen back and forth between the planets. His father contracted thyroid cancer and his family slowly dissolved after that with his sister leaving and his father dying. This storys overarching theme was coming-of-age. The form of family dissolution that it dealt with was illness. Though the main character himself was not sick, his father was, which fulfilled the goal of the project to show family dysfunction. Each scene showed a different coming-of-age test. Though the scenes were shuffled chronologically, the tests vary in strength until finally Cal was left alone with only his mother and was forced to claim the role as head of their family. The ending was left open so that the reader did not know at the end if he had passed or failed the test. 32 McCormick 33 The second story, Apanthropy, centers around a young womans escape or venture to freedom. Sali Thill, Cals little sister, realized her lover was married and left him, taking his wife with her. They venture to Earth where Sali and Yely, the wife, joined Salis family and Yely learned what it was to be in a loving family. She decided to return to her husband to lighten the burden on the Thills. The family dysfunction involved was very obviously cheating; the opening scene of the story was Yely listening to her husband cheat. Freedom was the thematic center of the story and each scene related to freedom in some way. Sali freed Yely from a husband who did not love her and then they both freed themselves from an oppressive culture by choosing to leave Venus, which was highly misogynistic. During the ride to Earth, Yely met people that are completely unlike anyone she had ever met, solidifying her freedom from the life she was used to. This gave her the ability to find her own true personality on Earth with Ceraline, Cal and Salis mother. By the end of the story, Yely has empowered herself to the point of enabling her to choose her own path. Guilt about being a burden on the Thills made Yely want to go back to Olli. After returning to her husband, she realized all of the freedom she had given up. The taste of freedom changed her and she could not simply return to a life of being disenfranchised. Radiate follows a nonlinear structure that highlights the theme and cycle of abandonment in one family. Cal Thills best friend from childhood, March, had a mother who was addicted to a Venusian version of heroin while his brother suffered from birth defects and health complications related to the War. This story, like Earth-shock, went back and forth through time, shuffling the chronology to display the elevation of 33 McCormick 34 abandonment throughout Marchs life. The dysfunction dealt with was addiction while the theme carried throughout the piece was abandonment. Each scene showed abandonment in Marchs life in various ways. His father abandoned him and his brother after his brother was born because of his illness. Shortly thereafter, his mother began doing drugs to dull the pain of his father leaving and the stress of having a permanently sick child. After his mother sold some of his little brothers medicine, March confronted her. She was clean for a little bit before slipping back into her old habits and disappearing. The brothers found her in the addiction ward of the hospital after being found in a drug house. March gave her an ultimatum: the drugs or her family. She chose the drugs and did not return to the family giving March the choice of whether he should abandon his brother as he had been abandoned or stay and take care of what was left of his family. The theme of abandonment is laced throughout all of the scenes and culminates in March having to choose whether to follow what happened in his life or if he should break the cycle and make the hard choice to stay with his brother. The theme of Shadow Dances was the hidden poverty or dark underbelly of the world. This story had a different structure than my other stories because instead of scenes that flow seamlessly into one another, it was comprised of smaller vignettes that encapsulate the multiplicity of scenes that occur in the story. The story followed the girls from Apanthropy, Sali and Yely, as they explored the solar system. They traveled from Earth to Jupiter where they spontaneously got involved with a grassroots social justice movement to help the homeless where Yely found a potential love interest in a fellow social justice warrior. Central to this story was the recurring theme of the dark underbelly 34 McCormick 35 of society. Each scene showed a different hidden piece of the world I created, from immigrant migrants to druggies to impoverished families to sex workers to homeless camps. They all showed a different side of a world of darkness and crime that underprivileged those without power whether it was in the form of money or influence. The final scene depicted the homeless of Marius triumphing over the rich in a social revolution. The symbolism was stark as the houses of the rich were short circuited in a planned attack and all go dark, switching the positions of power from the rich to the impoverished. The last story, Cygnet Song, was more complex thematically because since each act of the story was attached to each of the other stories, the acts had to perform double duty. The overall theme of Cygnet Song was consequences, both of the War and its effect on the social structure of the world as well as the actions of the other characters in the collection. Each act corresponded with a story, as discussed in the Method section, and carried hints of the respective stories themes as well. All this is to say that, though I wrote the stories for entertainment value and social commentary, no little effort went into making it critically acceptable as well. While many of my revisions worked on the readability and clarity of the stories and the collection, many more were dedicated to the symbols, metaphors, and themes of the stories and collection. In comparison to other short story collections of its kind, I believe that mine stands out as uniquely science fiction as well as being crafted by a young author. Though not of the same caliber as more established writers like Margaret Atwood, my collection shows quality and potential while also teaching me about my own writing process. 35 McCormick 36 Reflection When I began this project, I did not expect for creating the collection to be as intense as it was. I expected to write stories, revise them and submit them. I did not know how much work actually went into creating a story collection or the full-scale revision of a short story. The short story collections, books, and craft manuals that I read had a significant influence on my writing. During the project I solidified my creative process and the cycle of writing and revision that worked the best for me and my writing. Doing this project helped me not only identify what worked for me in my writing process, but also what did not. Some of the things that Professor McKelvey, my advisor, suggested as revision strategies did not fit my personal style for revision or creation, like using color coded post-it notes, but other strategies did. For example, my workshop partner and I both used fifteen foot pieces of paper to layout our stories and timelines. I also have to admit that I work better isolated from others where I can actually write instead of talking about writing. The cubicle chairs in the library worked well as an isolating barrier between me and the distracting outside world. This project really forced me to realize how much work actually goes into my chosen profession. Writing is much more difficult than I thought and takes more effort in the revision process than the drafting process. Looking back, I falsely believed that all writing sprang forth from the authors head fully formed and ready for publication. Any revision that occurred I believed to be minimal and cosmetic only, for grammar and 36 McCormick 37 spelling, not structure, character, and symbology. Instead, I came to realize that most of the writing process is actually revision, the least fun part of writing. The biggest thing I came to realize is something my professors have all but shouted in workshops but I never seemed to grasp until now. Each story has its own world with its own rules and its own history. Its my job as the author to be able to identify those rule and histories even if they never make it to the page. Writing is more off-page work than anything else. Planning, both of the story and the world containing the story, are almost more important than writing. Writing is really just getting something on the page to revise, but the before and after are what makes or breaks a writer. There are millions of people who take part in National Novel Writing Month but never do anything with their creations. They have the easy part down, the actual writing, but the revision and planning elude them. What this project taught me is that those things cannot and should not be avoided and are necessary steps in any writing process. I believe that the collection I produced is polished and complete enough to be ready for submission to chapbook contests and short story collection contests for publication. I also am looking forward to submitting the individual stories to literary journals to get them published on their own. 37 McCormick 38 Works Referenced Adams, Richard. Watership Down. New York: Macmillan, 1974. Print. Atwood, Margaret. Oryx and Crake: A Novel. New York: Nan A. Talese, 2003. Print. Bradbury, Ray. The Martian Chronicles. Garden City, NY: Doubleday, 1958. Print. Collins, Suzanne. The Hunger Games. New York: Scholastic, 2010. Print. Day, Cathy. The Circus in Winter. Orlando: Harcourt, 2004. Print. DuPrau, Jeanne. The City of Ember. New York: Random House, 2003. Print. Frank, Anne. Anne Frank: The Diary of a Young Girl. New York: Bantam, 1993. Print. Gardner, John. The Art of Fiction: Notes on Craft for Young Writers. New York: A. Knopf, 1984. Print. O'Brien, Tim. The Things They Carried: A Work of Fiction. New York: Broadway, 1998. Print. Stern, Jerome. Making Shapely Fiction. New York: Norton, 1991. Print. Westerfeld, Scott. Uglies. New York: Simon Pulse, 2005. Print. Zusak, Markus. I Am the Messenger. New York: Alfred A. Knopf, 2005. Print. 38 McCormick 39 Works Consulted Atwood, Margaret. The Handmaids Tale. Boston: Houghton Mifflin Company, 1986. Print. Link, Kelly. Magic for Beginners. Northhampton, MA: Small Beer, 2005. Print. Nutting, Alissa. Unclean Jobs for Women and Girls. Buffalo, NY: Starcherone, 2010. Print. 39 McCormick 40 Appendices Appendix A: Product Produced Earth-shock Cals dad had called him and his sister into the living room. The tarp still covered the hole where a stray piece of space shrapnel took out a part of their wall. They never quite made enough money to fix it. They worried more about buying food and paying for his dads medical bills. The doctors said there was something wrong with him, but they werent quite sure what. His dad stood in front of the tarp, his old sweater patched at the elbows and fraying at the hem. Brown reindeer danced on a background of faded maroon, and a yellow star hung dejectedly in the center of his dads chest. Sali sat next to Cal on the couch, waiting for whatever their dad wanted to say. She had told him that she thought they were finally moving off of this mess of a planet. Cal disagreed; if they couldnt pay to fix the wall, how could they afford a new place? His dad cleared his throat and both of their eyes riveted to his tired face. I have some bad news, he began, holding a folder in front of him. He had come home from the doctors earlier that afternoon clutching the folder. Cal picked him up in his car for the driving service he worked for after his shift ended. He asked his dad how 40 McCormick 41 the appointment went, but his pale face and wide eyes told Cal that it was nothing good. His dad had already shown the folder to his mom. They cried right there at the kitchen table. Sali had been out with one of her Venusian boyfriends. Cal didnt like them because they all flaunted their daddys money like it was something to be proud of even though they hadnt earned a dime of it. They always tipped horribly and filled Cals car with the blue vapor of their e-cigs. Im dying. His dad sighed. They found a cancer in my lymph nodes that hadnt shown up on the initial scans. Its too far along to stop. The radiation on those damn asteroids did it. He threw the folder on the coffee table and pulled off his old Cubs hat, fingering the holes along the brim, a single tear running down his face. He wasnt a man to cry, but death changes people. Cal froze. His dad had been indestructible. He worked on an asteroid mine blowing apart the smaller asteroids to get at the various precious metals in their cores. He was gone for weeks at a time and could handle giant flying pieces of rocks, but not a gland the size of a peanut. Sali began to cry, her shoulders shaking and the sobs echoing through the barren living room. Their dad sat down next to her and she leaned on him and cried into his shoulder. Cal didnt want to yell at Sali in front of their dying father, but he couldnt believe she was being this selfish when he was the one with cancer eating his endocrine system. He stormed out of the house through the flapping end of the tarp. He didnt know where he was going, but it had to be better than here. 41 McCormick 42 His mother found him at a little pocket park a couple blocks from their house. She walked up quietly to where he was sitting on the swings. He wanted to tell her not to worry about him and that he would take care of her but when he opened his mouth all that came out was a strangled sob. He choked it back and looked away from his mother who came up and held him against her. He looked down the street at all the broken terrestrial cars, their wheels popped and sagging. Thats what he felt like, a sagging wheel taxed with holding up a family. Its okay to cry, Cal. His mothers voice was soothing but it just made him feel like more of a child. He looked up at his mother. I will take care of you, he whispered. She had tears in his eyes and he hugged her back, repeating, I will take care of you. Cals best friend, March, worked in the radioactive waste fields. Sunflowers stood in tall rows of yellow, sucking the waste out of the soil. Marchs job was to harvest the plants for processing into cheap flour, sunflower seeds, or other foods for the underprivileged people who lived on Earth. It wasnt healthy or ethical, but it was affordable and everyone needed every penny they could save. Cal flew March to work every day. Cal could see Marchs shame when he dropped him off. March promised he would pay him back once Dilly, Marchs little brother, got better. I swear, man, once hes healthy, youll get your due. Okay, March, Cal would reply. March would give him a small smile. They both knew Dilly wouldnt get any better. 42 McCormick 43 Dilly had been born with radiation poisoning from the Venusian attack that targeted the nuclear power plants. Nuclear waste poured out and ruined miles around the power plants. Chicago sat in the middle of a triangle of three and was particularly badly hit, spawning a generation of sick children. Dilly had never been quite right in the head, always fixating on things like the twinkling stars of broken glass on a night time sidewalk. He loved to stare at the sky and pretend to see the constellations through the haze of smog and the crisscrossing rays of exhaust smoke. He would tell Cal and March the story of Orion the Hunter and how you could always find him by the three stars on his belt. He told them about the North Star that people used to navigate in the old days before Solar Positioning Systems. March and his mom could barely afford Dillys medicine. Once, he even had to ask Cal to loan him money just for a couple days. Cal had a hunch that it might have had something to do with Marchs moms drug problem, but decided if March wanted to talk about it, he would. Cal agreed, forking over the 6,000 units. When he told his mom, she had shuffled to her room and returned with a hundred more units to add to it. March refused to take the extra, but his mom insisted. He swore he would pay Cal back in full. Good to his word, the money was waiting just inside the tarp two weeks later, with a hastily scrawled thank you note attached. Cal was amazed that March would just leave money sitting like that where anyone could take it, but he supposed March had other things to worry about. 43 McCormick 44 Cals dad had taken him along to work once. Take Your Kid to Work Week only happened once a year if the bosses were feeling generous, because of the lack of extra oxygen masks. They didnt actually get to help either; they floated on the space station in a specially designed room with monitors watching the progress of all of the workers. It took them four days to get there and four days to get back; Cal slept on a cot in the back of the station while he waited for his dads shift to be over. Cals dad had been the shining star of the day. One of the men working on a larger asteroid had calibrated a charge wrong. The two halves of the asteroid shot apart, one leaving the belt to float aimlessly towards Jupiter. It would probably crash into the gassy surface of the planet without causing much damage, but the other half was rocketing right towards the command center. Cals father, instead of following code and letting the rogue asteroid damage a billion dollar piece of equipment, quickly hooked his own blast charge to his smaller asteroid and launched it at the larger piece. They collided in an explosion of rock and ore that rained on the command center, denting some of the antennae, but leaving it mostly unscathed. The children cheered at the amazing show, and his fellow workers clapped him on the back. Cals father had been reprimanded after work that day not only for wasting the charge, but also for exploding a level four asteroid and half of a level two, leaving most of the ore at their cores uncollectable. If it wasnt damaged beyond use, it was dispersed enough to make recovery impossible. He was reminded to stick to the code and not let it happen again. 44 McCormick 45 Dont you talk to my Daddy that way, Cal shouted at the screen. The manager couldnt hear him, but the minders in the room shushed him. Youll embarrass your father. Be a good little man and be quiet. Young Cal seethed but did as he was told, standing up to his full height and fixing the monitor with a hot-teared glare. His father was a hero. Sali left before their dad reached the final stage of his cancer. The cure was available, but far out of the reach of their budget. They had applied to the government for financial assistance since he was the only one with a job in the family besides Cal, who couldnt support the four of them as a cabbie. The government responded that since there were three employable adults in the house, there was no need for government assistance. Sali argued that once Dad died, there wouldnt be anyone to buy food or pay the rent. She didnt want to live on the street. Hell, she didnt even want to live in a shitty apartment with a hole in the wall but shed done that for her love of family. She argued that she wasnt abandoning the family; she was just lightening their burden by removing one of the mouths to feed. Why shouldnt she go? It wasnt like theyd never see each other again. If you leave now, youd better not come back, Cal warned sternly, his chest hot with concealed anger. She hooked a ride with a group of well-to-do Venusians who had come to Earth to go slumming amongst the trash that lived there. She impressed them with her smile, laugh, and short skirt. Cal stood on the front porch and watched her go, her boots clicking 45 McCormick 46 against the cracked pavement as their mother cried inside that her entire family was disintegrating. He watched them fly away until all that was left was an exhaust trail through the sky. Itll be okay, Ma. Im not leaving, he said, opening the tarp and walking back inside. Sali never called, though Cal got word through some of his clients about her. Apparently she was a mistress to some rich important Venusian. He took her out and showed her off, his new pretty little earth toy. Cal tried not to think about it and instead preferred to remember her from before their dad got sick. Cal, Sali, and March would all play War in the living room, shoes becoming battleships and teetering piles of books serving as the tall towers of Chicago. Usually they played as the Venusians because no one really wants to pretend to be the loser in War. Sali would always be a Venusian princess. She would tie her hair back with pieces of ribbon in it and put on one of their mothers nicer dresses. March was the unwilling prince, bossed around by a domineering princess, when really all he wanted was to be a battleship gunner and shoot down Cals shoe-ships from a turret made of rubber bands. Eventually Sali would cry that the boys werent playing with her when really they just werent playing the way she wanted to. One of their parents would interfere and playtime would be over. The boys would be sent outside and Sali would be enveloped in the warm embrace of their mother and soothed. Cal never got that. He was a man; he didnt need soothing. 46 McCormick 47 Once a week, Cal drove his mother to church. She liked to go to one of those oldfashioned churches where a bunch of people met in person in an old brick building with only one floor. It used to have a pointed thing on the roof, called a stoople or something, but a cargo craft knocked it off the year before and the patrons didnt have enough money to repair it. Cal swore that if he ever hit the SSLottery he would buy that church a stoople. His mom had Cals orbit phone on speed dial. She would call about nothing at all, just to check up on him. He was always at work when she called. She didnt like calling when he was off because she felt like she was intruding on his life. At least when he was at work she knew that talking to her was better than what he could be doing, listening to his rich customers blabber on about their own horrible shiny lives. He always answered no matter who was in the cab, even if it lost him his tip from an expensive trip. Cals mother had never acknowledged Salis leaving as permanent. She always asked when they were going to go visit her or if Cal had talked to her recently. She already knew the answer to both were no. Cal hadnt talked to Sali since the day she left and didnt know where she was, whether Venus, Mars, or some other identical shithole on Earth. But thats not what Cal would say. He would tell his mom that Sali had called a couple weeks ago and that she was really happy and they would visit real soon. One night a couple months after his dad died, Cal and March decided to just fuck the world and get wasted. They started out at bars, but as they got drunk, they got angrier. 47 McCormick 48 They were thrown out of even the scummy shithole, Long Daves, that served the staggering heroin whores who were as likely to puke on the floor as they were to buy a drink. The two wandered to an abandoned park that had seen the ravages of angry teenagers and neglectful city councils. The swings squeaked as they shivered to rusty life in the wind. March took a swig of his souvenir beer from Long Daves and drunkenly slurred, Hey, man. If you could change one thing, just one, what would it be? He sat down heavily on a dented park bench that looked like it had been set on fire in one of the protests that the Earth-dwellers threw to try to draw attention to the poor, polluted shithole. Cal thought for a second, staring at the moon colonies. Id bring my dad back and never let him go to those mines in the first place. Then hed still be here and Salid still be here and Mom wouldnt cry as much. March nodded and gulped the last of his bottle, falling over in the process and looking up at the sky. He chucked the bottle at the set of swings and set them swaying harder. Id make Dilly better. He looked at Cal with teary eyes. You know, man? Think of how much better life would be if Dilly was better. We, Ma and I and him, we could move to Mars or even Venus or hell Id settle for the moon. I could get a real job and live to an old age. We wouldnt have to buy those stupid pills and Ma could go to rehab and I could stop bumming off you. March gazed off. He was quiet for a while then rolled over and fell asleep right there on the park bench. 48 McCormick 49 Cal watched him and looked at the moon colonies, imagining all the little people in their little world while shit was falling apart all over Earth. He screamed and threw his beer at the moon. Nobody heard him and he missed. 49 McCormick 50 Apanthropy Yely knew what the noises from her husbands bedroom meant. She was rather familiar with his specific brand of moan-grunt and could hear his girlfriends higher pitched accompaniments through the thin walls of the apartment. She sat at their kitchen table clutching a rag in her folded hands. She looked at the door down the hall sadly, waiting for the noises to stop; for them to be done. She was supposed to be Ollis wife. She was twenty-four Venusian days old, almost sixteen in Earth years. She was his partner through life, his true other half. That didnt mean, though, that she was his only partner. Venusians had developed a culture of child marriage and acceptable adultery long before the War and their official separation from Earth. Before, though, there hadnt been much adultery because all the women were married and women werent allowed to cheat on their husbands. Female infidelity was against the law. Instead unhappily married men would search out Unmarrieds, women whose families couldnt find them a suitable husband, or try to find a woman willing to take the risk. When the borders opened up to immigrants, Earthlings, Mercurians, and even the stray Martian, overwhelmed their delicate family structure and filled the cloud cities with more than enough mistresses for everyone. The woman in the bedroom, Sali, was Ollis fifth mistress. She was twenty in Earth years. He would bring them home and introduce them to Yely, calling her his sister instead of his wife. Then they would disappear into his bedroom, separate from her own 50 McCormick 51 so as to conceal their marriage from his unaware mistresses, and the noises would start. Sali was especially strange, her light hair cut short around her face and arranged in spiky layers. She had glowing green eyes that made Yely wonder if they were real or some cosmetic trick. Yelys own dark hair reached her waist but was always pulled up in a bun properly; to wear your hair down was a scandal. When she was alone, or wanted Ollis attention especially bad, she would take it down in the living room and brush it out slowly and carefully, making the black shine on her olive skin. Olli would usually not notice, or only notice enough to pat her head in a patriarchal manner before leaving the house to go out with his friends or mistress. Yely picked at some dirt under her fingernail, idle with boredom. Suddenly, the noises changed in the bedroom. What had been moaning turned into yelling. The woman, Sali, was yelling at her Olli. At first, she felt indignant, but then remembered Olli saying that she was the best so far and that he liked her attitude and boldness. Sali made him happy. A moment later, a half-dressed Sali, tugging on her pants and carrying a duffel bag, stormed out of the room, the bedroom door crashing into the wall behind her and knocking pictures off the wall. She walked straight up to Yely, her lips puckered in anger. Are you and Olli married? her eyes flamed and she put her hands on her hips. Yelys confusion was evident on her face. Didnt this girl know how things worked? Yes, of course. How else could we live together? He introduced you as his sister. I just assumed it was true. You know he and I slept together? 