Client Goals Research Articles

A Life Participation Approach to Primary Progressive Aphasia Intervention.

Primary progressive aphasia (PPA) is a clinical neurodegenerative dementia syndrome characterized by deficits in spoken and written word retrieval, word usage, and/or word comprehension. Currently, there are no effective treatments to reverse or halt the underlying disease process; however, speech-language therapy may be helpful. The Communication Bridge Care Model was developed to address the unique communication and quality of life needs of individuals living with PPA. The core elements include person-centered care with dyadic instruction for disease education, and counseling, along with tailored levels of impairment- and compensatory-based communication strategy training. Our multicomponent approach incorporates guidance from the Life Participation Approach for Aphasia, including client-directed assessment and interventions that aim to maximize functional communication and participation in desired life activities. The direct and indirect use of technology is integrated into our tailored model of care to facilitate achievement of the client's functional goals. Here, we describe how to practically apply the Communication Bridge Care Model across treatment settings, including case examples from the Communication Bridge research study. This approach to care provides an opportunity to maximize communication effectiveness and quality of life for individuals living with PPA throughout the course of disease.

Bobath Concept Structural Framework (BCSF): Positioning Partial Aspects Within a Holistic Therapeutic Concept

Background: The Bobath concept is a complex, holistic approach to neurorehabilitation. This complexity presents difficulties for describing Bobath therapy in a comprehensible way. The purpose of this project was to develop an external structure to promote a better understanding of how specific therapeutic procedures are categorized, how partial aspects can be organized and how their interactions can be made more obvious. Method: A scoping review of the literature was undertaken and clustered for keywords. These data were assigned to four levels of a framework model: Conceptual level (leading thoughts), Principle level (essential characteristics of the system), Method level (systematic procedures) and Technique level (the execution tools). Drafts of the framework were presented at annual conferences of the International Bobath Instructor Training Association (IBITA). Feedback from members was sought informally and in questionnaires. Results: The BCSF was supported by 75% of IBITA members (N = 107). In the Conceptual level, three aspects were established; propositional knowledge, individual client context and professional practice knowledge. Seven components are represented in the Principle level; optimizing activity and participation, problem solving, interactive - dialogue approach, client goal oriented, identification of potential, ongoing interplay of assessment and intervention and 24 hours approach. In the Methods level, three systematic procedures were identified; activation, shaping and repetition. At the Techniques level, four execution tools were described; communication, facilitation, assignment of task and environmental arrangement. Discussion: The BCSF provides a structure for further research into the Bobath concept. At a qualitative level, this structure will allow different aspects to be explored whilst still viewing a single aspect as a component of the whole. At a quantitative level, the BCSF clarifies what kind of therapy constitutes a Bobath intervention and the factors that need to be present at all levels of the framework. Conclusion: The BCSF is a useful tool where partial aspects of the Bobath concept can be categorized into a comprehensive classification system. This classification makes it possible to focus on specific items without losing the big picture and to identify partial aspects and their interactions more clearly. Specific procedures can be presented in a structured and transparent manner and well documented core elements for rehabilitation of people with CNS disorders can be demonstrated.

What do speech–language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study

Purpose: The aim of this study was to investigate what speech–language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation.Method: A qualitative study including semi-structured focus group interviews with 11 speech–language pathologists. Interviews were analysed with the use of systematic text condensation.Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client’s process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client.Conclusion: This study showed that speech–language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech–language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.

A systems approach to understanding the perspectives in the changing landscape of responsible business in Scotland

The purpose of this paper is to present an application of Community OR (COR), using Soft Systems Methodology (SSM), to help a fund manager to understand how to unlock and release more resources into communities. The problem area under investigation is a perceived lack of connectivity and alignment between and within public, for-profit, and the third sectors in Scotland. We argue that as the for-profit sector controls the majority of resources in most economies, they need to be part of any solution. However, we propose an approach that offers an alternative to the neoliberal business paradigm that has become prevalent in society and suggest that this must involve the inclusion of people and communities, in part represented by third sector organisations. We collected and analysed data from 145 participants and the outcome from this research was the ‘Connect model’, which was proposed to achieve the client's goal and to address a range of stakeholder challenges. In the SSM study, the ‘investing in social capital’ system was deemed a necessary early intervention, to bring together actors in an ‘open system’ that addresses the ‘whole problem’ area (launched as the ‘Responsible Business Forum’). Three additional concepts emerged from the study that helped refine the ‘Connect model’ and have implications for theory and practice: 1) the co-creation of business-community value, 2) facilitated by a conduit, 3) that unlocks a ‘shared space’ based on a match of shared aspirations and values.

