You have just finished your initial OT assessment with your new client, and they have a long list of goals you will need to help them with. Where do you start?

This situation can be overwhelming for any OT, but especially for early career clinicians who may be trying to navigate this challenge for the first time. Whether you work in a community setting, or an inpatient hospital ward, there are six steps you can take to get you through.

Let’s use the case study of Anna as an example to talk through some strategies…

Anna is 54 years old and has a diagnosis of Multiple Sclerosis. She currently requires 1x mod assist for all transfers and self-care tasks. During your initial assessment you identify she is having frequent falls, has a grade 1 pressure area, and her adult daughter who lives with her is struggling to provide the care she needs. They only have basic assistive technology at home, including a shower chair and an over-sized manual wheelchair that is heavy and doesn’t fit easily through her doorways. Her bathroom has a shower-over-a-bath without any rails or assistive technology, so Anna has been having sponge washes for the last month. They are both desperate for you to help fix these difficulties as soon as possible!

Now for the strategies – let’s start at the beginning…

1. Breathe, and write a list.

Take a breath - a list this long will be overwhelming! Now write down all the things that you think you will need to help Anna with, and jot down some approximate timeframes. These timeframes will depend on the type of setting you work in (inpatient hospital or NDIS community), your own availability (how many days do you work, how many other clients are on your caseload), and factors outside your control (is assistive technology loan or hire difficult to access, who needs to sign-off funding applications for things like bathroom modifications and how long does this usually take?).

To make sure you don’t miss anything, go back to your favourite OT model (I feel the eyerolls but stay with me…). A common choice is the Person-Environment-Occupation (PEO) model – simple but effective. Have you considered all person (e.g. physical function, cognition, sensory), environment (e.g. suitability of her home), and occupation factors (e.g. mobility, self-care)?  Once you have a clear list, you’ll be able to start prioritising, but first, do step 2.

2. Set expectations.

Now that you’ve had a think about all the things you’ll need to cover and how long things might take you and Anna to achieve, set expectations. While we want to be able to help all our clients as quickly as possible, a list as long as Anna’s will take time to get through, and depending on our setting, it may be beyond our scope and something that we refer to other OTs to complete. To manage Anna and her daughter’s expectations, let them know your availability – how many hours per week can you spend working on Anna’s goals, or how often can they expect to hear from you with an update? Also let them know when timeframes are beyond your control (awaiting NDIS sign-off for AT or home mods comes to mind here…).

3. Use client-centred goal setting

Allow Anna the opportunity to play an active role in her treatment planning and involve her in a client-centred goal setting process where she can prioritise which goals are most important to her to work on first. BUT, make sure you provide Anna with enough information so she can make informed decisions in this process. For example, she may not realise how serious a new pressure area could become, or how long it would actually take to have bathroom modifications completed; providing her with this information may change her priorities.

In some instances, you can prioritise the to-do list together with a non-standardised interview, other times you may want to use something formal like the Canadian Occupational Performance Measure (COPM). Your goals could look like the SMART goals you practiced at uni, but it is also perfectly fine sometimes if they don’t, as long as you both know what you’re working on and what success will look like.

4. Prioritise high-risk issues

While it is important to allow Anna to be actively involved in planning her treatment program, sometimes we need to use our clinical knowledge to identify and prioritise tasks that hold the most significant risks for Anna’s health and safety. For example, addressing falls, pressure injuries and carer stress is likely more important than getting a new wheelchair for community access. Hopefully you considered this in the previous step and Anna may have already agreed with your concerns and priorities, but if you have your list and are still feeling lost at where to start, start with these things!

5. Acknowledge the long-term issues, but save them for later.

Anna will likely need major home modifications for her bathroom to make it wheelchair accessible, and a power-assist manual wheelchair would be a great piece of assistive technology to facilitate access within the community. But these are not quick processes; they will require joint visits with builders and equipment reps, detailed reports, and likely long waits for NDIS funding. While awaiting these things is likely impacting Anna’s quality of life, they are generally not leading to high-risk situations compromising her health, to the extent a fall or pressure injury would.

It's important that these things stay on the list, but if your time is limited, you may not be able to start work on them straight away. Depending on your setting, it may not be appropriate to work on them at all and instead you need to refer on to another OT (e.g. if Anna was in hospital for managing an exacerbation of her MS and you’re her OT on an acute neuro ward, you’re not going to start a complex bathroom modification, but you would start looking for a community-based OT that could). Tell Anna and her daughter that they haven’t been forgotten; make a start if you can (see step 6) but it may also be completely appropriate not to.

6. Discuss and delegate

Hopefully those strategies will get you through your initial meetings with Anna and leave you both feeling there is a clear plan for what comes next. But it is also OK if you are still feeling a little lost. Throughout the process, share your reasoning during clinical supervision! Debrief with a supervisor or colleague to check on how you have prioritized the tasks in your list. Have you missed anything? Are your expected timeframes unrealistic? Are there factors beyond your control that you haven’t considered which may change your reasoning? Sometimes the biggest time-waster for early career clinicians is over-thinking and self-doubt; having your thoughts confirmed by a supervisor or peer can be the confidence boost you need to move through your list efficiently.

Finally, if you’re lucky enough to work in a team, perhaps with admin support or an allied health assistant, consider if there are things you can delegate to others. Can an allied health assistant be contacting AT suppliers to find the pressure cushion you need? Can your admin assistant be juggling your diary to book in a future joint visit with a builder instead of you playing phone tag for a week? Consider what is appropriate to delegate and let Anna and her daughter know that others will be assisting you to work on her list, but don’t try to do everything yourself if you don’t have to!

So, what do you think? Does this step-by-step approach make your list feel more manageable? If so, you’re welcome! If not, reach out to your clinical supervisor for further advice and support.

Is there something missing from this list? Share your thoughts in the comments below!

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