51 McCormick 52 Yely nodded, unsure of where this line of questioning was going. Olli has had many lovers. You made him the happiest. Dont leave. Sali shook her head and forced Yely, who was trying to pull the duffle off of her shoulder, to look at her. Do you love him? He is my brother and husband, I No, Sali interrupted. Do you love him? Do you want to be his lover? His only lover? Yely bit her lip, thinking about what it would be like for her husband, the love of her life, to finally love her back. She had been raised in his household by his parents after the marriage and had never thought of any other life. She nodded her head slowly, almost solemnly. Sali nodded too. I thought so. She pulled her in for a hug. Ill be seeing you. Yely watched her walk out into the air-bubbled corridor of the cloud city. Wait! Sali turned to see Yely running down the path behind her, feet slapping the hot rubber floor. Where will you go? Yely looked behind her and saw Olli standing at the door to their apartment looking sad but decidedly not chasing after Sali like Yely had done. Yely begged her not to go, to stay with Olli and Yely. Sali refused saying good self-respecting girls dont sleep with married men. Yely teared up, less at Salis leaving, and more at the fact that this girl she barely knew cared more about her emotions than her own husband. 52 McCormick 53 Sali tipped her head back so that the rising sun could shine off her beautiful features. The high cheekbones, long eyelashes, and plump lips would have won any heart she had wanted on Earth. Instead, she had fallen in love with the one man on her planet that seemed incapable of loving her: her own husband. You dont have to stay here. You can come with me. To Earth. To anywhere. You dont have to stay. Sali took a deep breath and dove right in to the deep end of the girls emotions. Look at him. Look at that man standing there. She pointed over Yelys shoulder to where Olli stood, watching disinterestedly. He doesnt love you. You know he doesnt. He even said he loved me but he has done nothing to stop me from leaving. He doesnt need you. No, he doesnt deserve you. You could do so much better. You could find a man out there somewhere in our universe that will appreciate what he has when he has you, instead of bringing in lower class girls from the slums. Sali gestured to herself the grabbed Yelys hands in both of hers. Come with me. We could go explore the solar system together. My brother is a driver and hell give us free rides wherever we want to go. All you have to do is leave. Yely looked back at Olli, leaning against the door frame with his arms crossed. He looked upset, but it was true that he had done nothing to stop Sali, or any of his other girls, from leaving, and he had never made Yely feel like anything more than hired help. His dark, handsome features, the ones she had grown up with and was so familiar with, contorted before her eyes, forming something far uglier than she had ever seen on him before. He gestured to her, noticing her long stare, as if calling her back to him, like some pet dog. She imagined his hands, wide and strong, on her bare skin, touching her body 53 McCormick 54 like they had so many other girls. Then she imagined their family, the beautiful bouncing babies with her black hair and his dark eyes. Then she realized it was all just imagination. He would never love her past her potential for motherhood, not like he had loved Sali, not like Yely had loved him. She shook her head at him and turned back to Sali. When do we leave? The drop station was crowded with vehicles; hired cars, venuports, and shuttles all jostled for position. The Ion M cars, the most expensive and fastest, purred as their drivers waited for their charges contrasting the Ion Ls and Ks whose drivers were impatient as their cars hiccoughed. Sali and Yely boarded the shuttle, the slowest but cheapest form of transportation, to the nearest station twelve hours away, about a quarter of the way to Earth. They took two seats near the middle and Sali immediately began talking to their seat neighbors as if she had known them her whole life. Many of them were Venusian businessmen on their way to the other planets on job trips or to check on investments. One of the women was a Martian and Yely, from her window seat, craned her neck to see her. She didnt look much different than Sali, just a little darker and more dusty looking, and sadder, which made sense since Mars was practically wiped clean during the War. Yely didnt talk to anyone; in fact, she barely dared to breathe in the intoxicating aroma of the other travelers. They all smelled so strange to her untuned nose: like smoke and dust and vacancy. She realized at the second or third stop off of the planets surface that was what space must smell like. She wondered what it sounded like and looked out 54 McCormick 55 her window for some small clue. The stars twinkled at her, their unbending light rays interrupted by the solar wind from the nearby sun and the motion of their bus. She touched one of the tiny dots of light with her finger, blotting it from existence if only for a little while. She had just destroyed a star by choosing not to see something, not to acknowledge its existence, and it stopped existing in her world. She could go back to Olli, she reasoned, with this same thought process. Just cover up the fact that he didnt love her, that he would never love her, and ignore that he feels differently about anyone else. She could pretend that there was nothing else out there for her, nothing better to go to or to be. She removed her finger from the window with a sigh. The star was waiting on the other side, still shining just like it had been a moment before. Olli would never change; she could never pretend that he would. They had been lucky to board a bus to Earth during one of the rare windows when Earth was closest to Venus before their different orbital velocities separated them, so the trip was only going to take two and a half days. The girls were assigned bunk beds to sleep in during the trip that folded out from the wall above their seats, blocking the window. Sali had no trouble climbing into the bottom bunk and fell asleep immediately, snoring lightly. Yely laid on the top bunk listening to the breathing of the other passengers, some of them whispering softly to one another. She heard a creak and looked over to see two forms in one of the bunks, obviously kissing. She rolled over to give them some privacy and let her tears silently soak her pillow. She didnt want to wake anyone or be a bother, but she had just left everyone and everything she had ever known with a 55 McCormick 56 woman she had just met who was more familiar with her husbands bed than she was. She cried until the automatic lights in the bus told her it was dawn. The next day was much longer. The bus stopped at mid-orbit stations three times for meals, once every twelve hours, and Sali bought Yely strange foods that she claimed were Earth favorites. Ravioli and ramen and rice; Yely began to think all Earth foods began with r. Sali had struck up a friendship with the two men that sat behind them and initiated a game of poker using a deck of cards with scantily clad Unmarried women on them. Yely was invited to join but refused both because she didnt know how to play cards but also because of the indecency of degrading the women on the cards. Instead, she stared out the window, watching the depots come and go and listening to one of the bus-provided radio stations playing Earth classics from a thousand years earlier. She was especially fond of Beethoven; his harmonies and dissonances resonated with her in a way Venusian spirituals, the only music allowed on Venus, never had. Yely fell asleep that night to Ode to Joy. When they arrived at the depot on Earths surface, Yely was nervous that they wouldnt be able to find Salis brother. The station was crowded with so many cars and drivers and so many people, how would they ever find just one? But Sali seemed to have some sort of guidance system because she wove through the lanes of cars waiting for their patrons to a lot on the other side of the depot where her brother stood, smoking an old-time cigarette. Yely wondered where he had gotten it. Most of the tobacco companies 56 McCormick 57 went out of business after the War and everyone who still wanted to smoke switched to vapor. He had Salis blonde hair but his was longer and fell onto his face in a messy, disheveled way. Yely felt herself wanting to push the hair back and look into his clear green eyes she imagined were like Salis. Instead, she climbed into the back seat. The car was an older model and smelled like old smoke, sweat, and mildew. Sali and Cal exchanged formalities, but he didnt seem interested in further conversation and so the cab fell strangely quiet as they lifted off and headed into the dead air of space. The slight rocking of the car and the gentle hum of its Ion M motor, one of the best in the solar system, lulled Yely, and she realized that she hadnt slept well since Venus. She leaned her head against the door and watched the lane markers passing, passing, passing. Yely. Yely, wake up. Yely was being shaken awake and opened her eyes to the roof of the cab and Salis face smiling down at her. Were here. Yely sat up groggily, her hair a tangled mess since she hadnt thought to bring anything from the apartment, like a hairbrush, before she left. She looked out the window at a bleak city. The skyscrapers she had read about stood around her but what she had always imagined as majestic and grandiose seemed more broken and dead. The wall of the building nearest her had a jagged tear in its metal side, exposing three floors of what looked like offices to the elements, hollowing them out and turning everything a dreary sort of gray. Welcome to Chicago. Sali smiled and held her arms open as if hugging her home city. 57 McCormick 58 Yely got out of the car carefully, making sure the cracked pavement under her feet would hold her. She wasnt used to being on solid ground; Venusians lived in colonies above the clouds to avoid the sulfuric acid in the atmosphere below. She jump and felt the unmoving Earth beneath her and almost missed the hard rubber walkways of the cloud colonies. Cal and Sali had already started walking away towards a tarped-up hole in a nearby brick building. Yely hurried after them, not wanting to be left alone on the decrepit streets of an unfamiliar city on an unfamiliar planet. Through the tarp was a small living room with a worn and bowed couch on one side with a low coffee table sitting in front of it. A woman was smiling from ear to ear standing in the doorway to what looked to be a small hall. She ran forward as Yely came through the door and began hugging Sali with all the force her small frame could muster. Tears ran down her face and Yely felt very awkward watching this spectacle of human emotion. Suddenly, the womans face, which had been buried in Salis shoulder, popped up and her watery blue eyes found Yelys. She released Sali and advanced on Yely with open arms. Yely let her hug her but did so stiffly without really hugging back. Welcome home, my dears. You can call me Ceraline, she said to Yely in a quiet, whispery voice. The moment Cal told me you were coming, I could barely believe it. She bustled into the kitchen and set a large plate of what looked like yellow worms in red mud on a table next to the refrigerator which hummed noisily. I made your favorite, she said to Sali. Spaghetti. She got smaller plates and began scooping portions of the food onto each dish. Yely, who still hadnt said anything, sat down in one of the chairs 58 McCormick 59 and picked up her fork gingerly, poking at the food in front of her half expecting it to move. Mom, you really didnt have to do this for them, Cal said, hanging up his coat on a rack hear the tarp and sitting down across from his mother, putting Sali across from Yely. She was silently grateful because she didnt want to spend the entire meal staring at a stranger. The three began twirling their forks in the food and shoveling huge bitefuls into their mouths. Yely attempted to the same thing, her stomach turning at the thought of eating worms, but the technique seemed to be harder than it looked and everything kept slipping off her fork. Having problems with your pasta? Sali said around a mouthful of spaghetti. Pasta? Yes. Sali laughed and wiped her mouth. Its made out of flour and water and stuff. You boil it and eat it. The sauce is tomatoes. Their mother stared on in wonder. Dont you have spaghetti on Venus? Yely looked down at the plate and shook her head. They arent worms then? That caused the whole table to laugh and Yelys cheeks reddened with embarrassment. She managed to twirl a noodle onto her fork and gingerly lifted it to her mouth. Flavor exploded on her tongue like nothing she had ever had out of the hydroponic gardens at home. Garlic and tomatoes and peppers fought for control of her palate and Yely desperately swirled her fork for more, causing more laughter at the table. In the end, Sali gave her a knife and she cut the noodles into smaller pieces that she could scoop into her mouth instead of twirling it. 59 McCormick 60 This was delicious, Yely wiped her mouth with a paper napkin. Thank you. Salis mother smiled and held out a hand to Yely. Call me Ceraline, dear, Ceraline Thill. Yely took the hand and shook it like she had seen videos of Earthlings doing. Thank you, Mrs. Thill. Tomorrow Ill teach you how to make ravioli the way my grandmother taught me. She smiled and took away the red-stained plates. That night Yely slept on the beat-down couch she had encountered when she first arrived. Mrs. Thill and Sali had both offered her their own beds, but Yely didnt want to be a burden and chose to sleep on the couch, anxious staring at the tarp every time the wind made it move even the slightest bit. She was terrified that someone was going to walk right through and snatch her away while she was sleeping. The couch smelled like beer and bodies, a lingering smell that she couldnt seem to get out of her sinuses even after she ducked her nose into her shirt. Eventually she fell asleep out of sheer exhaustion, thinking about how nice it would be to have her bed back with her soft Venusian cotton sheets. Sali and Cal didnt get along. Yely figured that out fast and began hiding in the kitchen with their mother while they yelled on the other side of the tarp, Cals arms thrown up in anger and Salis voice ringing throughout the tiny apartment as she argued back at him. Sometimes they fought about nothing at all, things like whether or not meat was necessary for that nights dinner. Sometimes they fought about important things, like 60 McCormick 61 whether or not Sali should get a job to help support the four of them. Sometimes they fought about Yely. The first time it happened, Yely didnt know what to do. The two siblings stormed outside, their rage barely suppressed. They refused to fight inside, which Yely was a little grateful for. Cal began by asking why Sali had brought home a Venusian housewife who probably had a home and a family to go back to. Sali not-so-calmly replied that Yelys husband didnt love her and her marriage was falling apart. Admitting it to herself and hearing the words spoken were two entirely different things. Yelys eyes welled with tears and she turned away from Ceraline apologizing. She shushed her and hugged the young girl, folding her into her arms in a way Ollis mother never had during Yelys childhood. Hush, child. Itll be okay. You dont have to leave, just hush. Ceraline stroked Yelys long black hair. Sali and Cal were still shouting but Yely was listening to the sound of Ceralines heartbeat, slow and steady. Do you want to learn how to make some pasta? Ceraline asked. Yely smiled in reply. She learned to make all sorts of Earth foods during her stay there. Her favorite was ravioli and she found that the ones Ceraline taught her to make were better than what Sali had bought for her on the way there. Sometimes they couldnt afford meat to fill them so they just used mashed beans with a little bacon grease or beef fat which had been carefully saved since the last time they had the luxury of eating bacon or beef. The pasta they got was from the radioactive sunflower fields. The least radioactive plants were 61 McCormick 62 harvested and converted into cheap, though unethical, food for the hungry population of Earth. Sali frequently left for hours at a time and Ceraline usually took a nap in the middle of the day while Cal was at work, so that left Yely sitting alone on the couch. She would have gone for a walk, but this city didnt have a navigation system to safely return you home if you got lost like the cloud colonies did. Everything that had once been wonderful about Earth had been crushed during the War. Yely couldnt help feeling partially responsible for the destruction here, even if no one else was blaming her. The Venusians had wanted their independence from Earth and had taken it violently, leaving Earth broken and Mars empty. Destruction had followed where the Venusians went until there was nothing worth living in between Venus and Jupiter. Yely looked at her hands, their soft skin marred now with small patches of dry scaly red. The dirt under her nails had been accumulating and she hadnt taken the time to get it out. She picked at the dirt, scraping it out while thinking about the family she was intruding upon. Cal had told Sali that he couldnt afford them for much longer. He didnt get paid enough as a hired driver to feed four adults, even though Yely was only sixteen in Earth years. He had told Sali that either they needed to get jobs or they needed to leave. Yely stood and stared out the small gap between the tarp and the wall. The street in front of her had years of debris covering the pavement. The old non-flying cars were parked at strange angles with most of their windows broken out. They had long ago been looted for their valuables and wiring. The sun was shining on the broken glass in the street making 62 McCormick 63 it sparkle and hurt Yelys eyes. She stepped out of the tarp and stood in front of the apartment looking up at the polluted sky and thinking about her own home in the clouds. It had taken her a couple hours to find the consulate. She actually had to go into a shop selling day old food and ask the attendant if he had a sat-phone that she could use. Luckily, Venusian girls were made to memorize the consulate contact number so they could easily get help if they were ever kidnapped. It was a paranoid practice, but Yely was a little grateful for it then. The Venusian office had linked her to the Earth consulate which gave her directions to them. She had only been two streets away on Balmoral from where they sat on Bryn Mawr. Yely had to write down the name to keep from forgetting the strange Earth words. When she arrived, the Unmarried secretary at the counter shook her head at Yely in disgust. Embarrassment washed over her as she wondered what this other Venusian woman was thinking about her. At least she was trying to return to her husband and be a good wife, Yely thought. She wasnt staying here on Earth and eating meatless ravioli. The consulate had called Olli and told him that they had his wife. Olli immediately hired an Ion M car to drive her back to Venus. The orbits werent perfectly aligned anymore, but the planets hadnt moved much and the driver, who was thankfully not Cal, told Yely that she would be home in a little under three hours. Yely smiled demurely in reply and stared out the window. What have I done? she whispered. 63 McCormick 64 Olli picked her up from the cars drop point in a new Ion M of her own. He had it painted lavender, her favorite color, as a gift of repentance. He said he realized that she needed more freedom, but she knew he expected the car to sit in the garage unused. As he drove them back home, he kept glancing over at her. Yely supposed that now that she had seen more than just the cloud colonies of Venus she was more interesting to him. She knew her hair and clothes carried the scents of her explorations: cold, dust, vancancy, decay. I am quite capable, thank you. Yely said when Olli tried to open her door for her. She walked into their apartment and straight to her bedroom, putting away the few things she had gathered on her short absence quietly and meticulously. When she was finished, she came back out to the living room, where Olli stood awkwardly, unsure how to proceed with this new, foreign woman. Have you eaten? she asked, gesturing to the kitchen. He shook his head no. She bustled about a little, making quick and simple ravioli like Ceraline had shown her with cheese on top. She served the dish silently, still holding herself erect. She ate at the table with delicate movements, making Olli even more curious about where his wife had gone. Where was the girl who blundered through life, fretting about the tiniest detail, scared to set foot outside their door without him? He didnt know whether he should miss her or rejoice at what she had become. He reached his hand out and took one of hers, stroking the back of it with his thumb. She looked at it a moment before withdrawing her hand and continuing her meal. 64 McCormick 65 After dinner she retired to her bedroom early, lying down on top of the sheets and staring out the window. Where was Sali right now? Was she okay? Had she made a mistake coming back? A knock on her bedroom door snapped her to attention. Olli pushed open the door hesitantly. Can I come in? Of course. She nodded. He smiled and slipped into the room, shutting the door behind him. He sat on the edge of her bed and she sat up, looking at him. Yely, youve changed. I dont know what it is, but going out there with Sali has made you different. He touched her chin, gently turning her head this way and that, admiring her face in the pale afterglow of the sunset. You seem so much older now even though you havent aged a day. I dont understand it. Yely tried to see Olli. She knew this man. This man was the man she had grown up with, loved, and lost over and over again to woman after woman. Thank you, she replied. Olli took Yelys hand in both of his and looked at it, feeling its soft skin and delicate bones but also the secret strength there. Yely, I dont think I will be bringing home anymore women. Yely was startled but masked it by touching his shoulder gently. She knew what this meant. He was saying he loved her. He looked up at her with his large, dark eyes and she gazed into them. There was a time when she would have gotten lost in that gaze. She would have given anything for him to look at her the way he looked at the other women he brought home. 65 McCormick 66 She didnt say anything and he leaned forward, wrapping his arms around her and kissing her shoulder and neck. She looked out the window as they lay down on the bed and Olli tugged at the button on her pants. A single star struggled through the sunset haze as her pants began their journey down her legs. Olli pushed up her shirt, kissing her stomach and ribs and Yely shivered. The star winked knowingly at her. She held up one finger to blot it out. 66 McCormick 67 Radiate March woke to Dillys screams tearing through the air. He jumped from his bed and ran to his little brother. Dilly thrashed in his bed covered in sweat, eyes squeezed shut, legs tangled in the old solar system sheets. Dilly, March said, trying to liberate him from the sheets. Dilly whats wrong? March threw the sheets off the bed and picked his six year old brother up. He smelled like urine and sweat. Im so hot, March, Dilly whined wrapping his arms around his big brothers neck. My skin is on fire. March carried him into the bathroom and turned on the light with his elbow. Sure enough, Dillys skin was a frightening shade of magenta. March set him down and started a cool bath. He peeled Dillys pajamas off as Dilly plucked uselessly at the fabric. As March helped him into the tub, their mom appeared at the bathroom door. I heard him screaming, she said, leaning against the door frame with crossed arms. March shouldered past her with Dillys soiled pajamas. She followed him to the laundry room. March threw the clothes in the washing machine and closed the washer door. For a moment, his mother stared at her sons back: the muscles underneath clenched as he gripped the washer with his large hands. She noticed how much larger he 67 McCormick 68 was since he started working on the Martian mines. She thought about how she had never left the city since the War, and her son was off working on another planet. Did you sell Dillys medicine? Marchs accusation stunned her out of her reverie. She shrugged. We needed the money. March slammed his fist into the top of the washer and spun around, staring down his mother. God damn it, Mom! Dilly needs that medicine. We needed the money for food. Theres no point in him getting better if hes just going to starve. March eyed his mother suspiciously. I earned enough money for food. I always make enough for food. We needed more, was his mothers simple answer. Let me see your arms, March demanded, gritting his teeth. What? Let me see your arms. He held out his hand and his mom reluctantly put hers in it. His large hands dwarfed her slender ones as he turned her arm over and pushed up her sleeve. The small red sores followed the blue vein across her elbow. He threw her arm down in disgust. Well, what do you expect me to do? She cried, voice suddenly changed to a high, desperate whine. I cant handle this. We live in this shithole and youre gone working all the time and Im stuck here with my dying son! What do you want me to do? 68 McCormick 69 Yes, Dillys dying, March yelled, pointing his finger in her face, and you sold his medicine for drugs so you could get high instead of dealing with it. I didnt take the promotion because it would mean working on Mars and leaving him here with you. Youre killing him! His mom looked shocked and muttered, How could you say that? March pushed past her, knocking her into the wall. He grabbed a pot off the counter and began heating up soup. A small cry came from the bathroom. Just watch Dilly and try not to drown him. March fixed her with a penetrating gaze and she felt her insides curl with shame. She nodded and went to the bathroom. He thought of how he had been thankful when Cals family fell apart that his was still together. Now he wondered if that was better or not. Now he wondered if it was worth the trouble. Mommy, Dilly said when she entered, am I going to get better? She laid her cold forehead against her sons hot one. Yes, honey. Were both going to get better. When March was young, he remembered, his father used to go out and fly for miles to bring home donuts on Sundays. They were just old-world, run-of-the-mill donuts, but they would always be there when March woke up. He would bounce into the kitchen and snag his favorite, the one with chocolate icing, before anyone else could. His father would laugh and ruffle his hair while March wiped bits of icing off of the sides of his mouth. 