A Framework for Building Design Management in an Imperfect BIM Environment

Building design process is a wide spectrum activity, regarding its complexity. It begins by simple compartments structures till large multistory administrative buildings, involving various specialties. Complex design management, where a multidisciplinary team or teams are involved in the design process; requires high level of collaboration to reach the optimized client goals economically and on time. BIM provides a wide range support for such an activity, where the most critical criterion in design management is ensuring the appropriate flow of information between design partners. Each participant in the design process should receive relevant data or information in a complete form and on time. And consequently design participant should send and share their design outputs with relevant personnel. The perfect BIM environment requires that all participants within the design process are using BIM supporting software, and vice versa. Markets where BIM application is still in the growing phase some of the design participants adopt BIM while others don’t. The main target of this paper is to propose a collaborative scheme to ensure information flow between design participants, using COBIE forms and XBIM toolkit; in the case where some of the participants in design process are not using BIM supporting software.

Action: a bridge between vocational and mental health counselling

ABSTRACTA theory of goal-directed action is proposed as a conceptual link between vocational and mental health counselling. Originally emerging from the vocational counselling field, contextual action theory is presented as a critical conceptual link not only between mental health and occupational life but also between counselling practices in these domains. This specific application of goal-directed action to vocational and mental health counselling is addressed by describing counselling as goal-directed action, the five tasks of counselling it invites, and tools for supporting client goals, such as the self-confrontation interview.

American counselors' acceptance of non-abstinence outcome goals for clients diagnosed with co-occurring substance use and other psychiatric disorders

Previous research has examined clinicians' acceptance of non-abstinence for clients who have a substance use disorder (SUD), but many SUD clients also present with a psychiatric disorder. To evaluate the acceptability of non-abstinence as a final outcome goal for clients with co-occurring diagnoses, we recruited a nationwide sample of 751 American substance abuse counselors to complete a web-based questionnaire. Respondents rated the acceptability of limited/moderate consumption by clients diagnosed with each of 18 co-occurring disorders: three psychiatric disorders (Major Depressive Disorder, Post-Traumatic Stress Disorder, Social Phobia) x three substances (alcohol, cannabis, opioids) x two levels of severity (DSM-5 Moderate SUD, DSM-5 Severe SUD). On average, non-abstinence was rated as unacceptable for clients with any of the 18 diagnostic pairs, although one-fourth to almost one-third rated limited/moderate use of cannabis somewhat or completely acceptable for clients diagnosed with a Moderate Cannabis Use Disorder when paired with any of the three psychiatric disorders. Furthermore, small proportions of respondents (13% to 20%) rated non-abstinence at least somewhat acceptable even when clients were diagnosed with a Severe SUD for any of the three substances and any co-occurring psychiatric disorder. Based on our findings, clients with co-occurring disorders who want to moderate their substance use will typically find their counselor does not accept that outcome goal. Because supporting non-abstinence respects client autonomy, could attract and retain clients in counseling, and is consistent with a recovery-oriented treatment model, we encourage continuing education about the benefits of non-abstinence as a treatment goal for clients with co-occurring disorders.

Cultura de Gerenciamento de Projetos - Percepção dos Profissionais de Sistemas de Informação

Project management culture is a key element of an IS management model. In this context, this research aims to analyze the relationship between the characteristics of IS professionals and project management culture. To achieve this goal, we carried out a literature review on project management culture and on IS professionals. This research used a survey applied to 256 professionals and through the application of statistical techniques concluded that: the culture focused on client and company's goals was the most perceived by the professionals, as opposed to the culture of innovation that was the least perceived. In addition, different types of professionals had different perceptions regarding project management culture.

Intentions and experiences of effective practice in mental health specific supported accommodation services: a qualitative interview study

BackgroundDeinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients.MethodsWe interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis.ResultsThere were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement.ConclusionsThe findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.