69 McCormick 70 He hadnt known what they were talking about when they said radiation poisoning, just that Dilly was sick. He also didnt know what his dad meant when he said he was fed up with this. He did know, however, that when the donuts stopped, it meant he wasnt coming back. March had waited all day, sitting on the floor staring at the door, waiting for Sunday morning donuts, hoping his dad was just late, but his gut told him otherwise. His dad had stopped visiting Dilly at the hospital and he could hear his parents fighting when he was in his room at night. He blamed the problem on the damn Venusians coming and mucking up a planet that wasnt theirs to mess with. His mom had cried, at first secretly, alone in her room, but gradually more and more openly, moving to the couch, the kitchen table. One day, she moved completely out the door. She laid out a sandwich on the table and told March she was going to go see Dilly at the hospital. He had been born with radiation poisoning from the Venusians targeted attack on the nuclear power plants. March begged to go with herhe loved his new baby brotherbut his mother ignored his pleas. She was gone all day and March waited. He had nothing to do in the apartment so he ended up over at Cals place, playing war with him and his little sister. When darkness fell, March crept back home and snuck in. His mom still wasnt home. March woke that night to a crash and a curse. His mom stumbled past his door and into her room, knocking into the walls and shuffling her feet the whole way. When he crawled out of bed, she spun around and gave him a wide-eyed, surprised look. He saw the red marks on her arms and asked what they were. 70 McCormick 71 Mosquito bites, his mom had said, pulling down her sleeves. Now go to sleep, why dont you? Just after March found the missing medicine, his mom began acting strangely, always scratching her arms and pulling her sleeves all the way down. Its nothing, she said, pulling her already stretched sleeves down a little further and wiping her strained, tired eyes. She had been running laundry out on a precarious line March had run between their window and the opposite building thirty feet above the ground. Show me your arms, March said, feeling apprehensive and passing her the next pair of pants to hang March, I havent been, she started, putting her hands on her hips. Please? March asked, a child again asking his mother to do him a favor. Her eyes were bloodshot and her hands were shaking. He stood taller, setting down the laundry. Please. This time it wasnt a question. His mothers arms were an ugly bruised purple with raised red bumps up and down the prominent veins. She slid the sleeve down silently and turned back to the laundry. March turned his back on her and shook with anger. The next day when he came home from work, she was gone. She ended up in the addiction center of the local hospital, Sain Cabrini. The addicts occupied a small hall on the floor of the psych ward. She had been brought in by 71 McCormick 72 a pair of overworked cops with the rest of the inhabitants of a local heroin house during a raid. The doctors and nones that worked there were amazed that the drug she had been taking, a Venusian version of heroin specific to their metabolism and body structures, hadnt destroyed hers a long time ago. In a body like ours, a human body, it metabolizes differently, slowly. It creates the same high, is injected the same way, but lasts much, much longer. It is usually mixed with Earth heroin so it doesnt have as harsh of an effect, but the strain she was using, the strain that was in her blood, was almost pure Venusian the doctor told March. They stood over his sleeping mother as the doctor closed his clipboard and patted March on the back, leaving them to decide what to do. Dilly didnt realize what was going on and delighted in the small teddy bear one of the nurses had given him. March frowned, gripping the railing of her bed and willing the addiction out. Of course, that did no good. His mother would have been charged with possession, but the cops werent worried as much about harmless addicts like her as they were the dealers and homicidal ones. The cops were all but impotent now, when drugs and thievery were ways of life, not the recreational hobbies they were before the War. His mothers eyes had sunken and her face was covered in red spots like acne. March regretted bringing Dilly here; hed rather his little brother remember her as the happy, bright-faced mother of their childhoods, not this withered, wilted shell. Her eyes fluttered open and rested on a spot just above the light switch for a moment before focusing in on her sons. 72 McCormick 73 March, she began, trying to sit up. Her voice was raspy and harsh. March put a hand on her shoulder to put her back into bed. She looked around him to where Dilly was playing with his bear but March blocked her view, ushering Dilly towards the sparsely populated nurses station where the overworked nurses cooed over the adorable boy. Tears filled her eyes as March said seriously, We need to talk about this. Its not a problem, his mom stated, tears turning to steal against her oldest son. Mom, youre in the hospital because of it. That doesnt mean anything. They brought everyone here. Im not the worst addict in that house. Did you see them? Theyre crazy, shaking all the time and muttering to themselves. You are just like them. Marchs calm statement echoed in the room and she narrowed his eyes at her. I am nothing like them. Then get better, damn it. Let them treat you with whatever. Just get better. Do you know what its like to live alone, to take care of Dilly alone? You cant just abandon us for that stupid high. Dilly needs you. I, he stopped and turned around, running his hands through his hair in frustration. He couldnt admit he needed her, no matter how true it was. Turning back to her, he gripped the bed rail suddenly and forcefully, scaring his mother and making her jump away from him. Listen to me. If you get better, great. Come on home. But if you dont, if you start doing this shit again, dont you dare bring that home to Dilly. Do you hear me? This is done. If you want this life, this thing instead of us, thats your choice but I am not 73 McCormick 74 having it anymore. Is that clear? His blue eyes were sharp and dangerous, full of anger. His mother trembled slightly and nodded. He released the railing and strode towards the door. March? His mothers voice was small and childlike. He turned back to her, one hand on the doorknob. She held the blanket in both of her hands, covering the bottom of her pockmarked chin. You dont know what youre asking. Its hard. Its so hard. She started crying. I cant just give it up. You have to, Mom, or you wont be a mother anymore. She widened her eyes, their wet ocean blue matching Marchs hard sapphire. Maybe I just should never have been a mother to begin with. March didnt know if she meant for him to hear it or not, but it was enough for him. Goodbye, Alis. His mother jumped at her name, unused to hearing it from someone so much like her lost husband. I hope you end up happy. One of the nones contacted March later that week to inform him that his mother had checked out. She didnt come home. The apartment was empty, waiting, expecting her return, a return it would never get. March sighed and helped Dilly take his jacket off. There wasnt anything to do; Cals mom had made them a casserole to get through a few days without having to cook. March suddenly realized that his mom had always done the cooking and that he had no idea how to cook. He looked in the cabinet and found boxed macaroni and cheese and a 74 McCormick 75 few sleeves of crackers. They couldnt live on that. March realized he hadnt bought groceries the entire time his mom had been missing. March had always thought that maybe he and Dilly would be better off without her, but now, he wasnt so sure. He wanted her to come back. He felt the tears in his eyes and angrily wiped them away, grabbing some bowls from the cabinet. He scooped some casserole into a couple of dishes and went to get Dilly for dinner. He was crying in his room and looked up when March walked in. Whats wrong? Mom isnt going to get better, he sobbed, hugging the tiny hospital teddy bear. March sat down beside him on the bed and tried to think of something to comfort him. She is very sick. She might get better but it will take a long time. But she said that WE would get better. Both of us, he clung to March, wrapping his arms around the bulky frame of his brother. But now we cant. She knew that you both couldnt get better so she gave you all her better. March could hear the ridiculousness coming out of his mouth and couldnt believe he was actually saying it. His brothers eyes shone, though, and he knew it was the right thing to say. Thats how shes going to help you get better. Shes taking care of you. March stroked his brothers hair and looked at a small snapshot hanging on the wall of the three of them. It had been taken when Dilly was a baby and still fat and rosy cheeked. March was waving and his mom was smiling, holding her new son. His dad had taken the picture a few weeks before he left. March wondered if hed ever feel that whole again. 75 McCormick 76 He turned off the light and left the room, fighting the urge to just leave him as a ward of the state and take off to anywhere, maybe Venus. The women there were so famous for slumming with Earthlings that he was sure he could convince one to let him shack up with her. He imagined having a tiny Earth-Venusian baby and how cute it would be, his wild hair on top of their olive skin tone. His blue eyes in the signature diamond shaped face. He laid down on the couch and imagined pushing the baby through one of the elevated parks where you could look down on the planets surface, miles below, and feel the heat radiating up. As he dozed off, the baby ran in front of him, a red balloon tied to his wrist as he and its mother followed behind with the stroller prepared for when it got tired. He imagined wearing a suit and going to an office job, pictured his large hands gripping a ballpoint pen for a living and him selling stocks or running a construction empire or, God forbid, advising people on finances. He saw his baby playing in the living room on a bright red carpet, stacking blocks and building precarious towers. March, the baby said. March. The babys diamond face began to change, filling out in the cheeks and gaining a pink hue. Its hair shrunk back into its skull and lost its radiance, instead becoming a dull brown. The blue eyes remained, sparkling with life. He recognized his brother and started away, nearly falling off the couch. He stood up and walked back to Dillys room, scratching his eyes with one hand as he pushed open the door quietly. He looked at the prone form of Dilly and watched his steady breathing. 76 McCormick 77 Shadow Dances Sali heard conversation outside the living room. She had been napping on the couch before the intrusive high-pitched voice interrupted. She squinted blearily at the corner of the room where a large tarp was backlit by sunlight. A figure stood silhouetted against the tarp. Sali stood up grumpily, her short blonde hair standing on her head in spikes. She ripped the tarp aside, glaring at the person who had awaken her. Yely! She screamed, recognizing the other girl immediately. Yely almost fell over but was quickly pulled inside and pushed down on a couch. Salis nap was immediately forgotten as in her excitement. She quickly explained everything that had happened to her in the year since Yely left. Mom got a job washing clothes but it doesnt really pay much and I waitress but the men there look at me like a piece of meat so I might as well be prostituting again. Dont look so surprised, it pays well. Anyway we all have jobs now so you can stay as long as you like but we dont have a bed for you still so I hope the couch works again. Cal should be home later and Mom gets off in a couple of hours so we have a little bit of time to ourselves before anyone gets here. What do you want to do? We could go to the park and watch the children play or we have a little bread. We could go feed the birds at the lake. What do you want to do? Sali was nearly bouncing she was so happy to see her ex-lovers young wife. 77 McCormick 78 Yely smiled at the older girls exuberance but offered no immediate answer. Instead they just looked at each other for a moment. Salis smile dropped and she raised her eyebrows in question. Yely nodded solemnly, frowning. So you left him. You really left him? Yes. Its just me now. Just you? Just you are the most wonderful person in the world. You should be proud to be just you. Why the hell did you come here with your newfound freedom out of all places? Yely laughed. I wanted to see you. I dont know what to do or where to go, but I couldnt stay there, Id just end up back at Ollis. We could go anywhere, Sali, anywhere in the solar system. Ive done the traveling thing. We could go anywhere you want to. Ive seen it all, well, all of it this side of the asteroid belt. Never could afford a ticket on the ferry. Sali smiled at the adventure shining in the other girls eyes. She looked so much more alive than she had the last time Sali saw her. She looked like before she had been covered with a film and now she was clear and clean, purely herself. First, maybe something to eat? Sali offered. Yelys stomach growled in response. * Yely hadnt actually known how to get to Earth. Last time Sali had made all the decisions. Before, Yely had thought about the man she was leaving and the family she was being denied all the way to the next planet, a two day trip. This time, Yely didnt want to take the bus and have to traverse all of the foreign depots for food and converse 78 McCormick 79 with strange people in a guise of friendship. Instead, she played the good wife, doing Ollis laundry and organizing his things. Olli smiled, showing off his bright white teeth in his dark olive face as he watched her carefully fold his clothes and put them in the wardrobe sorter. She knew he liked watching her do things like these, wifely things that made her look feminine and matronly. What he didnt know was that being this close to his stuff gave her access to things like his EID card which let her order a Ion M car to take her to Earth and a guide to get her to Sallys. She left while Olli was at work, standing in front of the door and looking back at the only home she had ever really known. The Venusians sold their daughters for marriage as toddlers. She had been raised by her husbands parents in her husbands family to be her husbands ideal wife. She grew up knowing that she belonged by his side in his household. She had left it once before in haste, trying to follow the Earth girl her husband had cheated with. The first time she was rash, leaving with little thought and much emotion. She had returned when the emotion wore off, thinking that she could be happy, despite the fact that she had no power, no identity, and no love here. This time she left with full intention of never coming back. The fish Olli had bought her as an apology when she returned swam listlessly in their floating orb tank. Their bubbled eyes watched her stand with one hand on the door. She sighed, picking up her lightly packed bag which held everything she had any right to take. Goodbye, she whispered to the empty house. * 79 McCormick 80 As an apology for cheating, Yelys husband had bought her a car, an expensive Ion M. He had assumed she would use it to go to the groceries or the park if she used it at all, staying safely within the confines of the cloud colonys bubbled streets. Yely didnt know how to drive, but slowly, a day at a time, she learned how to fly the small purple car. She wasnt very good at first and frequently had to stop on the side of the road to calm herself down before she could get where she was going, but she learned. When she got in the car to leave, it felt different. This car was no longer about her husbands affairs but rather her own freedom from him. There was a sound system in the car, but she didnt turn it on. She wanted to spend the three hour trip in silence, listening only to the music of her heart beat and breathing, the sounds of a Venutian woman finally free for the first time. She imagined, not without pleasure, the look on Ollis face when he returned to find not only no dinner, but no wife. He had treated her better after her return, but he quickly slipped back into his old habits. He had been true to his word and not brought any other women home, but he wasnt interested in her for any more than her mothering possibilities. He didnt touch her or stroke her hair; he didnt stare longingly at her; he didnt come home with flowers or imported Mercurian chocolates. He simply looked at her flushed cheeks and observed without any sentimentality that she was ovulating, which was usually followed by a tender moment in her bed later. Yely almost wished that the car could go faster, but she knew that Olli, her husband, had bought her the fastest model available. She tapped her fingers on the console in front of her, tap taptaptap. 80 McCormick 81 She entered the Earths atmosphere at one of the crowded depots, the only place that vehicles were allowed to enter the atmosphere. Yely didnt know how to get to her friends house from here so she had arranged to meet a guide. The air was hazy with smoke and pollution. Yely wove her way through to a man in a neon green vest, an obnoxious flamboyant color that stood out in the sea of brown faces crowding the station. Hello, he said, his voice high pitched and lilting. Are you Yelyzaveta from Venus? Yes, I am, Yely said regally, opening the door and holding out her money. Tell me how to get to the Thills. The Thills, the family of her husbands ex-lover Sali, lived on Foster in what used to be a nice part of Chicago. Now everything was a wasteland, the city ragged and deformed from the War when the Venusians attacked for their independence. The man took her all the way up to the tarp covering the Thills front wall. He said it wasnt safe for someone as pretty as her to walk the streets alone. Yely thought this ironic since she seemed more likely to fit in than her neon-clad counterpart. He helped her find a suitable parking space in an alley behind the building where vandals and thieves were less likely to find it. I hope you find what you are looking for, my friend, he said to Yely in front of the tarp, holding up a hand. Yely didnt know how the proper response and he laughed. Usually people reply with, And you as well. And put their hands like this. He took her hand in his, crossing their forearms and pressing the backs of their hands 81 McCormick 82 together. You seem a nice girl. Dont lose it, he warned before skipping away, humming loudly to himself and looking up at the sky wistfully. * What do you mean youre leaving? Cal yelled. The two had gone outside but the tarp did little to silence their shouts. Their shadows played on the tarp like a puppet show, two larger-than-life figures pantomiming anger. I mean Yely and I are leaving tomorrow to go travel the solar system. She wants to see the worlds and I want to help show them to her. Sali wasnt angry, but she didnt understand how her brother couldnt see the logic of this solution. You just got back. Do you know what this will do to our mother? He hissed at her, leaning his face in close. Do I know what this will do to our mother? Do I know what this will do to our mother, you ask? Of course I know what this will do to our damned mother. You never quit telling me what Ive done to our mother. Ever since I got back you tell me how all Ive done is hurt her and how Im a horrible daughter and that nothing I ever do will fix it. Well guess fucking what. If I cant fix it why should I stay? If Im not good enough for this family, why should I even try? Hot tears filled her eyes and her face reddened from rage. Cal stared coldly at his sister. He had said those things, but was hoping that they would have the opposite effect. She hadnt had to watch their mother cry over Salis baby pictures like he had. She hadnt had to lie about when she would be coming back like he 82 McCormick 83 had. She hadnt had to see their beautiful family fall apart. Instead she had run. And now she was running again. Yely sat on the couch trying to pretend she couldnt hear them outside the tarp. Sali threw it aside and stormed inside, stomping past Yely and down the short hall. She returned with a bag of miscellaneous items, little more than what she had when she left Ollis a year earlier. Sali didnt speak but grabbed Yelys hand and dragged her off the couch. She let go long enough to let Yely grab her own bag placed strategically by the tarp for an easy exit. They walked past Cal who was still standing outside, anger etched on his face. Sali didnt look at him but instead began walking down the street. Yely looked at the man she had spoken to only rarely and smiled weakly. He wiped hastily at his eyes and she noticed he was crying. He nodded at her and she returned it with an incline of her head. She turned to walk away but he reached out and grabbed her arm. Wait. Wait, he repeated louder, causing Sali to stop and look at them. If you guys are really going to do this I can drive you somewhere. Just, he paused with a sigh and ran his fingers through his hair. It was the same color as Salis though longer and shaggier. Just this time promise me youll call. Mom misses you Sali. We both do. Sali looked at her feet and Yely put a hand on Cals arm in a grateful gesture. Thank you, Cal, but I have my own car. Embarrassment reddened his features and he looked away. Yely looked between the two siblings who were both avoiding eye contact. How couldnt they see how perfectly alike they were? 83 McCormick 84 I will make her call, though, Yely said, making Cal look up. We shouldnt both lose our families. * Two women arrived on Mars driving an expensive Ion M car. They parked near a dive bar and get out. One was a tall, beautiful woman, obviously Venusian by her dark olive skin tone and sharp cheekbones that accentuated her distinctly diamond-shaped face. She wore her hair down in long waves and had on a pair of old-fashioned sunglasses that covered the upper half of her face. The other girl was shorter with spiky blonde hair and a loud laugh. Her face was rather normal but her smile could make others smile. Both girls were wearing cut off jean shorts and tank tops, despite the cold of the Martian atmosphere. Sali lead them into the bar and waved the bartender over. Yely looked uncomfortable as she sat down on a sticky barstool, her bare thighs squeaking against the plastic seat. The room was dimly lit and miners shared the bar and the few booths available, laughing coarsely at a game of virtual billiards or staring pitifully into their booze. Two of your cheapest beer, Sali ordered, holding up two of her fingers. The bartender placed two half-liters of fizzy amber liquid in front of the girls. Sali took a large drink of hers and turned her back to the bar, looking out at the miners around them. She smiled and a couple of the less grim patrons smiled back. Yely sniffed her beer and placed it back on the counter in front of her. It smelled like old socks. 84 McCormick 85 Do you know of a good place to stay, Sali asked the bartender, turning back around. The bartender, a middle aged man in a dirty t-shirt and jeans, leaned forward on the counter. There aint nowhere near here that a couple of girls like you two wont get hurt. He gestured to the bar vaguely. Men around here get a little starved, you know? Sali nodded and took another drink. Yely nervously rolled the glass between her hands, collecting the condensation on her fingertips. Anywhere would help. We can take care of ourselves. A certain ferocity filled her voice as she replied. Well, he said, leaning back and wiping a glass with a rag, there is one place I can think of. Just meet me back here at sunset and Ill take you to them. Sali beamed. Thank you so much! For a small fee, of course. Salis smile went away and she pulled out fifty units, enough to cover the drinks and bribe. The planet was bathed in orange light as the girls waited for the bartender to finish locking up. Yely stared into the distance, Martian mountains made of red dirt blending in with the orange sunset sky. She had never seen anything so barren before. On Earth everything was destroyed, but there were still buildings and cars and life. Mars had been wiped clean of all of its agricultural fields and farming colonies. Only the mines were left, the planet dotted with them and a few sparse buildings to service their workers. The bartender silently beckoned that they follow him. Warily, they shadowed him to an archway in the side of one of the mountains. The inside was lit dimly with an everburning torch and Sali made sure she knew where her electrode taser was before she went 85 McCormick 86 in. Their footsteps echoed on the hollowed walls as they approached a stone spiral staircase that descended into the darkness below them. Yely didnt want to go, but Sali forced her, following closely behind. At the bottom they found a hotel of sorts. Beds were stacked three high and covered the walls of each room. The rooms themselves werent very large, maybe three meters by three meters, but a dozen men slept in each. When they entered, a woman the men called Mama shuffled up to greet them. Hello, Trivel. Who have you brought me this evening? The bartender moved aside to gesture to the two girls. Just two travelers looking for a place to stay tonight. Mama looked at the girls and waved Trivel away, he went back to the stairs, not even sparing them a second glance. One night will cost 25 units. 