Development of a memory application for structuring and supporting daily activities of clients with intellectual disabilities

BACKGROUND: Clients with intellectual disabilities benefit from a fixed daily structure due to difficulties in remembering appointments and in performing daily activities. OBJECTIVE: To develop a memory application to structure and support daily activities for clients with intellectual disabilities that contribute to independence and to provide a clear insight into the developmental process of the application. METHODS: A participatory design' (two development cycles) was used to understand users' needs, wishes, and abilities regarding structure and support of daily activities. Using a pre-A nd post-test design, two pilots (n= 14) took place in a real life setting' to evaluate usability of the application and gather data for further development using observations and interviews. RESULTS: The pilots showed that the application has the potential to contribute to the independence of clients, e.g. less control needed regarding daily structure offered by formal carers. This was most evident in the last pilot because of the improved ease of use, the added value perceived by clients and formal carers and the increased focus on the implementation of the application in the care process. CONCLUSIONS: For successful integration of the memory application in the care process, well-defined personal goals of clients in the care plan are needed and carers should act according to these goals. Further research is necessary to examine the generalisation of findings.

Ensuring good governance throughout the product life-cycle: A financial planner’s view

Chartered financial planner status is a relatively new concept in UK financial services. Practitioners have a higher standard of qualification (QCF level 6) than the baseline entry level required by the Financial Conduct Authority Rules which is set at QCF level 4 Diploma. Many chartered financial planners charge explicit fees to their client where advice is not dependent upon the implementation of a financial product: this advice will often be supported by a full and comprehensive financial plan, often supported by lifetime cash flow forecasting. Where a financial product is needed as part of a solution aimed at achieving client goals and objectives, most chartered financial planners will select such product solutions from the whole of the market. They will satisfy the Financial Conduct Authority (FCA) definition of ‘independent’.

“I’m not homosexual or heterosexual, I’m paedosexual”: exploring sexual preference for children using interpretive phenomenology

PurposeThere is little research that examines the experiences of individuals who were assessed as having a sexual preference for children. The purpose of this paper is to investigate the lived experience of five incarcerated participants who possessed a sexual preference for either prepubescent or pubescent children and had completed an accredited programme for males convicted of sexual offences in HM Prison Service in England and Wales.Design/methodology/approachSemi-structured interviews were carried out and the data were analysed using the principles of an interpretative phenomenological approach.FindingsThree recurrent themes were identified. These were: internal battle, I am always going to have these thoughts, and there is no help out there. In particular, these participants perceived that their sexual preference was relatively enduring and would require continuous management.Practical implicationsThe results have implications for clinical practice and further research. Clinicians may need to think particularly creatively about their therapeutic plans and extend the parameters of desirable treatment goals for clients with sexual preferences for children.Originality/valueTo date there are very few studies that have examined the accounts of men with a sexual preference for children regarding their lived experience. Paedophilia constitutes a stable sexual preference, suggesting that convicted perpetrators with such a preference face an inherent problem. Whilst sexual urges may be regulated and arousability reduced, the underlying attraction may remain intact. In response to the lack of research in this area, the aim of this study was to investigate the lived experience of a sexual preference for children.

Topology and Application Aware Dynamic VM Management in the Cloud

Cloud computing continues to mature and more applications continue to be deployed in public clouds. Client applications deployed in the cloud should automatically scale up and down to match changing workload demands, though they must be careful to ensure that sufficient resources are provisioned to achieve performance objectives. The cloud provider, on the other hand, attempts to reduce costs by reducing power consumption by consolidating load onto fewer, highly utilized machines. In this work, we introduce an algorithm that integrates both application autoscaling and dynamic virtual machine (VM) allocation into a single algorithm in order to achieve the goals of both cloud provider and client. Further, we consider multi-VM applications, such as multi-tiered web-based applications, and extend the integrated algorithm to take the network topology into account when placing or migrating applications. The goal is to reduce VM-to-VM communication latency; our focus is on trying to contain applications within the same racks. We evaluate our work through simulation, showing that the integrated algorithm can achieve better application performance with a significant reduction in virtual machine live migrations, and the topology-aware extension successfully places applications within a single rack.

Simple or complex? A case study of physical and mental health co-morbidity

AbstractPeople with epilepsy are significantly more likely to have a mental health disorder than those without a chronic illness. The reasons for this are multiple but may include the mental health difficulties being perceived as complex due to the presence of a chronic illness. In part due to the apparent complexity of the co-occurring physical and mental illness, many are not offered evidence-based treatment (EBT) for the mental health disorder. There is little guidance to inform clinicians about the interventions to use to treat mental health disorders in people with epilepsy. The present paper reports a case of treatment for depression using a standard EBT in a young person with epilepsy. The patient also had clinically significant symptoms of anxiety and an eating disorder and would be considered ‘complex’ according to standard criteria. The intervention, however, was relatively simple and was delivered as guided self-help via 10 weekly telephone calls of approximately 30 minutes duration, and two follow-up calls at one month and three months post-intervention. Self-report and parent-report questionnaire measures were completed before and after the intervention, and at both follow-up time points. A blind-rated online diagnostic interview measure was also completed before and after the intervention. The young person and her family also completed a qualitative interview of their experiences of the intervention. This simple intervention was effective in working towards the client's goals, although pre–post measurement on standard measures was variable. This interesting case raises questions about whether patients with mental and physical comorbidities are complex, or just perceived as complex.