50 if you want a bed. Each. She looked at them expectantly. Sali sighed and pulled another 50 units out of her purse. If they kept spending money like this, theyd be broke before they even got across the asteroid belt. Mama smiled and led them to their room. You get the floor here, she said, pointing to a rug on the cold stone floor. After Mama left, a man threw his bag at the spot she had just pointed out. He pushed through the girls and laid down on the rug. Hey! Sali put her hands on her hips. We paid for that. The man didnt even look up, just pointed behind them and said gruffly, Ladies shouldnt sleep on the floor. Take my bed. Yely looked behind them at the empty bed he was pointing to. Thank you, sir. 86 McCormick 87 The man grunted, covered himself with a blanket and rolled over to face away from them. Sali and Yely made themselves comfortable on the bed, sharing the single pillow and blanket offered. When they woke in the morning, Salis body was curled protectively around Yelys smaller frame. The man on the rug had already left. * The girls found their car vandalized but not looted. The paint was scratched and a window broken, but nothing had been taken and their bags were still in the trunk. Sali offered to try to find a mechanic to fix the window and make it flyable, but Yely didnt care. I really just want to get rid of the thing. Its Ollis, not mine. The two decided to sell the car and pocket the cash; Sali was an experienced hitchhiker. Trivel, the bartender, offered to buy the car from them for three thousand units saying his cousin owned a junkyard on the other side of Mars. The offer was a modest amount, if a bit low, and the girls took the offer. They hitched a ride off the planet with a carload of immigrant workers that had stayed at Mamas the night before also. The group had been hired as miners when a vein of chromium was discovered but once that vein was exhausted, they were let go to find other work. They were heading to the asteroid belt to hopefully work on the asteroid bombing mines there. The car they were taking, an old Ion J van, was already full when the girls asked so they didnt get seats. Instead, they were stowed away in the cold 87 McCormick 88 luggage compartment. They had to crack a door for air and sit snuggled up next to the bags of clothes and blankets. Yely fell asleep curled up in an old Earth-style afghan, but Sali spent the trip doodling in the frost that formed on the walls of the van. She drew anything her imagination could create, starting with crude penises and vaginas, laughing to herself, but slowly moving onto more intricate, delicate drawings of her favorite place on Venus: a park just below the city where you could see the movement of the clouds and the way the sun glinted off the surface on clear days, the Earth emporium between Venus and Earth that housed the best her planet had to offer and had an entire section just for shoes, the skyline of Chicago, the view of her street from the tarp in the living room. Her fingers trembled and she took out her phone. It only rang once. Hey, Mom, Sali said softly. * Yely had no experience with prostitutes, but Sali didnt seem nervous at all. They were dropped off outside of a brothel just outside the asteroid mining companys borders. The women wore too much makeup and fake smiles, but were friendly. The girls met a girl named Leela who was two years younger than Yely. She boasted that she was only there to save money for a trip across the asteroid belt to Jupiter where she was certain she would before an actress at one of the great holostudios there. Im going to be a star, she said, tossing a silk scarf over her shoulder and smiling a blue-painted smile at the girls. She poured them each a glass of clean water. 88 McCormick 89 People tell me that I look just like a young Scarlet Johanson, and you know that look is coming back in style, that sort of vintage thing. She had just finished with a patron and was walking them out when she noticed the two women standing near the brothel not looking like they belonged. Her shift was over for the night so she had invited them up to her room. When they explained that they just wanted a place to sleep, she offered to house them for a night. Having someone around that was even remotely close to her in age and didnt berate her for her life decisions was refreshing. The bed was rather large to make the guests more comfortable and all three women fit in it without having to touch. Yely slept in the middle and had a better nights rest than since before she left Olli the first time. In the morning, the brothels owner heard word of unpaid visitors spending the night and wasnt happy. Apparently, one of the other women had seen them entering the room. Lesbians were fine, but not in the sex trade business, and she had told. The owner promptly kicked them out. They offered to bring Leela with them to Jupiter, but she just laughed and waved them off, promising that she would earn her own way eventually. * Sali didnt want to spend any more money but the only way off the station with the brothel on it was a sleazy taxi service. When they walked in the front door, an antique bell jangling as the door slammed shut behind them. The man behind the counter had on a tank top that probably used to be white but was now a sweat stained yellow. He looked up when they walked in and a greasy smile spread across his face. 89 McCormick 90 Um, Yely, why dont you go back outside? Ill get us a good price. But, I Yely started. Dont worry about it. Sali pushed her back out the door as the man came around the front of his small counter and looked her up and down. I need a ride to the ferry station, Sali said in a strong voice. The man chuckled. What are you willing to do for it. Sali rolled her eyes. The mattress in the backroom had no sheets and smelled like urine. * The ferry across the asteroid belt was only active for passengers once per Jupiter anum, when the planet was closest to the path or the ferry. Usually the ferry was used as an industrial vessel to transport the ore from Uranus and Neptune to the other planets. It was converted into a commercial passenger ferry by adding seats on the upper level and loading the luggage into the bottom. Due to the amount of modifications it took to convert the ferry, tickets werent cheap. Even with the money from the car, there wasnt enough to afford two tickets. Sneaking onto the ferry wasnt too difficult. They just had to forgo the comfort of the passenger cabin and opt for a space in the unpopulated luggage bay. They nestled themselves between a load of thankfully well-secured iron beams, an assortment of luggage labeled with the name Trasi, and directly above the engines, which caused the metal around them to grow to a scorching heat. Sweat poured down their faces as they 90 McCormick 91 tried not to imagine spending half a day this way. They fried eggs on the ground for lunch. Why hadnt they just saved their money for tickets in the passenger cabin? * There was nowhere to go when the ferry landed. They didnt have a ride to Marius, the capital city of Jupiter, and they desperately needed to sleep. They crawled out of their hiding spot and looked down the platform to where the ferry workers were unloading the other luggage. Behind a tall crate of what looked like rolls of carpet stood a man and woman. Look, more stowaways, Sali pointed to where the woman was helping a child and a teenager off the ferry. The workers were glaring at them but saying nothing. The family, once successfully unloaded looked around before making a beeline for a three foot crack in the concrete wall. Where are they going? Yely asked, hoisting her half-empty bag a little higher on her shoulder. Sali didnt answer and instead nailed her eyes to the spot on the wall where they had disappeared. Yely had to jog to follow her as she darted through the crowd of workers and cargo that littered the platform. The crack in the wall looked like a service entrance to maybe work on the plumbing, but if that family had gone in here maybe there was something else. Piles of rags lined the service tunnel. Sali kicked one and it groaned. Out of the rags came a homeless man who hadnt shaved in what looked like his entire life. Im so sorry, she gushed. The man just waved her off and resituated himself as a pile of rags, pointing down the hall as if that would answer their questions. 91 McCormick 92 The tunnel continued on until the people who constituted the piles of rags actually became people standing and milling about. They were drinking water from a burst pipe in the wall that gushed beautifully clean water in an arc to the drain in the center of the floor. The family the girls had seen were standing by the small pool of water splashing their faces and washing their hands. The child was playing in the water like it was a tiny swimming pool. The parents eyes were tired but the children seemed to be sparkling with life. Excuse me, Sali said, ducking into the line of sight of the parents and waving. Hi. We were on the ferry with you guys in the cargo bay. What is this place? The parents sighed at her and Yely. This is a refuge for the homeless. Clean water, food, blankets. Its not great but it is safe and thats something. They gestured to where they had placed their bags. There was a rack of day-old discarded food fifty feet away and a pile of stolen blankets next to that. The familys skin was red and raw from the Martian wind and the heat in the cargo bay. They invited Sali and Yely to join them and together the six of them feasted on free food and slept in a nest of threadbare blankets. * Sali and Yely stood on the top deck of the ferry station for a couple hours before a fellow passenger picked them up. He thought that it was funny that they were using the traditional Earth sign for hitchhikers, a bent thumb, since they were two planets away. I just got back from a business meeting on Venus, he told the girls while he helped them load their bags into the trunk. Everything is so gorgeous there, even the 92 McCormick 93 people. He looked at Yely who blushed. Anyway, now Im heading back to Marius to my wife and son. Where are you guys heading? He climbed in the drivers seat. The girls followed suit and Sali climbed in the passenger seat; Yely claimed the back seat. Marius sounds great, Sali said gleefully. The man smiled and adjusted the window screen shade so that more sunlight entered the car. * Thanks! Sali waved at the leaving car before turning to Yely. Okay, lets find somewhere to sleep. She headed towards the elevator that would take them into the first of Jupiters gas layers and towards the heart of the floating city of Marius, named after one of the men to first spot the planets moons. I can help you, miss. A woman approached from under the shadow of the platforms awning, her clothes dirty and her hair unkempt. I have somewhere to stay. Yely was hesitant but Sali seemed to be impervious to all senses of danger. If their options were sleeping on the ground or following a ragged, shoeless woman, Sali was willing to take her chances. The elevator down to the city was slow and played obnoxiously tinny muzak. Sali tried to make conversation, but Yely was sulking and the other woman kept her head down and her hands in her sleeves. When the doors finally opened, Sali breathed a sigh of relief and nearly ran off the elevator. Beyond the doors was a world of neon and music. Its like New York City! Sali exclaimed, spinning in a circle trying to take it all in. The roof of this level of the city was a giant mirror miles above their heads that 93 McCormick 94 reflected all the signs and lights back down to them so that it was bright as daylight even though it was way past sunset. Youve never been to New York City. Youre too young, the ragged woman said. It was destroyed before you were born, when I was just a girl. She led the way through the labyrinthian streets until Sali was fairly sure she would never find her way back out. They arrived at a splendid hotel whose walls were reflective bronze with yellow lights set along its edges. Sali went to go in the front door, but the woman pulled on her hand. Not that way, dear, this way. They walked around to the back of the building and entered into a small brown door set into a recess off of the alley. After carefully locking the door, the woman turned to them. My husband and I are the superintendents here at the hotel. We take care of the maintenance and upkeep; fixing the plumbing, keeping the floor buffer running, that kind of thing. She opened another door and gestured for them to enter. They found a modest living room that was significantly cleaner than what they had expected from the woman. Let me go clean up. She hustled out leaving them sitting alone in the living room. The couch squeaked as they sat down, but they made no noise otherwise. Yely was obviously terrified, her large eyes taking in every detail of the place. Sali was less wary, instead working on their cover story as to why a Venusian sixteen year old was traveling with an Earthling twenty-two year old. When they heard a door open down the hall, they both turned to look and were amazed by what they saw. 94 McCormick 95 The ragged woman had transformed herself quite completely. She was no longer stooped over in a servile way, but stood tall, wearing a chic blue dress with her hair up in a bun. She could easily be the owner of the place instead of simply the superintendent. You look amazing! Sali gasped, surprised. The woman looked down demurely and smiled. Thank you. I usually dress like that while getting patrons because we dont want to get anyone that the hotel would recognize and the type of people that would stay here, she gestured around her, wouldnt follow a woman in rags. Why would you want to do that? Yely asked, her first words to someone other than Sali in months. Because, she sat down on the sofa arm beside Sali, this hotel, the Capra, is a menace. Dont be fooled by the shiny exterior and the beautiful artwork. The owners are horrible and use this hotel to fund their political alliances. The Chevres are trying to take apart everything that we have been working for, everything the entire planet has been working for. They want to privatize entry to the city so that only the rich can enter, and banish all those who cannot pay into the outer colonies where they wouldnt even be able to find food properly. What does that have to do with us? I mean, its horrible, but were just tourists, Sali asked. Exactly. There are tons of empty rooms in this hotel every night. You said it yourself, youre homeless. What would be better revenge on someone trying to ruin our city than by filling up their precious hotel with the exact kind of people theyre trying to 95 McCormick 96 keep out? I want every homeless person, every person who is down on their luck, every person who has nowhere to sleep, to find refuge here, in the eye of the storm. So were pawns in your political rebellion against a capitalist system? Yely questioned. Sali gave her a look that she shouldnt meddle. Yes, is that a problem? Actually, Yely smiled, I like you a lot better that way. * The girls found themselves in a hallway on the fourteenth floor with a beautiful view of the city lights. Their neighbors were a homeless couple from Mars and two female activists from Earth that had come to help fight the expulsion of the poor. In the beginning, they planned on only staying for a night, but then one night became two, then a week, then Sali met a computer scientist in the bar. She got him drunk and brought him back to their room, explaining the delicate political predicament they were in and he expertly hacked the hotels computer, making it look like the Chevres had booked the entire hallway for an undetermined amount of time. He also made sure to mark them all as Do Not Disturb in the system to the maids would not be up to discover them. The computer scientist, Geofri, after sobering up, became a regular feature in their room, talking politics and strategy with Yely while Sali worked on the people end of the organization. Sali was in charge of who should be where when and regulating how many homeless were in each location so that they didnt draw attention. The Capra ended up having about 40% of its rooms given to homeless with the help of Geofri. Other hotels had more, depending on how noticeable they were compared to the usual patrons. 96 McCormick 97 * The ballroom of the Capra was lit with glowing orbs that floated above the heads of the guests, bumping into each other softly and subtly changing colors from red to yellow to blue to purple. People mulled beneath them holding flutes of champagne though not really drinking any. The talk was amiable but quiet. Yely stood in the center wearing an orange dress lined with fiber optic strands that fluoresced red and yellow. The technology was a little outdated but so well-made that no one would notice unless they looked closely. Her hair was piled on top of her head and curled down around her as she smiled at the other guests. Anything interesting yet? Geofri asked, a slightly buzzing voice in her. He was just trying to make conversation. Yely had been sent down to scope out the opposition, the wealthy and well-to-do of Marius who wanted to eliminate the homeless crisis by simply sending them away. As a beautiful Venusian, Yely was admitted into the upper class with no questions asked. Many believed, not inaccurately, that she was the wife of a rich businessman, though they also assumed that she was there with her husband. A woman approached her, champagne sloshing around in the other womans glass, showing her over indulgence. How wonderful is this champagne? she asked, smiling at Yely. I dont really drink, Yely answered politely. I just felt bad telling the attendant no. Oh, the woman was speaking too loudly and Yely looked around, feeling conspicuous. So wheres your husband? Venusian girls always have husbands. 97 McCormick 98 Hes downtown arranging a business merger, Yely lied. He gave me leave to come enjoy myself. The role of submissive house wife was familiar and Yely was uncomfortable with how easily she donned it. She was really there to distract the owners and keep them in the ballroom should they try to leave. Sali and Geofri were sneaking in as many people as possible tonight, reveling in the rush of sneaking them in right under the Chevres noses. Weve reached a critical mass of homeless, Geofri said through her earpiece. We have literally every homeless person in the city off of the streets. The only thing to do now, is to start the downward spiral. Get all of them located in one central area. We have enough people sympathetic with our cause that it should be easy. All we need to do is take down this place. * The night before the election, Yely and Geofri stood over a computer. Every room had been rented out to illegitimate patrons; the poor and lonely all taking refuge in luxury for a night. Each of them had been giving a small white box to set next to the wireless electrode for the room. Ive rigged them all to communicate with our mother computer, here. When the Chevres are about halfway through their speech, which we can watch on this screen, he pointed his mouse-ring at a screen to their left, we will activate the codes and the surge of information will scramble the system. The computer matrices of the hotel will be fried and itll take them months, maybe even a year to rebuild and reformat it. His eyes grew wide with child-like wonder. Do you know how wonderfully intricate their computer 98 McCormick 99 matrices are? I mean the Capra was the first to use such a complicated system. Theyve made the human operators practically useless. The hotel cannot function without the computer system, which is bad for them, but good for us. Yely placed a hand on his leg. Please shut up. She smiled. Okay, okay, now we wait. They settled down in front of the screen Geofri had said would be showing the screen. All it showed now was an two dimensional view of a podium set up at the end of the ballroom. People milled about, chatting and drinking from long stemmed champagne flutes that fluoresced slightly, changing colors slowly and making the bubbles sparkle. Sali marveled at the technology that had been so long missing from Earth. The War hadnt extended past the asteroid belt, so Jupiter had remained mostly untouched by the massive destruction felt on Earth and Mars. Instead, it stood as a technological reminder of what used to be. Sali could feel the tension in the room as they watched Mr. Chevre move to the podium, his wife at his shoulder. He cleared his throat and began to speak. Hello. Hello and welcome. Id like to invite you all to take your seat and join me in this first annual Capra gala. We are here to discuss the planned plutocracy of Marius. Applause erupted. Just jangle your jewelry; its loud enough, Geofri quipped. The impoverished are fundamentally different from us. They are rapists, drug dealers, and criminals, and some, I assume, are good people as well, but they are trapped in their own downward spirals. And they hate us. They hate us because we are not 99 McCormick 100 nosediving with them. That hatred is beyond comprehension. These people have a pathological hatred of us. You cant cure that. You cant cure pathological problems like child molesters. There is no cure; they are just pathological. Sali turned to look at Yely, sitting behind her with Geofri. Did he just call us child molesters? Yely laughed and nodded. The other cities, Gali and the rest, theyre like poverty factories, and thats horrible, but what can we do? We need to make Marius better and let the others deal with themselves. The poor, those not like us, they have nothing. They are dishonest, absolute scum, and one of the biggest problems of them is that good people dont let themselves fall that far. They are a disgrace and we should make Marius better by expelling them to their own cities. Let Gali and Oelilag have them and house them in their socialist little utopias. We have enough heaven here without them. Cheers erupted again and a woman in the front row spilled her champagne. Sali winced at the careless waste of expensive alcohol. I think thats quite enough of that, Geofri said, kicking his chair backwards and holding his finger over the keyboard. You ready? Wait, wait, Yely scrambled up and ran to the window where she could see the hotels reflection in the ceiling. Go. Geofri pressed the button as Chevre began to talk about the virtues of wealth and reinstating the gospel of wealth, a doctrine he thought wise from a thousand years earlier. Suddenly the lights flashed bright and vanished. The entire room dissolved into darkness. 100 McCormick 101 All of their screens were blank and Yely watched as the brass lost its luster and the lights turned off, running down the building like water. A flicker caught her attention as below her a small building burned bright for a moment before also fading away. Guys, come look. Youve got to see this. Geofri and Sali hurried to the window to see what was happening. Radiating out from the Capra, buildings were slowly glowing and turning off. The wave quickened, moving from one building at a time to couples, then tens. Slowly, the entire city faded into darkness. The feedback from the media holocams and the personal gadgetry of the audience must have created an energetic sink hole, Geofri said, his eyes shining like a childs. This is more than I had hoped for. Yely took his hand in hers. Geofri? Shut up. Sali stepped forward and stood on her other side and the three of them watched as the last light of Marius blinked out. Everything was dark. 101 McCormick 102 Cygnet Song March paced in the hallway outside his little brothers room, much too familiar with the look of Sain Cabrini Hospital, the sterile white walls, the clean tile floors. He was used to being on the ground floor where the free clinic was housed. When his little brother started vomiting blood, however, he didnt want to take the time to wait in line and instead sold everything valuable he owned and used the extra money from his new job as a foreman on Mars to get a room with real doctors that would focus on making his brother better. Dilly slept fitfully in the bed, calling out every once in a while for his dog moM, an ugly square-headed beast that had followed him home from school one day. March had said that the dog couldnt stay, but the next morning when they opened the door, there she lay, and the next and the next, until March had no choice but to let the damn dog in. moM was asleep at Marchs and worriedly jumped up to greet him every time he came home, her sweet eyes imploring him where her owner was and if he was okay. March had wanted to name her something much more appropriate for a dog like Dori or Pitta, but Dilly was adamant that the dog should be called moM. Its like Mom in reverse, he exclaimed, hugging the smiling dog around its neck. And we need a mom around. How could March argue with that logic? Dilly woke up to a woman talking on the television, his stomach turning underneath the hospital gown dotted with forget-me-nots. He had always loved forget102 McCormick 103 me-nots. He thought the tiny blue flowers looked like miniature versions of the sky and in the middle as another world with another Dilly and March and more forget-me-nots holding their own little worlds. Somewhere out there, a larger version of himself was looking down at his universe and calling it a forget-me-not. March, Dilly said, trying to sit up in his stiff hospital bed. The sheets crinkled as he moved. March. His big brother came through the door, putting on a brave face and a smile that even Dilly could tell was fake. What do you need, kid? Can you get me some water? The one in the green bottle? Dill, you know youre not supposed to have that. Its carbonated and the doctor said no carbonated drinks until youre feeling better. I feel fine. See? Dilly threw the blankets off and tried to get out of bed. His stomach growled, louder than the creaking bed beneath him. Yeah, maybe tomorrow, kid. You should get back in bed. Can I see moM today? Dilly said, putting his skinny white legs back underneath the itchy blanket. Cals watching her while Im at work, but Ill tell you what, kid. Just as soon as the doctor says you can go outside, well take her to that park you love, the one with the swings, and well all have a great day, okay? Dilly smiled, a piece of chocolate from his cake the night before still stuck in his teeth. Okay. 103 McCormick 104 After a week, Dilly couldnt stay in his bed anymore. His legs were restless and there were no more shows on the three channels the television offered. Besides, the TV made his eyes hurt. He stood up slowly, trying not to make too much noise. He found the pants that he had worn when March had taken him to the hospital. He knew there had to be something fun to do here, something that wasnt watching television which was okay, but not what he wanted to be doing for the rest of his life. He left on the forget-me-nots, thinking that it would be a nice touch for anyone that he met to know he wouldnt forget them. If he really was dying, he would remember anyone he met for the rest of his life. He wanted to find the fabled cafeteria, where the wonderful chocolate cake came from, but instead found himself wandering through an area of the hospital where the walls were painted bright primary red and there were significantly more happy posters and the nurses wore scrubs with cartoons on them. Finally, he found an open door. Hello? He leaned his head in. Hello? Is there anyone in here? A girl about Dillys age sat up in her bed. Her skin was pale to the point of translucency and her eyes sat deep within her skull. Her hair was gone and she seemed tiny within her small hospital gown. Oh! I didnt even see you there. Were you just laying down staring at the ceiling? The girl laid back down. Yes, I was. Can I come in? The girl let out a sigh. I suppose so. 104 McCormick 105 Dilly walked in and lied down on the floor beside her bed. Why were you staring at the ceiling? Do you see those dots? The girl pointed out a collection of dots that was especially close together. I was imagining that they were stars and they would start expanding towards all the other stars. Because the universe is expanding, you see. This guy on the TV was talking about it. The universe is expanding and the galaxies are moving farther apart, but things are growing in the space in between, and some things, the things that arent wanted, those things are called a cancer. I have a cancer. So I was thinking that if those dots could grow and spread apart without growing a cancer then maybe my body will take the hint and stop growing cancer. Do you see what I mean? She leaned over the edge of the bed and looked down at Dilly lying on the floor. Do you have cancer? This is the childrens cancer ward. We all have cancer. Thats why none of us have hair. But then again you have hair so you cant have cancer, can you? Dilly smiled up at her. No, I dont have cancer. I was born when all the nuclear reactors were rupturing and got radiation poisoning. Ive always been dying, but recently Ive been dying more. Oh, the girl frowned and lay back down. I dont want to die. I dont want you to die. Im Lizabel, by the way, but all of my friends call me Zaba. Hello, Zaba. Im Dilly. He pointed up at the ceiling. Do you see the reddish dot beside the yellowish one? Yes. 105 McCormick 106 Imagine that is the eye of a cat. The yellow is its tooth, the blue on towards the window is the tip of the ear. Do you see it? I think it looks more like a dog than a cat. No, its definitely a cat. You know what? You do have cancer. Cancer of the eye if you dont see that is definitely a dog. Dilly rolled his eyes. Sure. A dog. What are you doing here? A nurse bustled in the room and shooed Dilly up off the floor. Weve been looking everywhere for you. Come on now, up you get. Its time you were back in your own room not laying on this cold floor. Ill be back, Dilly whispered to Zaba as he stood up. The nurse led him back to his own room and noticed that the floor tiles were colored like the walls. His own room was in the white hallway, Zabas in the red. There were four other colors, red, blue, green, and orange, and Dilly swore to himself that he would figure out what each color stood for. When he got back to his room, he took the coloring book they gave him and found the blankest page. He pulled out the crayons and wrote the five colors on the page. Next to red he put Childrens Cancer and Zaba. The next morning, the nurse was barely out of Dillys room before he was out of bed and into his pants again. He followed the yellow line straight to the lemonade hall and checked each room until he found Zaba, this time sitting by the window looking out over the parking lot and the half-demolished parking garage across the way. 106 McCormick 107 What took you so long? She said accusingly, standing up and pulling her IV with her on its rolling stand. I came straight here. I dont know what youre talking about. She made a face at him, but followed him as he waved her out into the hallway. They paused at the door and looked out to see if a nurse was around. Dilly pointed at the floor. Choose a color. Purple, Zaba said. There isnt a purple. Whyd you say purple? Purples my favorite color. I thought thered be a purple. Dilly rolled his eyes at her. Mine is green. Well then, lets follow green. She ducked around him out the door and headed down the hallway. She had slid on an oversized sweater over her hospital gown so that the little yellow daisies were just visible under its red hem. You coming? She turned back to look at him, her pale skin shining in the fluorescent lights. The one over her head flickered and she looked up. Dilly laughed and followed her and the green line down the hall. The first floor held the free clinic, a place of half-dressed, ragged people clutching babies to their chests or otherwise clutching parts of themselves that they hoped could be fixed, an e.coli infected stomach here, a broken leg there, a ruptured spleen or appendix, a child who swallowed something he shouldnt have. Dilly and Zaba blended into the wallpaper, two skinny children in a hospital of rushing doctors and distracted nurses. Peoples eyes pleaded for mercy from a higher 107 McCormick 108 power they couldnt prove existed, but Dilly only saw the sadness in Zabas eyes at the poor families who were being torn apart by things that they had no control over, rotten food and contaminated water or broken homes letting cold air into lungs already pained with the dirty, dusty air. Behind a door the emergency care center bustled, an area full of blood and bandages and nurses rushing around talking to overworked doctors. Zaba and Dilly werent allowed inside and instead stood outside the double door and watched the chaos inside. People were crying and every few minutes or so someone would run in or out with expressions of horror on their faces. One man was rolled in on a gurney moaning and holding his stomach. The blood seeped out from the bandages he held there and stained his shirt. Zaba had to turn away and Dillys stomach tried to forcefully eject his lunch. I dont think we should stay here, Dilly said, a hand over his mouth as he fixed the wall opposite the emergency care center with a very fixed gaze and tried to get interested with the pattern of the wall to convince his stomach it didnt need to come out his mouth. Are you okay? Im fine, well I mean, as fine as I can be here, you know? Yeah, I know. When March showed up for his visit a two weeks later, Dilly told him about the small girl in the red hallway. He laughed. 108 McCormick 109 Look at you. He rubbed Dillys hair and pushed his brothers shoulder. Chatting up all the girls, are you? March, please. Dilly pushed his big brothers arm away with two hands. Shes not my girlfriend or anything. I dont even like her like that. Shes just nice. March smiled. Mhmm, sure. Whatever you say, kid. He picked up and apple off of Dillys dinner tray and tossed it in the air before taking a large bite out of it. So whats she look like, this girl? Little pieces of apple fell from his bottom lip as he spoke, causing Dilly to laugh. Her name is Zaba and she has cancer. She looks likelike, he glanced around the room to try to find a comparable thing to Zabas firecracker personality. She looks like a wild cat trapped in a person with fire for eyes and starlight for breath, he spoke in a rush, his words all running together. Does she now? And where did you hear that stuff? Dilly blushed a little. I might have taken a book from the nurse. She was reading Lybov Wolanski. Id never heard of it before but it had such beautiful words. March scratched his neck. I think shes a Venutian poet. They write lots of sappy love stuff. I thought it was pretty, Dilly replied indignantly. March took another bite out of his apple and looked at his brother, eyes shining talking about a girl. Hows your new job? Dilly patted the comforter in excitement. His brother was working on a different planet, wasnt that awesome? 109 McCormick 110 Its good. I dont like having to stay on site for so long, but its fine as long as I can get away from your annoying butt. He playfully punched Dilly with his non-apple hand. When do I get to see moM? March had hoped hed forgotten the dog; the nurse had told March his brother wouldnt make it back home again. Soon, buddy, soon. A couple days later, Dilly woke up to Zabas face leaning over him, a plastic tube running from her nose to over her ears. He jumped up, shocked at her proximity. He hadnt seen her since before his brothers visit. While the nurses had given up on healing him and were just making his descent easier, she was in an active ward where they gave her medicine and hooked her up to machines. Her parents visited often, but seemed to come less and less as she grew smaller. She had been sick last week when he visited and had looked like a shrunken, dead version of herself. How did you get in here? Zaba, very much alive, gave him a look as though he were the dumbest person she knew. Its a hospital. There arent locks. Oh. Well, I still need to put on pants. So can you, like, go over there or something? Zaba rolled her eyes and walked over to the window, looking out at a bird perched on the remnants of a nearby streetlamp. Dilly hurried to pull on his pants before she turned around. 110 McCormick 111 Where to now? He asked when he was finished. Blue line is next. Zaba said, leaving the room and rolling her IV cart down the hall. The line led to the middle floor of the hospital, a gray-blue carpet covered the lobby area and the halls were a chipper teal. I know this place, Dilly said, his voice dropping its usual chipper tone. This is where they took my mom when she died. He didnt tell her that his mom might still be here, but that he just didnt know. For all intents and purposes, his mother was dead. It hurt more to believe that she was alive and didnt want him. Zaba didnt know what to say. Most people said that they were sorry when they hear someone has died, but that never quite covered it, besides saying youre sorry implies that you did something wrong. Instead Zaba just gazed down one of the hallways where a woman was trying to climb the wall and a man stood in the stairwell blowing smoke out an open window. A man walked by them with scars covering his arms wearing no shoes and whispering to himself. They only caught a little of his mumbling, but it contained blood and death and pain. I dont want you to worry, Dilly began, looking at the mans back instead of at Zaba, but Im not leaving the hospital. Not ever. March, my brother, doesnt think I know, but I heard the nurses tell him that Im not going to get better. He looked at her face, her mouth open with something like shock or hurt. I just thought you should know. Im dying too, she whispered, looking at the ground. 111 McCormick 112 Dilly began to say something but Zaba cut him off. Im moving to the white hall tomorrow. The rest of the hospital calls that part the hall of the walking dead because you never know when one of them is going to die. Her voice broke on the last word and tears ran down her face. If she had had any hair, it would have hid her grief, but she didnt and her pain was plain on her small, slight features. Dilly wrapped his arm around her shoulders and led her away from the blue. Zaba didnt want to explore anymore, but Dilly insisted that it would make them both feel better if they did. Besides, he reasoned, weve only got one color left. He gently guided Zaba down the yellow path, linking arms as they went. The yellow floor was just below the psych ward and was the maternity and prenatal ward. Through every door they looked there was a tired looking woman holding a new human that looked vaguely like a pink potato. Dilly mentioned the starchy likeness and Zaba laughed, a ringing bell-like sound that echoed off of the empty walls and cold tiles. As they passed on of the rooms, a kid ran out and bumped into Dilly, almost knocking him over with surprise. Hey! Zaba yelled, prepared to confront whoever had run into her friend. Sowwy, the child said. Galic? What are you doing? a voice called out from the room. The three went back inside to find a skinny young mother holding a squealing baby wrapped in a light blue threadbare blanket. Who are you? 112 McCormick 113 Dilly held his hand out. Im Dilly, this is Zaba. We were just exploring the hospital when Galic ran into us. Galic! What have I told you about running in the halls? No, no, Dilly held up his hands defensively. Its alright. He didnt hurt anyone. Were both fine. The woman didnt look appeased but didnt continue. This is Baby Brother, Galic said, toddling over to his mother and climbing onto the bed. He peered into the babys tiny face and smiled. We havent named him yet, the woman explained. His name isnt really Baby Brother. She held him out slightly so that the two kids could see the baby. His face was red and wrinkled and he didnt look at all like the fat, happy babies that decorated the diaper boxes Dillys mom had used to organize her stuff before she left. Dilly kneeled and looked Galic in the face, I think Baby Brother is an excellent name. Galic smiled as Zaba tugged on the back of Dillys shirt, signaling it was time for them to go. Galic scrambled off the bed to follow his new friends, but Dilly put a hand on his tiny shoulder. You need to stay here, he said, pointing at his mother and brother. They are going to need you now. You need to teach Baby Brother how to be a man. Galic smiled and ran back into his mothers bed, holding out his little arms for his brother. Dilly watched and wondered if March had been that excited about his birth. He had to have been a baby here at some point, a resident of the yellow hall filled with pink 113 McCormick 114 new babies. Now he lived in a hall bleached of color and life, a hall only waiting for its residents to abandon it for a world far different. What are you thinking about? Zaba asked from the door as Dilly absentmindedly followed her out. Were two ghosts living in a world of color, he answered, pensively looking down the hall. What do you mean? She asked with a laugh. He looked at her, focusing in on her young angular face with its sunken eyes and sharp cheek bones. She was much too mature for her age, even in her face. I dont think I can explain it, he answered quietly. Dilly hadnt wanted to let Zaba go for the night, but it was dinner time and she needed to eat if she was going to get better. They separated, promising to meet again next week after she moved rooms, though to do what they didnt know. Dilly picked at his food, pushing it around the tray instead of eating. He hadnt felt like eating in days, but didnt want March to worry. He spooned a large bite of mashed potatoes and shoved it down, barely tasting it. March had gone out to find him a proper dessert, saying that the yogurt they provided didnt really count. Dilly took turns forcing down bites of unseasoned food and staring out the window at the dark night sky. Sometimes the smog cleared long enough that he thought he saw a star twinkling through the dark clouds. 114 McCormick 115 So I couldnt find you any cake, but I did get chocolate pudding, March said, coming in with a large bowl of jiggly gelatinous pudding. He set it down on the tray and brandished not one, but two spoons. Hope you dont mind if I share. Dilly ignored the pudding and looked at his older brother. I have a favor to ask. Wow, he said, taking a large bite of pudding. You sure are straight to the point tonight. Got an itch you cant scratch because, kid, I dont want to do it either. Dilly fixed him with a serious gaze. March, stop. Im dying. You know it, I know it, so lets not pretend that its not going to happen, okay? I have something I want to do before I go and I need your help doing it. March set down his spoon and wiped his mouth on the back of his hand. Okay, kid. Shoot. I need you to help me get up on the roof. The roof? Why the heck would you want to go up on the roof? I want to see the sky. Can you get me up there? March looked around and thought for a minute. He remembered the sassy nurse that had complimented him Dillys first week there. She might have been flirting, but March had been too distracted to notice. Sure, he rubbed his chin. What had her name been? I can do that Anda? Amra? March sauntered up to the nurses station to a woman a little younger than he frantically typing away on a computer. He leaned against the counter and snuck a look at the nametag hastily pinned to her scrub shirt. 115 McCormick 116 Hey. He put on the smile that he wore on the rare occasion that he visited a bar. Hello. The nurse glanced up distractedly before staring intently back at her work. Wait, hey, she said, stopping and looking at him. Youre the guy with that brother down the hall. Sweetest kid. An hour later, March returned to Dillys room triumphantly waving a little white card around. Look, she needs this back tomorrow night. Its her spare, but itll get you onto the roof so dont lose it, okay? Dilly bounced on the bed excitedly and held out his hands in a gimme expression. March slapped the heavy plastic card into his hand. You just get on the elevator and insert the card in the reader above the call box and tell it you want to go to the roof. She said that they used to have voice recognition, but since the war they havent had time to scan in the new hires voices and so they just turned that off. It should work. Dilly smiled and held the card out in front of him like it was made of gold. When he looked at his brother, his grin grew lopsided and he started laughing. What? Marched asked. I think you have lipstick on your face. Dilly laughed and Marchs face reddened as he shoved Dilly back into his pile of pillows. The next day, Zaba met Dilly after dinner outside of her new room. Her parents had already left for the day and she was waiting in front of a small room off of the hallway on the other side of the nurses station from Dilly. She seemed to sag as she waited, relying on the pure strength of her bones to hold her up, like a melting statue. 116 McCormick 117 When she saw Dilly, she straightened up and smiled, but she couldnt keep the sadness out of her eyes. Lets go, Dilly said, putting an arm around her shoulders. Zaba allowed him to steer her down the hallway and to an elevator. He brandished the shiny card and did exactly as March had told him and the doors shut with an inaudible rush of air. I had my brother swipe it for me yesterday before he left for work, He explained as he told the elevator to take them to the roof. Why would we go to the roof? Just wait. Youll see. There was no music on the elevator and so the ride up was filled with them joking around and Zaba tickling Dilly with well-timed jabs to the ribs. They settled as the numbers climbed closer and closer to the stop floor. I dont think my parents want to watch me die, Zaba said sullenly. Dilly couldnt help but think that she was lucky to even have parents, but he didnt say anything. They left today and didnt even seem excited to come back and see me tomorrow. I mean I know it sucks, but at least before they acted excited. Sometimes theyd stay the night and just watch me sleep. I think theyre giving up on me. Dilly didnt know what to say, but luckily for him, they reached the top right at that moment and he instructed Zaba to close her eyes. She groaned but did so and let Dilly guide her out of the elevator as the doors opened. They walked a little way out before he said, Here. Open them. 117 McCormick 118 Zaba cautiously opened her eyes to the most beautiful sight shed seen in her short life. The sun was setting over the broken down city. What used to be the Sears Towers shattered windows shining and reflecting the cloudless sky and Michigan Lake in sharp glass fractals. The city smiled up at them in all of its decrepit glory and even the light seemed to sing at them that they were alive, gloriously, happily alive, if only for the moment. Below them, old car carapaces shined in the golden light like scarabs and a few people moved around, beautiful ants in a glass ant hill. Dilly could see a man walking a dog in a derelict park and imagined it to be March and moM. The dog stopped to scout a bush as a possible bathroom and the man put his hands on his hips and looked up at the sky. Doesnt it just make you feel like you could shatter and expand like the universe? Like the stardust in your bones is shining with all of the power of the sun? Dilly looked over at Zaba. Like dying isnt the end? It makes me feel purple, she replied. 118  ...

... Therapeutic Benefits of an Equine-assisted Learning Group for Children with Disabilities Neva Graper May, 2018 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: Jennifer Fogo, PhD, OTR Running head: EQUINE-ASSISTED LEARNING 2 A Capstone Project Entitled Therapeutic Benefits of an Equine-assisted Learning Group for Children with Disabilities Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Neva Graper Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date EQUINE-ASSESSED LEARNING 3 Abstract There is limited research regarding the benefits of unmounted equine assisted learning (EAL) activities, therefore the focus of this DCE is to investigate the benefits of an EAL program for children with a variety of diagnoses. Participants ranged from 6 to 15 years old and included 2 male and 10 female. EAL program lesson plans were developed by an Occupational Therapy Student (OTS). The 12 participants were divided into four groups of two to four participants per group. Each group met one day per week for one-hour sessions for a total of six weeks. A Professional Association of Therapeutic Horsemanship International (PATH) certified instructor and OTS led the participants through a variety of EAL activities including grooming, feeding, tacking, leading, tack cleaning, horse stretching, and vital checking. A Goal Attainment Scale (GAS) was designed specifically for this project to measure social skills, problem solving skills, activity engagement, safety awareness, and lesson plan use. Data were collected through observation and recorded after each session by the OTS. It was found that participants had improved social skills and safety awareness at the end of the EAL program. Therefore, EAL programs may be an effective alternative or supplementation to tradition therapy, however future research needs to be conducted to verify these results. EQUINE-ASSESSED LEARNING 4 Therapeutic Benefits of an Equine-assisted Learning Group for Children with Disabilities Children with disabilities come in many different forms with many different problem areas. There are a lot of treatment interventions being used to address these problems, however due to the individuality of the children, there is no golden way to address all issues. Humans have a variety of motivators that drive them in their everyday participation in life. Being able to find what motivates a person is important when trying to implement change. Occupational therapy is client centered and provides a holistic approach to treatment that aims to improve the overall quality of life of the clients served. However, skilled rehabilitation services are very costly, therefore insurance often dictates how often services are received. So, it becomes important to identify some alternative, affordable, yet effective treatment options for children with disabilities. Equine-assisted therapies may be an alternative to bridge the gap between being beneficial to the client and cost effective. Humans have domesticated animals as pets for thousands of years. Humans and animals have long formed unique bonds of companionship and trust. This unique bond can be utilized as an intervention tool to promote change in children with disabilities. Animals are a good way to motivate and encourage participation in activities that a child may otherwise not want to participate in (Yap, Scheinberb, & Williams, 2017). The human-animal interaction has been shown to have many benefits including increased social interaction among humans, increased trust, decreased depression, increased positive mood, reduced stress and anxiety, increased concentration, improved pain management, increased empathy, and decreased negative behaviors (Beetz & Bales, 2016). EQUINE-ASSESSED LEARNING 5 Literature Review Model of Human Occupation The Model of Human Occupation (MOHO) focuses on the connection between the mind and body that leads to occupational participation. A person's motivation to participate in activities is driven by their volition, habituation, and performance capacity (Cole & Tufano, 2008). Animal-assisted therapy fits well into MOHO due to using the animal as an environmental modification as well as a motivating factor for occupational participation. According to a case-study by Taylor and colleagues (2009), volition in a child with ASD increased over time when participating in hippotherapy. The results demonstrated that the child had increased motivation to participate in everyday activities outside of hippotherapy throughout the course of the hippotherapy intervention (Taylor et al., 2009), indicating that there may be a benefit of using horses as a motivator to participate in intervention thus increasing overall occupational participation. Animal-assisted Interventions Animal-assisted interventions (AAI) is defined as various procedures that are goaldirected and targets the specific aspects (developmental, therapeutic, emotional, behavioral, etc.) of individual or groups of people involved in working with trained animals (Glossary of terms, 2016, para. 7). AAI is an overarching term that encompasses animal-assisted activities (AAA), animal-assisted therapy (AAT), and service animal programs (SAP) (Calcaterra et al., 2015). Occupational therapist can use animals alongside traditional occupational therapy interventions to facilitate occupational performance. Many animals have been used in AAT such as dogs, cats, birds, horses, dolphins, guinea pigs and cows (Poleschuck, 1997). Research has shown that AAT can be used with clients along the lifespan (Andreasen et al., 2017). AAT has been used for EQUINE-ASSESSED LEARNING 6 children with a variety of diagnoses including autism spectrum disorder (ASD), attention deficit hyperactivity disorder, cerebral palsy, down syndrome, fetal alcohol syndrome and victims of neglect or abuse (Andreasen et al., 2017). Animal-assisted Therapy & Autism Spectrum Disorder. OHaire (2017) completed a systematic review that reported the outcomes of research examining the use of horses, dogs, guinea pigs, and dolphins in AAI; horses were the most commonly used animal. According to OHaire (2017), increased social interaction is the most commonly reported outcome from AAI for children with ASD. Other benefits for children with ASD include improved language and communication skills, decreased problem behaviors, increased positive emotions, and improved motor skills (OHaire, 2017). Another study by Funahashi and colleagues (2014), investigated the effects of animal assisted activities on the social behaviors of a child with ASD. Quantitative data revealed that an increase in the number of smiles throughout an AAA resulted in an increase of positive social behaviors. The number of smiles was associated with the incorporation of a dog into therapy to promote positive social behaviors (Funahashi, Gruebler, Aoki, Kadone, & Suzuki, 2014). Animal-Assisted Therapy and Physical & Mental Disabilities. Animal assisted therapy has been found to enhance goal attainment during occupational therapy intervention with children with physical and mental disabilities (Elmaci & Cevizci, 2015). Elmaci & Cevizci (2015) found that children with fears and anxieties were more likely to overcome obstacles with the assistance of an animal compared to those without the assistance of an animal. AAT can also provide physical improvement such as balance. Badau and colleagues (2017) found that with the combination of canine and equine assisted therapies, children with neuromuscular disorders had greater increases in balance than those participating in canine assisted therapy alone. They EQUINE-ASSESSED LEARNING 7 reported that the children had a greater motivation to change their behavior to participate more actively in the treatment sessions with animals (Badau, D. et al., 2017). Equine-Assisted Activities Equine-assisted activities (EAA) is a broad term used to encompass a variety of ways to connect clients and horses. According to the Professional Association of Therapeutic Horsemanship International (Smith, n.d.), equine-assisted activities are defined as any specific center activity, e.g.. Therapeutic riding, mounted or grounded activities, grooming and stable management, shows, parades, demonstrations, etc., in which the centers clients, participants, volunteers, instructors and equines are involved. One specific form of EAA used to promote change is equine-assisted learning (EAL). EAL is defined as experiential learning approach that promotes the development of life skills for educational, professional and personal