One Client, One Team - Health Care Integration for Populations with Complex Care Needs: Driving Redesign in a Complex System for Those Who Need It Most

Introduction : Working in a provincial environment where the health care system is fragmented, across 60,000 primary care physicians, 155 hospitals, 162 home care providers, and over 1,000 community support service organization, presents a compelling need to integrate care and services to make the system less confusing for clients (patients), particularly those clients and their families with complex care needs, who frequently have to access services from multiple parts of the health care system. Our aim was to start with the largest jurisdiction in Ontario to improve client experience, outcomes, and value with the goal of clients and families to experience multiple providers across different systems of care as one team. Description : The Toronto Central CCAC, a publicly funded home and community health care delivering health care to approximately 74,000 clients annually, began its integration journey in 2010, positioning the home and community care sector at the center of driving system change and integration across the care continuum. For five years, the Toronto Central CCAC has been driving integration for populations with complex needs and building integrated care teams within a quality improvement and evidence-based framework built on and aligned with leading global practices in integration. This integration strategy, entitled One Client, One Team, has been implemented in one large jurisdiction with the goal of developing a scalable model for the province of Ontario. The strategy is marked by using existing resources and creating partnerships across many sectors – primary care, acute care, paramedic services, and community services to deliver wrap-around care services to complex populations. In 2014, the organization partnered with The Evaluation Centre for Complex Health Interventions to perform a more comprehensive, mixed-methods evaluation that is informed by a theory-driven framework. The evaluation provides a deeper understanding around what is working well and helps to inform opportunities to advance implementation, drive scalability and build a shared vision for integrated care across the province. Key Findings : The impact of Toronto Central CCAC’s integration strategy has been felt at the system and leadership level across the care continuum, at the point of care across care teams and providers, and at the experience level of clients and families. Four kinds of findings will be shared at the conference: - Learnings about the mechanisms by which integrated care can impact person centered care; - Learnings from the trajectories of outcomes of clients with complex conditions and how the evaluation can help develop learnings about how such trajectories can be modified; - Video and qualitative evidence on how person centered care can make a difference to health outcomes. - Successes and barriers in enabling integrated care and leveraging lessons learned to inform scale and spread The discussion of the results will highlight the contexts and mechanisms by which integrated care can impact person centered care and inform implementation and scalability—all of the discussion on mechanisms will be supported by both qualitative and quantitative evidence. The concept of an ‘ecology of evidence’ – the types of evidence that are needed to support implementation of a complex coordinated care system will inform the presentation of the findings. Highlights : Throughout its integration journey, the Toronto Central CCAC has learned that sustainable, system level change can be driven locally, by any organization, with key foundations in place, including strong leadership competencies, trusting relationships across stakeholders and a common commitment across all partners to putting the client’s and family’s care experience at the center of the change. Health care organizations have an accountability to evolve the way they work and waiting for a complex solution to a complex problem is often not the most effective path to change. Conclusion: This approach to integration leverages practicality, innovation, and partnership to improve the client experience. The strategy is highly relevant for integrated care delivery and development internationally is as it highlights the need for fundamental shifts in the conceptualization of integrated care, program implementation, and the role of evaluation within integration efforts to inform improvement, scale, spread and sustainability.

Effective Interpersonal Health Communication for Linkage to Care After HIV Diagnosis in South Africa.