goals through equine-assisted activities (Smith, n.d.). There is limited research on the benefits of EAL due to it being a relatively new concept. However, there is extensive research regarding the benefits of therapeutic riding and hippotherapy. Equine-Assisted Therapy and Autism Spectrum Disorder. Equine assisted therapy (EAT) can have a significant impact on social skills for children with ASD. Borgi and colleagues (2016) found that through a combination of mounted therapeutic riding and unmounted ground work, children with ASD demonstrated a significant improvement in social functioning, as well as, milder improvements in motor abilities and executive functioning when compared to children in a control group that did not receive EAT. Bass, Duchowny, and Liabre (2009) found that a 12week therapeutic riding program with children with ASD resulted in improved social functioning such as decreased distractibility, increased attention, and increased social motivation when compared to the waitlist control group. Anderson and Meints (2016) found that a 5-week EQUINE-ASSESSED LEARNING 8 therapeutic riding program resulted in a decrease in maladaptive behaviors and an increase in empathizing. However, insignificant changes of socialization and communication were noted, which contraindicates other literature (Anderson & Meints, 2016). Therefore, dependent upon the length of the program and the children involved, therapeutic riding and equine assisted therapy may be a beneficial intervention in the treatment of children with ASD. Equine-Assisted Therapy and Physical & Mental Disabilities. Therapeutic riding can improve gross motor function in children with developmental delay (Winchester, Kendall, Peters, Sears, & Winkley, 2002), spastic cerebral palsy (Cherng, Liao, Leung, & Hwang, 2004), and Down Syndrome (Rigby & Grandjean, 2016). Other benefits of therapeutic riding include decreased spasticity, decreased muscle asymmetry, increased balance, and improved gait (Rigby & Grandjean, 2016). These finding demonstrate that equine-assisted therapies not only provide social and cognitive benefits, it can also illicit physical benefits. Occupational Performance and Participation Equine assisted learning (EAL) programs are very similar to hippotherapy, however many differences are noted. According to Professional Association of Therapeutic Horsemanship (PATH) International, EAL is defined as experiential learning approach that promotes the development of life skills for educational, professional and personal goals through equineassisted activities (Smith, n.d.). Hippotherapy is defined as how occupational therapy, physical therapy, and speech-language pathology professionals use evidence-based practice and clinical reasoning in the purposeful manipulation of equine movement to engage sensory, neuromotor, and cognitive systems to achieve functional outcomes (American, n.d.). Both programs have a therapeutic goal and incorporate use of the horse as a motivational tool and an environmental constraint. However, hippotherapy is focused on promoting changes in everyday EQUINE-ASSESSED LEARNING 9 activities and occupational performance (AOTA, 2014), while EAL is focused on increasing horsemanship with a secondary increase in life skills (Smith, n.d.). Both hippotherapy and EAL have functional outcomes; however, hippotherapy is more generalized to everyday activities as compared to EAL. The greatest difference to note is that EAL does not involve an occupational therapist. EAL is normally designed and implemented by a certified PATH instructor. Autism Spectrum Disorder (ASD) is a main diagnosis among participants with difficulties in social skills. Occupational therapy practice uses social skills training groups to promote changes in social skills for children with ASD (Case-Smith & Arbesman, 2008). These groups have been found to improve a participants ability to initiate and maintain conversations with others, as well as increase confidence and self-esteem (Broderick et al., 2002). Similarly, EAL brings children whom have a lack of social skills together; it promotes them to work together to problem solve through activities and communicate their needs and wants. However, social stories are often incorporated into OT sessions to guide and teach appropriate behaviors (Case-Smith & Arbesman, 2008). EAL lacks this aspect of social groups due to the focus of EAL being on increasing horsemanship skills. Occupational therapy in the school systems is a related service which means that the OT services must support the educational goals (Dunn, 1988). Likewise, EAL is a related service that must support a horsemanship goal (Smith, n.d.). However, both services still incorporate interventions that can be applied to everyday activities and occupational participation. Many school systems work under the direct service model in which children are treated individually or in small groups to reach educational goals (Dunn, 1988). EAL also is a direct service provided in small groups that is used to elicit changes to reach individuals goals. EQUINE-ASSESSED LEARNING 10 Many positive effectives of animal assisted therapy and therapeutic riding have been noted, however there is limited research on the effects of unmounted equine-assisted learning activities. Therefore, the purpose of this Doctoral Capstone Project is to determine the benefits of an equine-assisted learning program for children with a variety of diagnoses. Unmounted interactions with the horse will be used to elicit positive social, cognitive, emotional, and physical changes through the development of grounded horsemanship skills. Methods Setting Morning Dove Therapeutic Riding Inc. is a Premiere Accredited Center of the PATH located in Zionsville, Indiana. All instructors must be PATH certified to facilitate classes and programs (About us, n.d.). Assessment A needs assessment was conducted to gain information through interviews, review of electronic records, and observation. Interviews took place face-to-face in both individual and group settings with three PATH certified instructors at the facility. Interviews were used to gain perceptions and thoughts on needs of the facility, needs of the target population, and identify resources available. Next, electronic records were reviewed as a nonintrusive method to gain information about the target population. Target populations diagnoses, strengths, weaknesses, and goals were identified through review of records and categorized into groups in which the target population was going to participate in the equine assisted learning (EAL) program. Evidence based research through review of journal articles was used to gain greater insight into rider diagnoses. Lastly, the target population was observed in the first EAL program session to get a greater understanding of their real-life behaviors, abilities, and limitations. EQUINE-ASSESSED LEARNING 11 The needs assessment determined that Morning Dove needed an equine assisted learning (EAL) program to address the needs of the participants during the winter months when therapeutic riding was not in session. The overall goal of this program was to increase grounded horsemanship skills. The EAL program was named Barn Buddies because the participants helped with completing daily chores throughout the barn. EAL Program Participants. The target population was a convenience sample of participants that attended therapeutic riding or hippotherapy classes at the facility, Morning Dove. Participants were hand selected by the executive director to participate in the EAL program based on therapeutic need, potential gains, and schedule availability. Participants ranged from 6 to 15 years old and included 2 males and 10 females. Participants were not excluded for having comorbid diagnoses. Participant diagnoses included Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), spinal cord injury, nonverbal processing disorder, anxiety, hypotonia, cerebellar ataxia, epilepsy, speech & language delay, or no diagnosis. Participant goals for participation in equine activities were to develop coping skills, emotional regulation skills, problem solving skills, and social communication skills. Additional goals were to increase independence, confidence, focus, and to overcome fears. Program Planning. The PATH certified instructors and the Occupational Therapy (OT) student brainstormed and constructed a lesson plan topic list for the EAL program. The finalized topic list included feeding and nutrition, basic horse facts and first aid, horse leading and behavior, parts of tack and cleaning, and tacking of horse. These topics are areas of basic horsemanship (Horsemanship, 2017) that the PATH instructors felt would be most beneficial for the participations to learn and practice. Next, the OT student gathered resources regarding the EQUINE-ASSESSED LEARNING 12 topics and developed individualized lesson plans for each session. Lesson plans included horsemanship objectives, life skills objectives, program activities, discussion topics, and ways to grade activities for all levels to promote therapeutic outcomes. Instrument. The primary outcome measurement tool was the Goal Attainment Scale (GAS). The GAS is a five-point scale from -2 to +2 that can be used to measure outcomes from different contexts and make quantitative data out of qualitative outcomes (Sharp, 2007). Kiresuk (1994) has found that GAS is a valid and reliable measure of quantitative data, dependent upon the individual scoring the levels. A GAS was designed by the OT student to measure the outcomes of the EAL program. The OT student observed all individual and group interactions throughout each session. One GAS was scored each week to obtain an overall scoring of individual and group performance. The participants were assessed in areas of social communication, occupational engagement, safety awareness, and problem-solving skills. Also, the instructors were evaluated on how often they followed the lesson plans designed for the program. For further review, please see the GAS in the Appendix. Data Collection & Analyses. One Occupational Therapy (OT) student completed data collection through observation of participants and recorded observations after each session. Data collection was performed at the facility. Data were analyzed by finding the average of all scores for the GAS. These averages were used to determine if goals were met. Implementation Training. The certified instructors had daily access to the weekly Barn Buddies lesson plans to review at their leisure before their scheduled day of instructing. However, during the weekly staff meetings, the OT student reviewed the lesson plan for the week with the certified instructors, demonstrated priority areas that were most important to be addressed with EQUINE-ASSESSED LEARNING 13 participants, allowed time to review resources, and answered the instructors questions. The OT student made sure all resources were prepared each day for the sessions. Intervention. The 12 participants were divided into four groups with two to four members per group. Each group came to the facility and participated in the lesson one day per week for duration of six weeks. Each session lasted for one hour. Each session began with participants throwing grain for horses and ended with filling grain buckets for the following morning. These activities were used as grounding activities to provide consistency and carryover each week to promote successful activity participation and decrease anxieties (Vernberg et al., 2008). The middle portion of the session varied each week and consisted of activities such as making horse treats from a recipe, taking vital signs, practicing horse stretches, leading horses, grooming horses, cleaning tack, tacking up a horse, and learning about safety awareness. At each session, both a certified PATH instructor and the OT student were present. The certified instructor served as the teacher and mentor related to horsemanship. The instructor led the group through the lesson plans, taught horsemanship skills, and assessed safety awareness around the horses. The OT student assisted with transitions, promoted activity participation, promoted social communication, and assisted with problem solving. The OT student worked both one-on-one and in the group format with participants. One-on-one interactions included helping participants refocus their attention to task, grading activities to just-right challenge for each participant, promoting respect of personal space, and facilitating social skills through conversation and communication. The OT student assisted the group with problem solving through activities, learning to take turns and share materials, and recognizing body language of others and horses. EQUINE-ASSESSED LEARNING 14 Results Goal Attainment Scale. After the termination of the six-week equine assisted learning program, collected data were assessed utilizing the GAS. Participants scores for each goal were averaged. Possible scores ranged from +2 to -2. The results are listed below. Lesson Plans. Data were collected based on percentage of utilization of lesson plans. The expected goal of usage was 80%. The final score was -1, which was less than expected level of success. The results indicated that the lesson plans were utilized 63% of the time. Instructors reported that they veered from lesson plans due to time restraints, decreased preparation, weather conditions and incompatibility with participant skills. Social Skills. The OTS observed participants for initiation of conversation with peers and adults. The final score for initiation of conversation with peers was 0, which is expected level of success. On average, 70% of participants initiated conversations with peers throughout the six week duration. The final score for initiation of conversation with adults was +1, which was more than expected level of success. On average, 85% of participants initiated conversation with adults (which included the instructor, OTS, barn manager, executive director or volunteers). Therefore, the results indicate that participants initiated conversations with adults more often than with their peers. During week one, 25% of participants initiated conversations with their peers. By week six of the program, 85% of participants initiated conversations with their peers. Therefore, participants social skills increased through the six-week EAL program. Problem Solving. Participants were observed as a group throughout each session and an assistance level was determined for the level of assistance required to problem-solve through a specific task. At every session, each group distributed dinner to the horses and made grain for the following morning. This task required participants to work together and follow multistep written EQUINE-ASSESSED LEARNING 15 instructions. The final score was -1, which was less than expected level of success. The participants required minimal assistance 35% of the time, moderate assistance 48% of the time, and maximum assistance 17% of the time. Overall, the amount of assist required decreased each week due to the repetition of the activity. However, when group dynamics changed (such as when a participant was absent), the assist level changed. Engagement. The final engagement score according to the GAS scale equated to -1, indicating less than expected level of success. This indicated that an average of 46% of participants stayed engaged throughout an entire activity and did not require any redirects back to the activity. Activities were different each week, therefore length of time, motivation to participate, and difficulty level varied each week. Safety Awareness. The final safety awareness score according to the GAS equated to 0, indicating expected level of success. Seventy-eight percent of participants demonstrated safety awareness each week around the horses. The need for safety awareness varied each week due to the amount of horse interaction based on the weekly activity. Some activities, such as grooming, required more safety awareness than others, such as cleaning tack. However, safety awareness was needed each session due to some form of interactions with the horses. Discussion Based upon the needs assessment, Morning Dove Therapeutic Riding Center needed lesson plans for their unmounted equine assisted learning program. Therefore, the lesson plans and resources created by the OTS for the Barn Buddies program met the needs of the facility. For quality improvement, results of the GAS was used to analyze how often the lesson plans were utilized during the sessions. It was found that instructors utilized the lessons 63% of the time which was less than the expected amount of use based on the goal of 80%. The GAS allowed the EQUINE-ASSESSED LEARNING 16 OTS to determine effectiveness of lesson plans to make suggestions and edits of the lessons for the following year of Barn Buddies. The sessions were implemented by four different instructors; therefore, each instructor followed the lesson plans in their own way. The lesson plans were made available to each instructor via a hard copy and online. The lesson plans and resources remained at the facility after the conclusion of the DCE to be used in the future. Due to the involvement of the OTS in the implementation of the Barn Buddies lesson plans, the OTS recommended that the instructor have a second volunteer to assist with implementation of lessons in the future. The positive impact an equine assisted learning program can have on children with disabilities is evident based on the results. Social skills were shown to increase over the course of the program based on the increase from 25% to 85% participants initiating conversations with peers. Therefore, a significant improvement in social skills throughout the duration of the Barn Buddies program was determined which indicates that the program met the social needs of the participants. However, participant engagement in activities decreased from 50% of participants during week one to 42% of participants during week six. The results indicate that more participants were engaged at the start of the program as compared to the end of the program. Participant engagement may have decreased due to decreased motivation to participate, decreased interest in the sessions activity, instructors not following the lesson plans, or increased distractions from peers due to increased likelihood of initiating conversations with peers. During week one, 62% of participants demonstrated safety awareness. By week six, 85% of participants demonstrated safety awareness around the horses. This shows that participants were more aware of their bodies in space in relation to that of the horse. They also had a better understanding of EQUINE-ASSESSED LEARNING 17 safety needs by the end of the EAL program. Overall, this shows that participants had increased levels of social skills and safety awareness at the discontinuation of the EAL program. Overall Learning Leadership Skills. According to Mumford and colleagues (2000), three skills needed to make an effective leader include increased levels of subject knowledge, problem solving skills, and social skills. As an OT student, I had a large volume of subject knowledge relating to human occupations and ways to promote successful participation with individuals of all skill levels. However, I had limited knowledge relating to horsemanship skills as compared to that of the certified instructors located on site. Therefore, I continued to develop my skills through research, education, and on-site experience with the horses as I developed the Barn Buddies lesson plans. Through this continued research, I developed a basic level of horsemanship knowledge and skills that allowed me to plan sessions to promote a learning experience for the Barn Buddies participants. I determined ways to increase my knowledge on my own and used my social skills to communicate and learn from others with a large knowledge on horsemanship. My strong social skills allowed me to assist the participants with developing their own social skills and problem-solving strategies. I provided services through direct, group, and consultative routes. I worked as a consultant to Morning Dove through planning programs and increasing resources for future use. During the implementation of the Barn Buddies program, I worked one-on-one with group members, as well as assisted with facilitating group interactions. Therefore, I fulfilled multiple leadership roles throughout the course of my DCE experience including directing others, relationship building, verbal and non-verbal communication, and coaching. EQUINE-ASSESSED LEARNING 18 Conclusion The Doctoral Capstone Experience (DCE) was a learning experience that made me grow as a professional and as a person. Throughout my DCE at Morning Dove Therapeutic Riding Center, my professional oral, non-verbal and written communication was challenged which, in turn, forced me to grow and adapt. I interacted with a variety of individuals throughout my DCE including Morning Dove staff members, PATH certified instructors, participants, and participants family members. I had the most interactions with the Morning Dove staff members, due to the small number of employees, spending 40 hours onsite, and sharing an office with three other staff members. I communicated verbally and non-verbally daily with the staff members through informal day to day interaction, facility orientation, formal and informal interviews, learning sessions about therapeutic riding and horses, lesson planning assistance, advocating for OT, and weekly meetings. During weekly meetings, I updated the staff members about my project progress, asked questions, and shared plans for the future. I also communicated frequently with the PATH certified instructors while developing and implementing the lesson plans. During the planning stage, I communicated with the instructors about their goals for the program, topics to incorporate into the lessons, and potential resources to include. When writing lesson plans, I developed and followed a lesson plan template to ensure that the lessons were parallel and easy to follow. Lessons were reviewed and approved by the instructors before implementation. Interactions with participants and family members were always held to the highest standard of professionalism. I always introduced myself and my role upon first interaction with a participant or family member. I also made sure they felt welcome and comfortable by offering a smile and a calming presence. When working with the participants during the implementation of EQUINE-ASSESSED LEARNING 19 Barn Buddies, I made sure I was available for questions or assistance when required, offered guidance toward solutions, or gave praise and encouragement for positive behaviors or actions. I gave participants space when they needed a break or provided encouragement to participate when they needed redirecting. I attempted to maximize participants experience by being an effective therapist that was able to read a situation and implement an appropriate solution based upon the specific needs of the child. Overall, I learned a lot about my own abilities and grew in my confidence through the DCE. Since Morning Dove does not have any therapists on site, I had to rely on my education and professional experience from the past three years to successfully implement the lesson plans I created. This really pushed me to trust myself and my abilities during implementation. Therefore, I feel that this professional experience has made me ready for being an independent therapist in the future. EQUINE-ASSESSED LEARNING 20 References About us. (n.d.). Retrieved February 07, 2018, from http://morningdovetrc.org/about-us/ American Hippotherapy Association, Inc. (n.d.). Retrieved February 07, 2018, from http://www.americanhippotherapyassociation.org/ American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Andreasen, G., Stella, T., Wilkison, M., Moser, C. S., Hoelzel, A., & Hendricks, L. (2017). Animal-assisted therapy and occupational therapy. Journal of Occupational Therapy, Schools, & Early Intervention, 10(1), 1-17. doi:10.1080/19411243.2017.1287519 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. Journal of Autism & Developmental Disorders, 46, 3344-3352. doi:10.1007/s10803-016-2869-3 Badau, D. et al. (2017). Improving balance by experimenting through animal-assisted therapies. Palestrica of the Third Millennium, Civilization, and Sport, 18(3), 139-143. Bass, M. M., Duchowny, C. A., & Liabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism & Developmental Disorders, 39, 1261-1267. doi:10.1007/s10803-009-0734-3 Beetz, A. & Bales, K. (2016). Affiliation in human-animal interaction. In L. S. Freund, S. McCune, L. Esposito, N. R. Gee, & P. McCardle (Eds.), The social neuroscience of human-animal interaction, 107-125. http://dx.doi.org/10.1037/14856-007 EQUINE-ASSESSED LEARNING 21 Borgi, M. et al. (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 Broderick, C., Caswell, R., Gregory, S., Marzolini, S., & Wilson, O. (2002). Can I join the club: A social integration scheme for adolescents with Asperger syndrome. Autism, 5, 427431. Calcaterra, V., Veggiotti, P., Palestrini, C., De Giorgis, V., Raschetti, R., Tumminelli, M., Ostuni, S. (2015). Post-operative benefits of animal-assisted therapy in pediatric surgery: A randomized study. Plos One, 10(6), 1-17. doi:10.1371/journal.pone.0125813 Case-Smith, J., & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. American Journal of Occupational Therapy, 62, 416429. Cherng, R., Liao, H. Leung, H., & Hwang, A. (2004). The effectiveness of therapeutic horseback riding in children with spastic cerebral palsy. Adapted Physical Activity Quarterly, 21, 103-121. Cole, M. B. & Tufano, R. (2008, p. 93). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: Slack. Dunn, W. (1988). Models of occupational therapy service provision in the school system. American Journal of Occupational Therapy, 42(11), 718-723. Elmaci, D. T. & Cevizci, S. (2015). Dog-assisted therapies and activities in rehabilitation of children with cerebral palsy and physical and mental disabilities. International Journal of Environmental Research and Public Health, 12, 5046-5060. doi:10.3390/ijerph120505046 EQUINE-ASSESSED LEARNING 22 Funahashi, A., Gruebler, A., Aoki, T., Kadone, H., & Suzuki, K. (2014). Brief report: The smiles of a child with autism spectrum disorder during an animal-assisted activity may facilitate social positive behaviors- quantitative analysis with smile-detecting interface. Journal of Autism and Developmental Disorders, 44, 685-693. doi:10.1007/s10803-013-1898-4 Glossary of terms (2016). Retrieved from http://www.aai-int.org/aai/glossary-of-terms/ Horsemanship. (2017). Funk & Wagnalls New World Encyclopedia, 1p. 1. Kiresuk, T.J. & Lund, S.H. (1994) "Implementing Goal Attainment Scaling". In Kiresuk, T.J., Smith, A. & Cardillo, J. E. (Ed.s) Goal Attainment Scaling: Applications, Theory and Measurement. Hillsdale, New Jersey, Lawrence Erlbaum Associates. Mumford, M. D., Marks, M. A., Zaccaro, S. J., & Reiter-Palmon, R. (2000). Development of leadership skills: experience and timing. University of Nebraska Omaha Psychology Faculty Publications, 1-30. OHaire, M. O. (2017). Research on animal-assisted intervention and autism spectrum disorder, 2012-2015. Applied Developmental Science, 21(3), 200-216. doi:10.1080/10888691.2016.1243988 Poleshuck, L. R. (1997). Animal-assisted therapy for children and adolescents with disabilities. Work, 9(3), 285293. Rigby, B. R. & Grandjean, P. W. (2016). The efficacy of equine-assisted activities and therapies on improving physical function. The Journal of Alternative and Complementary Medicine, 22(1), 9-24. doi:10.1089/acm.2015.0171 Sharp, D (2007). Goal Attainment Scaling: An evaluation tool to improve evaluation design and data collection for accountability and program improvement, Workshop Paper, P.E.R.S.O.N.A.L. (Research & Evaluation) Consultancy Pty Ltd. Retrieved from EQUINE-ASSESSED LEARNING 23 http://www.personalresearchandevaluation.com/documents/goal_attainment/ColinSHAR P-Paper-Workshop2-GAS.pdf Smith, C. (n.d.). Learn about EAAT. Retrieved from https://www.pathintl.org/resourceseducation/resources/eaat/27-resources/general/193-eaat-definitions Taylor, R. R., Kielhofner, G., Smith, C., Butler, S., Cahill, S. M., Ciukaj, M. D., & Gehman, M. (2009). Volitional change in children with autism: a single-case design study of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192200. doi:10.1080/01642120902859287 Vernberg, E. M., Jacobs, A. K., Watson, P. J., Layne, C. M., Pynoos, R. S., Steinberg, A. M., Ruzek, J. I. (2008). Innovations in Disaster Mental Health: Psychological First Aid. Professional Psychology: Research and Practice, 39(4), 381-388. Winchester, P., Kendall, K., Peters, H., Sears, N., & Winkley, T. (2002). The effect of therapeutic horseback riding on gross motor function and gait speed in children who are developmentally delayed. Physical & Occupational Therapy in Pediatrics, 22(), 37-51. EQUINE-ASSESSED LEARNING 24 Appendix Goal Attainment Scale Goal: Much more than expected level of outcome +2 More than expected level of outcome +1 Expected level of outcome: success 0 Less than expected level of success -1 Much less than expected level of success -2 Lesson plans will be utilized 80% of the time. Lesson plans utilized 100% of the time Lesson plans Lesson plans Lesson plans Lesson plans utilized 90% of utilized 80% of utilized 40% of utilized 0% of the time the time the time the time 50% of group members will initiate conversation with peers each session. 100% of group members initiate conversation each session 75% of group members initiate conversation each session 50% of group members initiate conversation each session 25% of group members initiate conversation each session 0% of group members initiate conversation each session 50% of group members will initiate conversation with an instructor each session. 100% of group members initiate conversation each session 75% of group members initiate conversation each session 50% of group members initiate conversation each session 25% of group members initiate conversation each session 0% of group members initiate conversation each session Group will require min A for problem solving group tasks in each session. Independent with problem solving Standby A for problem solving Min A for problem solving Mod A for problem solving Max A for problem solving 50% of group members will stay engaged in group activities each session 100% of group members will stay engaged in group activities each session 75% of group members will stay engaged in group activities each session 50% of group members will stay engaged in group activities each session 25% of group members will stay engaged in group activities each session 0% of group members will stay engaged in group activities each session 75% of group members will demonstrate safety awareness each session. 100% of group members demonstrated safety awareness 90% of group members demonstrated safety awareness 75% of group members demonstrated safety awareness 50% of group members demonstrated safety awareness 25% of group members demonstrated safety awareness  ...

... Running head: FALLS PREVENTION 1 The Role of Occupational Therapy in a Community-Based Falls Prevention Program Shannon Nale May 2018 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: Julie Bednarski, OTD, MHS, OTR FALLS PREVENTION 2 A Capstone Project Entitled The Role of Occupational Therapy in a Community-Based Falls Prevention Program Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Shannon Nale Doctorate of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date FALLS PREVENTION 3 Abstract The purpose of this doctoral capstone experience and project was to explore and evaluate the role of occupational therapy in a community-based falls prevention program. The goal of the program was to address falls prevention among community-dwelling older adults to increase their ability to safely engage in meaningful occupations and remain in their homes. A doctor of occupational therapy student completed this program as part of the doctoral capstone experience with members of a seniors program at a local non-profit community center. The program was based on B. Howards My Safe and Sound Plan: For Staying Falls-Free (2018), which is an evidenced-based falls prevention guide. Each of the six sessions consisted of education, demonstrations, and interactive activities. At the conclusion of the program, 90% of the participants demonstrated an increase in understanding of how to prevent falls and 80% plan to make changes to decrease their fall risk. To ensure sustainability of the program, staff members received education and resources on falls prevention to provide to future members. After completion of the program, it was concluded that an occupational therapist led falls prevention program in a community-based setting is effective for increasing older adults awareness of how to prevent falls and decrease fall risk. FALLS PREVENTION 4 Literature Review Falls among older adults are extremely common, with more than one in four adults over the age of 65 falling each year. Falls are often devastating for older adults, causing 7 million injuries and 27,000 deaths annually (Centers for Disease Control [CDC], 2016c). A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (World Health Organization, 2018). Additionally, the number of falls results in an annual Medicare cost of $31 billion (CDC, 2016b). As the baby boomers continue to age, the population of older adults over the age of 65 in the United States is expected to more than double from 46 million in 2016 to 98 million in 2060 (Mather, 2016). With the increase in the aging population, it is important to address the issue of falls prevention, in order to help improve the health and wellbeing of the older adult population and decrease healthcare costs related to falls. Role of Occupational Therapy The Occupational Therapy Practice Framework: Domain & Process 3rd Edition supports the involvement of occupational therapists (OT) in falls prevention. OTs have the unique ability to address multiple facets related to falls prevention, including the persons physical and mental wellness, environment, and performance patterns in order to decrease falls and increase occupational performance (American Occupational Therapy Association [AOTA], 2014). Research shows that OT involvement in falls prevention has focused on environmental modifications, exercise interventions, and multicomponent interventions (Leland, Elliott, OMalley, & Murphy, 2012). However, OT can also be involved in areas such as medication management, management of postural hypotension, and reducing the fear of falling (Leland et al., 2012). FALLS PREVENTION 5 National Organizations Many organizations nationwide have recognized the need to reduce falls in the older adult population. In 2015 the National Council on Aging (NCOA) released their 2015 Falls Free National Falls Prevention Action Plan (NCOA, 2015). This plan is a combination of goals and strategies that NCOA intends to implement over the next ten years. The five main topics addressed in NCOAs plan are; 1) physical mobility, 2) medication management, 3) home safety, 4) environmental safety in the community, and 5) cross cutting. Cross cutting involves NCOAs plan to fund, promote, and expand evidence-based falls prevention programs (NCOA, 2015). The CDC is also taking steps to help reduce falls through their Stopping Elderly Accidents, Deaths, & Injuries (STEDI) initiative (CDC, 2016a). STEDI is a toolkit that provides healthcare providers with access to free online information, resources, and training. STEDI resources include fall risk assessments and screens, and falls prevention resources that providers can give to their patients and families (CDC, 2016a). In 2001 the American Geriatrics Society (AGS), the British Geriatrics Society (BGS), and the American Academy of Orthopedic Surgeons created The Guideline of the Prevention of Falls in Older Persons. Then in 2010, AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2010) was published by AGS and BGS as an update to the first guideline and to include recent falls prevention literature. The revision was created along with other falls prevention experts, including members of AOTA. The purpose of this guideline is to provide clinicians with evidence-based knowledge for assessing and managing fall risk of their older adult patients (AGS & BGS, 2010). AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2010) uses evidence from the literature to make recommendations regarding assessments and interventions FALLS PREVENTION 6 for older persons who may be at risk of falling. A detailed assessment aids clinicians in creating a client-centered intervention plan that addresses the clients unique risk factors. AGS/BGS recommends multifactorial interventions that include these topics: medication management, exercise, vision impairments, postural hypotension and other heart conditions, vitamin D, foot problems and footwear, home environment modification, and general falls prevention education (AGS & BGS, 2010). Exercise Interventions Many falls prevention interventions and strategies have been researched, including exercise (Li, Harmer, & Fitzgerald, 2016; Power & Clifford, 2011; Zhao, Chung, & Tong, 2016). Zhao et al. (2016) found that a community-based Exercise for Balance Improvement Program, increases the balance in older adults and also decrease the fear of falling. Li et al. (2016) implemented an evidence-based falls prevention program called Tai Ji Quan: Moving for Better Balance (TJQMBB) at four community senior centers. TJQMBB was found to be effective in reducing falls by 49% (Li et al., 2016). Power and Clifford (2011) conducted a detailed review of the literature to determine the characteristics of optimum falls prevention exercise programs. Power and Clifford (2011) found that the most effective exercises were completed three times a week. The intensity of exercises was highly variable; however, the researchers found that exercises were most effective if the intensity slowly progressed as the clients abilities progressed. Furthermore, comprehensive exercise programs that included balance, strength, endurance, and flexibility exercises, were found to be effective in reducing fall risk (Power & Clifford, 2011). Multicomponent Interventions FALLS PREVENTION 7 The effectiveness of exercise interventions alone in reducing falls is moderate (Chase, Mann, Wasek, & Arbesman, 2012). Similarly, the evidence for the effectiveness of home modifications and assessments alone is moderate. However, when falls prevention programs include exercise interventions, home modifications, education, and vision and medication checks, the strength of evidence is strong. Therefore, evidence suggests that multicomponent falls prevention programs are the most effective (Chase et al., 2012). Falls prevention programs such as A Matter of Balance, Tai Chi: Moving for Better Balance, Stepping On, and Otago are becoming more available around the United States (Peterson, 2011). A Matter of Balance is an evidence-based, multicomponent falls prevention program that was developed in the 1990s at Boston University (Chen, Edwards, & Janke, 2015; Haynes, League, & Neault, 2014). The program includes exercises and information along with a cognitive-behavioral approach to reduce the fear of falling (Chen et al., 2015; Haynes et al., 2014). A Matter of Balance has been shown to significantly improve physical risk factors of falling in community-dwelling older adults (Chen et al., 2015). Falls in the Community Chippendale and Bear-Lehman (2011) call to attention that outdoor falls are almost as common as indoor falls, yet most falls prevention programs focus only on home modifications and exercise. Chippendale and Bear-Lehman (2011) state that adults who go outdoors are more likely to maintain their functional status. OTs can help their clients become aware of potential hazards in the community in order to help limit outdoor falls. Additionally, OTs can collaborate with community leaders to make positive changes in the community that will limit fall hazards for older adults when they are outside their homes (Chippendale & Bear-Lehman, 2011). Fear of Falling FALLS PREVENTION 8 Approximately 33-55% of community-dwelling older adults have a fear of falling (Borska et al., 2016). Choi, Jeon, and Cho (2017) found that fear of falling is one of the strongest risk factors of falling in older adults. Fear of falling is related to activity restrictions and greater functional decline, which increases the risk of falling (Choi et al., 2017; Painter et al., 2012). Painter et al. (2012) also found a relationship between fear of falling and depression and anxiety. Additionally, Schepens, Sen, Painter, and Murphy (2012) define fall-related efficacy as confidence or belief in ones ability to perform activities without losing balance or falling (p.137). Schepens et al. (2012) completed a meta-analytic review and found that older adults with a higher fall-related efficacy were more likely to engage in activities. Theoretical Basis As a future OT, I recognize the impact that fear of falling and fall-related efficacy have on activity engagement for older adults. The Cognitive Behavioral Frame of Reference (FOR) focuses on how emotional and psychological barriers affect an individuals ability to engage in activities (Cole & Tufano, 2018). During this Doctoral Capstone Experience (DCE), I will use the Cognitive Behavioral FOR to help older adults achieve a positive and realistic mindset about their fall-related efficacy and fear of falling (Cole & Tufano, 2008). Helping older adults increase their fall-related efficacy and decrease their fear of falling, should in turn improve their ability and wiliness to safely engage in meaningful occupations, and decrease their fall risk. I will also use the Canadian Model of Occupational Performance (CMOP) during my DCE to create a client-centered falls prevention program. The CMOP focuses on the interaction between the person, the environment, and occupation in order to achieve occupational performance (Cole & Tufano, 2008). The CMOP views the person in three parts, physical, cognitive, and affective. I will address the physical person through exercise, and the cognitive FALLS PREVENTION 9 and affective person through discussion of fear of falling and what motivates each individual. Occupations are different for each older adult, and may require different modifications in order to be completed safely. I will make individualized suggestions on modifications and adaptations that clients can make in their home and community environments (Cole & Tufano, 2008). By focusing on each clients unique person, occupation, and environment, I will be able to help them improve their occupational performance and reduce their fall risk. Hu, Vance, and Strak (2016) gathered information from community-based OTs and adults 65 years of age and older regarding essential elements of falls prevention programs for medically underserved older adults. Common themes that emerged were trust, autonomy, cost, readiness to change, and health literacy (Hu et al., 2016). I will be working with older adults who live in a medically underserved area during my DCE. I will use evidence from the literature along with these themes in order to create and implement an effective client-centered falls prevention program. Screening and Evaluation The initial screening process for this DCE consisted of speaking with the senior program director and deputy director at the site (Flanner House). Both individuals have experience working with the older adults who attend the seniors program at Flanner House. During the initial needs assessment these individuals stated that the older adults in the program would be interested in falls prevention, as many of them have previously fallen. Additionally, one of the members of the seniors program recently fell and passed away in their home and another member fell and broke their hip while out in the community. Gaining background information from the staff in this community-based setting, is similar to obtaining information from a chart review in a traditional OT inpatient or outpatient setting with an individual service delivery FALLS PREVENTION 10 model. After speaking with staff members and determining the need for a falls prevention program at Flanner House, extensive research was completed. A literature review over incidence of falls, community-based falls prevention programs, reasons for falls, and fall risk assessments was conducted to determine the needs of this population. The American Geriatric Society and the British Geriatric Society recommend that assessments and screens should be multifactorial and ideally include a focused history, physical examination, functional assessment, and environmental assessment (AGS & BGS, 2010). A variety of assessment tools and screens have been used to determine fall risk in communitydwelling older adults. Tomita, Saharan, Rajendran, Nochajski, and Schweitzer (2014) found that the Home Safety Self-Assessment Tool (HSSAT) is a valid and reliable tool to pinpoint fall risk at home. The HSSAT is used by community-dwelling older adults in order to help them identify fall risk factors in their home (Tomita et al., 2014). Elliott et al. (2012) used a modified version of the Falls Risk for Older People: Community Setting (FROP-Com), which includes fall history, home environment, functioning, and daily tasks, and the Activities-specific Balance Confidence (ABC) scale at a community adult falls prevention event. The evaluation for this DCE was completed through a needs assessment with the clients. The needs assessment consisted of a survey (See Appendix A). Assistance was provided to each participant while completing the survey to ensure correct understanding of each question. The survey was developed based on common themes found in the research, such as fear of falling. Fear of falling is a major risk factor for falls; therefore, it was important to address in the needs assessment (Choi et al., 2017; Painter et al., 2012). Of the older adults that completed the survey, 83.3% said that they strongly agreed or agreed that they were afraid of falling in the community. Additionally, 50% of the older adults answered strongly agree or agree that they FALLS PREVENTION 11 were afraid of falling at home. However, only 33.3% of the older adults strongly agreed or agreed that fear of falling keeps them from participating in activities. Another risk factor for falls is a lack of physical activity or exercise, as older adults who are active are less likely to fall compared to older adults who are inactive (Carlson, Kruger, Kohl, & Buchner, 2006). Of the older adults that completed the survey, 66.7% stated that they strongly agreed or agreed that they participate in some form of exercise 3 times a week. Another area assessed in the survey was the older adults level of understanding on how to prevent falls in their home and in the community. Ideally, the student would visit the home and community of each older adult in order to make recommendations on how each client could prevent falls; however, that was not an option in this setting. Many assessments such as the HSSAT and the FROP-com focus on the safety of the home environment when determining an older adults fall risk (Elliott et al., 2012; Tomita et al., 2014). Surprisingly, only 33.3% of the older adults answered disagree with having a good understanding of how to prevention falls while at home and while in the community. Age was another important piece of the evaluation, as the prevalence of falls increases from about one and 4 older adults over the age of 65 falling each year, to about 50% of adults over the age of 80 falling each year (CDC, 2016c; Plaksin, 2014). The average age of the older adults who completed the survey was 76, with 2 older adults being over the age of 80. Fall history was included in many of the assessments found in the literature and was found to be a major risk factor for having multiple falls (Dionyssiotis, 2012; Elliott et al., 2012; Plaksin, 2014). AGS/BGS (2010) also recommend that a fall risk screening include fall history. Furthermore, about half of the falls in adults over the age of 65 occur in adults who have previously fallen FALLS PREVENTION 12 (Dionyssiotis, 2012). Of the older adults who completed the survey, 83.3% reported that they have fallen in the past. Completing the survey one-on-one with each older adult also provided the opportunity to gain further knowledge about each individuals fall risk and fall history. Other fall risks noted by the older adults were history of osteoarthritis, chronic obstructive pulmonary disease (COPD), diabetes, and congestive heart failure. Many of the older adults stressed that they would like more information on falls prevention so they can remain in their homes. The needs assessment and speaking one-on-one with each older adult in this community-based setting, would be similar to completing an occupational profile in an outpatient or inpatient setting with an individual service delivery model. Standardized tests are commonly used in traditional areas of practice such as outpatient and inpatient settings. Due to the nature of this project, the community-based setting, and this particular population; a standardized test was not used to evaluate the fall risk of this group. Although the needs assessment survey provided valuable information about each of the participants, AGS/BGS (2010) suggests that fall risk assessments should also include a functional assessment. In order to test the physical and functional abilities of the participants, the fall risk screening from B. Howards My Safe and Sound Plan: For Staying Falls-Free (2018) was used (See Appendix B). This assessment assesses the strength, endurance, balance, functional reach, and balance confidence of each participant in order to determine their fall risk (Howard, 2018). Falls in the inpatient setting are also very common, with thousands of falls reported annually in the United States and about 30-50 % of falls causing an injury (Joint Commission, 2015). Similar to community-based fall risks, Hayakawa et al. (2014) found that age and history FALLS PREVENTION 13 of falling are two of the major fall risk factors for patients in the inpatient setting. Falls in community-dwelling old adults and patients in the inpatient setting can be devastating and can lead to a loss of independence, functional impairment, and decreased ability to complete activities of daily living and instrumental activities of daily living (Chase et al., 2012; Hayakawa et al., 2014). The goal of this DCE is to help older adults at Flanner House prevent falls and decrease their fall risk by using the unique role of OT to help them maintain their independence and functional abilities in order to remain engaged in meaningful activities (AOTA, 2014). Implementation Phase Program Planning Program planning for this DCE project began with a needs assessment with key staff members and the older adults at Flanner House. A review of the literature was conducted in order to determine what elements needed to be addressed within the falls prevention program. The review of the evidence included falls prevention programs, interventions, and reasons for falls. After review of the literature, it was concluded that B. Howards My Safe and Sound Plan: For Staying Falls Free (2018) would be used as a guide for the falls prevention group, as it contains many of the suggested elements of a falls prevention program according to AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2010). Implementation The falls prevention program was held at the Flanner House in the seniors room, with 6 to 10 older adults attending each session. Each session was about 45 minutes in length and began with an icebreaker or game to engage the older adults. The icebreaker or game lasted for approximately 15 minutes and the other 30 minutes were spent discussing falls prevention utilizing B. Howards My Safe and Sound Plan: For Staying Falls Free (2018). The falls FALLS PREVENTION 14 prevention program materials were printed and made into a booklet for each participant. The participants followed along in their booklets as the capstone student verbally and visually provided education to them on each topic area. Due to the varying cognitive and physical levels of the older adults in the falls prevention program, there were not a specified number of sessions scheduled. The capstone student used clinical reasoning to determine the amount of material covered each session by taking into consideration the needs of the older adults and the time available. The program concluded after six sessions, and upon completion of all of the information in the booklet. Once the group was finished, participants took their booklets home to use as a reference in the future. Principles of lifestyle redesign were used to implement each session, with the intent to help the older adults make positive life changes in order to safely engage in meaningful occupations (Jackson, Carlson, Mandel, Zemke, & Clark, 1998). The sessions were structured in the format of a lifestyle redesign group, beginning with a didactic presentation or teaching component. The sessions then progressed through peer exchange, active engagement, and self-reflection (Jackson et al., 1998). The initial session focused on completion of the pre-assessment and introductions between the capstone student and the older adults. The capstone student spent time talking with each older adult in order to build rapport with each of the participants. The capstone student then introduced the falls prevention program and discussed both internal and external reasons for why people fall. Risks for falls in order adults were discussed and the participants were encouraged to reflect on reasons why they have fallen or why they might be concerned about falling. During the second session, six participants engaged in a holiday themed game and completed the fall risk screening tool in B. Howards My Safe and Sound Plan: For Staying Falls Free (2018). The screening consisted of five yes or no questions. Of the five questions, FALLS PREVENTION 15 four required the participants to physically test their skills. Skills that were physically tested were strength, endurance, balance, and functional reach. The participants completed the screening while sitting in or standing by a chair with supervision provided by the capstone student for safety. Participants were encouraged to stop at any time if they felt too unsteady or that they might fall. If a participant answered no to any of the questions, they are considered to be at risk for falling. Of the older adults who completed the screening, 83.3% answered no to at least one question, indicating that they are at risk for falling. See Table 1 for fall risk screening results. Table 1 Fall Risk Screening Results (n=6) Question Category Yes No* Strength 6 0 Endurance 1 5 Balance 3 3 Functional Reach 6 0 Balance Confidence 6 0 Note: *No response indicates risk for falls The third session focused on three topics: 1) being open to thinking in new ways, 2) managing medications, and 3) heart health. Participants were encouraged to share what changes they may make in order to limit their fall risk. A few participants shared that they could ask for help from family members if they thought the task was unsafe. However, the participants had a FALLS PREVENTION 16 difficult time giving examples of what they may change. The capstone student made suggestions such as: placing commonly used items on waist height shelves, removing clutter from the floor, and moving rugs off the floor. Next, the group discussed the impact that medications may have on their fall risk. Participants shared how they manage their medications and their strategies for knowing when to take their medications. Most of the participants displayed good knowledge of their medications and when to take them. Lastly, the capstone student educated the group on the importance of blood pressure, heart rate, and heart rhythm. The participants were very interested in this topic and ways that they could improve their blood pressure. Session four topics included: vision, footwear and foot care, vitamin D and calcium. Participant engagement and discussion was increased during this session. Participants were willing to share what changes they had experienced in their eyesight and how it was affecting them. Many participants said that they keep a nightlight in their bathroom or bedroom to increase their safety when getting up during the night. The older adults were educated on the importance of wearing the correct shoes and taking care of their feet to decrease fall risk. Each of the participants had on appropriate shoes during the session. The importance of vitamin D and calcium were also discussed. Many of the participants were already taking vitamin D or calcium supplements. If a participant was not currently taking a vitamin D or calcium supplement, they were encouraged to talk to their doctor to determine if these supplements would be beneficial for them. The fifth session covered exercises for falls prevention. The capstone student explained the importance of exercise and how it can reduce fall risk. The group discussed the importance of slowly easing into exercising and building upon exercises, as they get stronger. Strength, endurance, balance, and stretching exercises were demonstrated and discussed. The participants FALLS PREVENTION 17 were encouraged to engage in the exercises within their own abilities. About 75% of the seniors participated in the exercises, 25% refused. The capstone student closely supervised the participants for safety while they completed the exercises. Clinical reasoning and judgment were used to help modify some of the exercises to ensure safety of all participants. After completion of the exercises, the group discussed which exercises they would perform at home and how they would do so safely. The sixth and final session include home safety and a post-assessment. The group discussed home safety and how to check each room of the house for fall hazards. The group went though a safety checklist for: entrances, halls, steps, kitchen, bathroom, bedroom, and living room. In addition to home safety, the group talked about ways to modify activities and behaviors. Although the group went through the checklist during the session, participants were encouraged to go through the checklist a second time once they were at home. Next, the capstone student briefly went through all the topics that were covered during each session and participants had the chance to ask any questions they had regarding falls prevention. Finally, ten older adults completed the falls prevention post-assessment to determine the effectiveness of the program. Overall, post-assessment results showed the falls prevention program was effective in increasing the older adults understanding of falls prevention. Results are further discussed in the outcomes section. Leadership Many leadership qualities were needed in order to plan and implement the falls prevention program. The capstone student was required to have good communication skills in order to effectively communicate with staff members to plan and determine the need for the falls prevention program. Additionally, effective communication skills were necessary when leading FALLS PREVENTION 18 the falls prevention group. It was important to understand the cognitive levels of the participants to make sure they understood the material. The capstone student had to communicate the falls prevention information in a clear way to ensure understanding of the material. While leading the groups, the capstone student had to be assertive enough to capture the attention of participants while encouraging active engagement. Adaptability was needed in order to modify or change sessions based on the needs of the group. This included knowing when to stop each session based on the engagement of the participants and the time available. Overall, the capstone student had to continue to develop appropriate leadership skills in order to successfully implement the program and to assist with staff development. Staff Development Throughout the implementation process, the capstone student updated the senior coordinator and the deputy director about the groups progress and topics covered. Although the falls prevention program will conclude prior to the capstone student leaving, it is important that the seniors continue to be aware of their fall risk in order to preserve their safety. The senior coordinator and deputy director were educated on ways to encourage the seniors to continue decreasing their fall risk. This included encouraging them to: engage in exercise, stay active, and be cautious while out in the community. Upon the capstone students departure, the staff can continue to lead the seniors in exercises that have been provided along with the falls prevention program. Staff members were given a copy of B. Howards My Safe and Sound Plan: For Staying Falls Free (2018) to reference if the seniors have questions. The capstone student educated the staff members on the idea of lifestyle redesign so they can continue to encourage the seniors to engage in healthy activities at home, in the community, and while at Flanner House. FALLS PREVENTION 19 In addition to the falls prevention program, the capstone student worked with staff members on professional development. The capstone student educated the staff on depression, work stress management, and reflective coloring. The staff at Flanner House recently discovered that many of the clients they serve experience signs and symptoms of depression. Therefore, the staff felt that it would be beneficial to increase their knowledge of depression and the impact it can have on individuals. The capstone student provided the staff with an educational handout on depression that included: signs and symptoms, statistics, causes, risk factors, impact on work performance, and how to work with someone who has depression. The capstone student and staff discussed additional community resources available to individuals with depression and their own personal experiences of working with someone with depression. Reducing work stress is a great way to reduce burnout, increase job satisfaction, and boost staff morale, so that they can provide their clients with the best possible care. The work stress presentation addressed ways to minimize stress at work, how to organize their time and desk to limit stress, the benefits of sleep, healthy eating, exercise, and how to fight the Monday blues. The staff members were receptive to various ways to reduce stress at work and indicated that they were specifically interested in yoga and reflective coloring. The capstone student led a reflective adult coloring session focused on resilience and how it could be applied to their daily work. Staff members reported that they learned valuable information on how to improve their job performance and satisfaction through the staff development meetings. Discontinuation Phase Outcomes The goal of the falls prevention program was to decrease participants fall risk and increase their knowledge of how to prevent falls. Upon completion of the falls prevention FALLS PREVENTION 20 program, the participants completed a four question post-assessment (See Appendix C) to measure the effectiveness of the program. Ten participants completed the survey, with 90% reporting an increase in understanding of how to prevent falls. More than half of the participants reported a decreased fear of falling. Many participants also reported they plan to continue exercising regularly or start exercising regularly, and they plan to make changes to prevent falls (Table 2). Overall, results indicate that the program was effective in increasing awareness and knowledge of how to prevent falls. Table 2 Fall Prevention Post-Assessment Results (n=10) Question I have a better understanding of how to prevent falls Yes Neutral No 9 1 0 I am less afraid of falling 6 3 1 I plan to continue to exercise regularly or start exercising regularly 9 0 1 I plan to make changes to prevent falls 8 2 0 Continuous Quality Improvement Continuous quality improvement was used throughout the falls prevention program. Before, during, and after each session, participants were asked if they had any questions regarding previously covered material. Questions were answered using knowledge FALLS PREVENTION 21 from the literature and clinical reasoning to ensure the participants had a good understanding of the information. At the end of each session, all of the information was summarized in an effort to clarify any questions from the group. After each session, the capstone student reflected on what went well and what could have gone better. Then, the capstone student would determine what changes needed to be made to the structure of the session in order to make it more successful and meaningful for the group. Small changes were made prior to the start of each session. Some of the changes included: repositioning a few participants so they could better participate, speaking louder while presenting, and encouraging participants to increase their participation in discussion. Additionally, after each session, the deputy director of Flanner House was briefly educated on topics covered, so that she could gain a better understanding of falls prevention and ways that she may be able to help the seniors in the future. Although the falls prevention program formally concluded, continuous quality improvement was utilized in order to continue to reduce the fall risk of older adults at Flanner House. At a staff meeting, which included the deputy director and senior coordinator, the capstone student presented information regarding the falls prevention program. During the meeting, the staff gained knowledge on the importance of falls prevention, basic information on how to prevent falls, and the outcomes of the program. The deputy director and senior coordinator were each given a paper and PDF copy of B. Howards My Safe and Sound Plan: For Staying Falls Free (2018). Staff members have been encouraged to provide the falls prevention booklet to seniors who come to Flanner House in the future. Additionally, staff members were encouraged to keep at least one booklet in case any of the seniors had questions on falls prevention. During the rest of capstone students time at Flanner House, she continued to work on various aspects of lifestyle redesign with the older adults. This included healthy FALLS PREVENTION 22 cooking demonstrations, activities with children from Flanner House, education on Alzheimers, and adult coloring for relaxation and stress management. The seniors were encouraged to ask any questions they had regarding falls prevention, home modifications, or anything else related to safe completion of daily activities. Response to Societys Needs As mentioned in the literature review, more than one in four adults over the age of 65 fall each year and many of these falls are devastating (CDC, 2016). OTs have unique qualities and training that allow them to address client and environmental factors related to fall risk. The Occupational Therapy Practice Framework: Domain & Process 3 Edition states that OTs can rd use their knowledge of the relationship between an individual and their occupations in order to facilitate a positive change in client factors that allow the individual to more effectively engage in meaningful occupations (AOTA, 2014). Throughout the falls prevention program, client factors such as fear of falling, blood pressure, vision, and physical fitness were addressed. Home environmental factors such as lighting, clutter, placement of items, stairs, and rugs also were discussed. During each session, the group examined how the relationship between each individuals own unique client and environmental factors affect their risk of falling. Participants worked through the falls prevention booklet to gain a better understanding of how they could change their client and environmental factors in order to decrease their fall risk. A majority of the older adults at Flanner House live in their homes and plan to continue living there. In order to do so safely, it is important that they understand how to prevent falls so they can remain safe. Making small mental and physical changes will help them continue to age in place (AOTA, 2011). As society continues to age, it has become more important to consider the safety needs of older adults. It is the duty of occupational therapists to help preserve the FALLS PREVENTION 23 safety and well-being of older adults in order to help facilitate their ability to engage in occupations and live as independently as possible. Overall Learning Communication Effective communication with the seniors and staff at Flanner House was one of the most vital tools used throughout this DCE. Written and verbal communication with the seniors was challenging to do their varying cognitive levels. First, the language used had to be clear, concise, and easy to comprehend to allow for maximum understanding. I had to make a few adaptations to my communication style in order to better articulate the information to the seniors. For example, the pre-survey for the program was too complicated for some of the seniors to fill out correctly, and many of the seniors required individual assistance to complete the survey. Therefore, I simplified the post-survey to allow for easier completion. When presenting information to the seniors, I had to speak loud and clear in order for them to hear everything I was saying. Second, to make interventions and activities with the seniors successful, I clearly explained the value and role of OT related to this community-based setting. In return, they were able to express their needs relative to occupational therapy. Communication with the seniors continued to improve as I built rapport with them and as they felt more comfortable sharing their needs with me. Lastly, I had to make sure I used proper nonverbal communication with the seniors in order to express my genuine desire to help them meet their needs. There were many times when I had to be conscious of my facial expressions to show that I being an active listener. In order to successfully implement the falls prevention program, I had to effectively communicate with the seniors program coordinator and deputy director. I had to express what I needed to facilitate and complete the program. These needs included adequate time with the FALLS PREVENTION 24 seniors, and various tools and equipment. Additionally, prior to beginning the program, I completed a needs assessment with the seniors program coordinator and deputy director to better prepare for the anticipated needs of the seniors. Throughout the program, I continued to communicate with key staff members regarding the seniors schedule and what continuation of this program would look like once I was gone. Leadership and Teamwork In order to be self-directed, I had be an advocate for myself. I had to effectively use time management to get projects and assignments done. I also had to be disciplined and focused to stay on task throughout the day and to learn as much as possible throughout this experience. Leading the falls prevention group gave me a great opportunity to improve my leadership skills. I had to learn how to facilitate conversation and encourage engagement from participants. I also had to learn how to capture and hold the groups attention during educational and activity sessions. During this DCE I had the opportunity to work with many different staff members including: social workers, social work students, community builders, childcare workers, and administrative assistants. While at Flanner House, I learned how important good teamwork is at a non-profit organization. There were many events and programs that required help from multiple individuals to be successfully completed. In order for that to happen, it was imperative that everyone used their unique skills and abilities to complete tasks. I witnessed how well events and programs such as job fairs, skills to success classes, family dinners, and support groups can go when everyone works together. One of the biggest things I learned from this experience is the importance of operating as a team, and that everyones job matters, no matter how big or how small. FALLS PREVENTION 25 Preparation for Practice Through my experiences at Flanner House, I have learned and developed many new skills that will be beneficial for future practice. I had the opportunity to work with and learn from many different cultural, ethnic, and age groups. Working with different groups of people has increased my cultural competency and my ability to connect with all types of individuals. In addition to leading the falls prevention program with the seniors, I led a fine motor skills group with two year olds each week, and I led a stress management session with staff members. This gave me the chance to improve my group leadership skills with children, adults, and older adults. Having the opportunity to lead and plan several different groups improved my confidence for leading and developing various types of group interventions. Overall Learning Overall, this DCE has been a great learning experience. I have learned how to effectively manage my own time and how to advocate for myself. I also gained a better understanding of the role and the value of OT in a community-based setting. Understanding my role as a capstone student at Flanner House took time, energy, and research. However, after many discussions with the staff at Flanner House, OT faculty, and other OT students, I was able to find several ways to incorporate OT into various programs and services. As a result of this experience, I have a greater appreciation for the role of OT in falls prevention and in a community-based setting. Most importantly, I have improved my confidence as a future OT and I now feel more prepared to join the OT workforce. FALLS PREVENTION 26 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain & process (3 ed.). American Journal of Occupational Therapy, 68(Suppl. 1), rd S1-S48. American Occupational Therapy Association (2011). Remaining in your home as you age. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/consumers/Adults/AginginPlace /Remaining-in-Place-Aging.pdf American Geriatric Society & British Geriatric Society. (2010). Clinical practice guideline: Prevention of falls in older persons. Retrieved from http://www.medcats.com/FALLS/frameset.htm Borska, E., Groves, M., Huang, Y., Alvarez-Jett, N., Peyton, C., & Erickson, T. (2016). Relationship between fear of falling and fall precautions taken by community dwelling older adults. American Journal of Occupational Therapy, 70. doi: 10.5014/ajot.2016.70S1-PO6078 Carlson, S. A., Kruger, J., Kohl, I. W., & Buchner, D. M. (2006). Cross-sectional relationship between physical activity and falls in older adults, united states 2003. Journal of Physical Activity & Health, 3(4), 390-404. Centers for Disease Control (2016a- B). Important facts about falls. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Centers for Disease Control (2016b- C). Older adult fall prevention. Retrieved from https://www.cdc.gov/media/dpk/healthy-living/injury-falls-older-adults/older-adultfalls.html FALLS PREVENTION 27 Centers for Disease Control (2016c-A ). About CDCs STEDI (stopping elderly accidents, deaths, & injuries) toolkit. Retrieved from https://www.cdc.gov/steadi/about.html Chase, C. A., Mann, K., Wasek, S., & Arbesman, M. (2012). Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. American Journal of Occupational Therapy, 66, 284 291. http://dx.doi.org/10.5014/ajot.2012.005017 Chen, T.-Y., Edwards, J. D., & Janke, M. C. (2015). The effects of the a matter of balance program on falls and physical risk of falls, tampa, florida, 2013. Preventing Chronic Disease, 12. doi: 10.5888/pcd12.150096 Chippendale, T. & Bear-Lehman J. (2011). The issue is- Falls, older adults, and the impact of the neighborhood environment. American Journal of Occupational Therapy, 65, e95-e100. doi: 10.5014/ajot.2011.000729 Choi, K., Jeon, G., & Cho, S. (2017). Prospective study on the impact of fear of falling on functional decline among community-dwelling elderly women. International Journal of Environmental Research and Public Health, 14. doi: 10.3390/ijerph14050469 Cole, M. & Tufano, R. (2008). Cognitive behavioral frames. In M. Cole & R. Tufano, Applied theories in occupational therapy: A practical approach (pp. 149-163). Thorofare, NJ: SLACK Inc. Dionyssiotis, Y. (2012). Analyzing the problem of falls among older people. International Journal of General Medicine, 5, 805-813. doi: 10.2147/IJGM.S32651 Elliott, S. J., Ivanescu, A., Leland, N. E., Fogo, J., Painter, J. A., & Trujillo, L. G. (2012). Feasibility of interdisciplinary community-based fall risk screening. American Journal of Occupational Therapy, 66, 161-168. http://dx.doi.org/10.5014.ajot/2012.002444 FALLS PREVENTION 28 Hayakawa, T., Hashimoto, S., Kanda, H., Hirano, N., Kurihara, Y., Kawashima, T., & Fukushima, T. (2014). Risk factors of falls in inpatients and their practical use in identifying high-risk persons at admission: Fukushima medical university hospital cohort study. BMJ Open, 4. doi: 10.1136/bmjopen-2014-005385 Haynes, M., League, P., & Neault, G. (2014). A matter of balance: Older adults talking control of falls by building confidence. Frontiers in Public Health, 2. doi: 10.3389/fpubh.2014.00274 Howard, B. (2018). My Safe and Sound plan for staying falls-free. Retrieved from https://issuu.com/bshowardotr/docs/bhoward_safe_and_sound_workbook_201 Hu, Y.-L., Vance, K., & Strak, S. (2016). Elements of effective fall prevention programs: perspectives from medically underserved older adults. American Journal of Occupational Therapy, 70. doi: 10.5014/ajot.2016.70S1-PO1064 Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_55.pdf Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark F. (1998). Occupation in lifestyle redesign: The well elderly study occupational therapy program. American Journal of Occupational Therapy, 52(5), 326-336. Leland, N. E., Elliott, S. J., OMalley, L. & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence and future directions. American Journal of Occupational Therapy, 66, 149-160. http://dx.doi.org/10.5014/ajot.2012.002733 Li, F., Harmer, P., & Fitzgerald, K. (2016). Implementing an evidence-based fall prevention intervention in community senior centers. American Journal of Public Health, 16(11), 2026-2031. FALLS PREVENTION 29 Mather, M. (2016). Fact sheet: Aging in the united states. Population Reference Bureau. Retrieved from http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstatesfact-sheet.aspx National Council on Aging (2015). Falls Free: 2015 national falls prevention action plan. Retrieved from https://www.ncoa.org/resources/2015-falls-free-national-falls-preventionaction-plan/ Painter, J. A., Allison, L., Dhingra, P., Daughtery, J., Cogdill, K., & Trujillo, L. G. (2012). Fear of falling and its relationship with anxiety, depression, and activity engagement among community-dwelling older adults. American Journal of Occupational Therapy, 66, 169 176. http://dx.doi.org/10.5014/ajot.2012.002535 Peterson, E. W. (2011, September). Reducing fall risk: A guide to community-based programs. OT Practice, 16(16), 15-20. Plaskin, J. (2014). Falls in older adults- risk factors and strategies for prevention. The NYU Langone Online Journal of Medicine. Retrieved from https://www.clinicalcorrelations.org/?p=8114 Power, V. & Clifford, A. M. (2013). Characteristics of optimum falls prevention exercise programmes for community-dwelling older adults using the FITT principle. European Group for Research into Elderly and Physical Activity, 10, 95-106. doi: 10.1007/s11556012-0108-2 Schepens, S. Sen, A., Painter, J. A., & Murphy, S. L. (2012). Relationship between fall-related efficacy and activity engagement in community-dwelling older adults: A meta-analytic review. American Journal of Occupational Therapy, 66, 137-148. Hhtp://dx.doi.org/10.5014/ajot.2012.001156 FALLS PREVENTION 30 Tomita, M. R., Saharan, S., Rajendran, S., Nochajski, S. M., & Schweitzer, J. A. (2014). Psychometrics of the home safety self-assessment tool (HSSAT) to prevent falls in community-dwelling older adults. American Journal of Occupational Therapy, 68, 711718. http://dx.doi.org/10.5014/ajot.2014.010801 World Health Organization (2018). Falls. Retrieved from http://www.who.int/mediacentre/factsheets/fs344/en/ Zhao, Y., Chung, P., Tong, T. (2016). Effectiveness of a community-based exercise program on balance performance and fear of falling in older nonfallers at risk for falling: A randomized, controlled study. Journal of Aging and Physical Activity, 24, 516-524. http://dx.doi.org/10.1123/japa.2015-0224 FALLS PREVENTION 31 Appendix A Falls Prevention Pre-Assessment Please rate your level of agreement from 1 to 5. 5= Strongly Agree 4= Agree 3=Neutral 2=Disagree 1=Strongly Disagree 1. I have a good understanding of how to prevent falls while I am at home: 5 4 3 2 1 2. I have good understanding of how to prevent falls while I am in the community: 5 4 3 2 1 3 2 1 3 2 1 2 1 3. I am afraid of falling in the community: 5 4 4. I am afraid of falling at home: 5 4 5. I feel stable when I walk around inside my home: 5 4 3 6. I participate in some form of exercise 3 times a week: 5 4 3 2 1 7. Fear of falling keeps me from participating in activities: 5 4 3 8. I have fallen before: YES 9. How old are you? NO 2 1 FALLS PREVENTION 32 Appendix B *Printed with permission FALLS PREVENTION 33 FALLS PREVENTION 34 Appendix C Fall Prevention Post-Assessment Please answer the following questions: 1. I have a better understanding of how to prevent falls: YES NEUTRAL NO 2. I am less afraid of falling: YES NEUTRAL NO 3. I plan to continue exercising regularly or start exercising regularly: YES NEUTRAL NO 4. I plan to make changes to prevent falls: YES NEUTRAL NO  ...