Background:Early in the global response to HIV, health communication was focused toward HIV prevention. More recently, the role of health communication along the entire HIV care continuum has been highlighted. We sought to describe how a strategy of interpersonal communication allows for precision health communication to influence behavior regarding care engagement.Methods:We analyzed 1 to 5 transcripts from clients participating in longitudinal counseling sessions from a communication strategy arm of a randomized trial to accelerate entry into care in South Africa. The counseling arm was selected because it increased verified entry into care by 40% compared with the standard of care. We used thematic analysis to identify key aspects of communication directed specifically toward a client's goals or concerns.Results:Of the participants, 18 of 28 were female and 21 entered HIV care within 90 days of diagnosis. Initiating a communication around client-perceived consequences of HIV was at times effective. However, counselors also probed around general topics of life disruption—such as potential for child bearing—as a technique to direct the conversation toward the participant's needs. Once individual concerns and needs were identified, counselors tried to introduce clinical care seeking and collaboratively discuss potential barriers and approaches to overcome to accessing that care.Conclusions:Through the use of interpersonal communication messages were focused on immediate needs and concerns of the client. When effectively delivered, it may be an important communication approach to improve care engagement.

Personalized Virtual Reality for Upper Extremity Rehabilitation: Moving from the Clinic to a Home Exercise Program

Introduction: Traditional rehabilitation does not provide adequate repetitions for maximal motor recovery in the clinic and home exercise programs (HEPs) have low compliance rates. Personalized virtual reality (PVR) is a promising low-cost therapeutic tool for improving compliance by incorporating the client's interests, abilities, and goals into a motivating and engaging intervention using internet games. Objectives: The current study aimed to develop and refine a clinic-to-home PVR intervention, determine its feasibility and usability in an outpatient rehabilitation clinic and as a HEP, and examine its effects on motivation/engagement, compliance, motor repetitions, and functional motor performance. Methods: The PVR system utilizes a Microsoft Kinect sensor to track the participants’ movements, free software to translate movements to keystrokes, and free internet games. The therapist matched participants’ interests to internet games, customized therapeutic movements for game play, and increased the movement thresholds for game activation as participants improved. Two participants who had strokes resulting in upper extremity (UE) hemiplegia were recruited. The participants attended outpatient occupational therapy (OT) services twice weekly. Following training, the participants used the PVR system at home in place of their UE HEP. They continued to receive traditional OT once a week and clinic-PVR once a week for 5-8 weeks. Results: The PVR intervention was successfully implemented in the clinic and the clients’ homes. PVR increased motivation and treatment compliance. The clients exhibited improvements in UE active range of motion, function, symptoms, and occupational performance. Conclusion: Preliminary evidence suggests PVR can improve motivation, compliance, function, and occupational performance. However, larger scale studies and protocol refinement are necessary.

Piloting an Integrated, Interprofessional Programme for People Living with Type II Diabetes: Outcomes and Experiences

This paper reports quantitative and descriptive qualitative findings from a mixed-methods study exploring and evaluating the outcomes and experiences of clients, staff and students piloting an integrated interprofessional programme for community members with type II diabetes. The one-day per week, eight-week programme included interprofessional appointments, group education sessions and case conferences led by students from exercise and nutrition, health promotion, nursing, occupational therapy, oral health, physiotherapy, podiatry and counselling psychology. Participants shared their experiences in individual interviews or focus groups. Client outcomes were evaluated using basic clinical indicators and the Canadian Occupational Performance Measure (COPM) that assesses client goal satisfaction and performance. While only small expected changes to clinical indicators were noted, there were moderate increases in mean COPM scores for performance and satisfaction. Descriptive qualitative analysis identified enjoyment from working as a team, better client outcomes and new knowledge or learning as the most frequent experiences. Findings suggested increased self-management empowerment for clients and their support people, while students and staff experienced both learning from, appreciating and educating each other about their own and others’ roles, and better collaboration. The success of the pilot programme has led to its continuation; however, timing and resourcing challenges noted by participants could threaten sustainability and accommodation of more clients and students.

Family Traditions, Cultural Values, and the Clinician's Countertransference: Therapeutic Assessment of a Young Sicilian Woman

ABSTRACTDespite recent advances in models and instruments to understand the role of a client's cultural background, clinical psychologists are not immune to implicit cultural biases that are potentially damaging to the therapeutic alliance. In this article, I present a Therapeutic Assessment with a young Sicilian woman conducted in a university-based student clinic in Italy. During the assessment, I assumed that because we were both Italians, my client shared my perspective (northern Italian) about family and individual values, which resulted in a therapeutic impasse when I responded on the basis of my individual and culturally shaped view of interpersonal and family relationships without appreciating important differences between my own and my client's microcultures. To overcome the impasse, I had to openly acknowledge such differences and reorient myself to my client's goals. I discuss the core processes involved in such a repair in the context of a cross-cultural psychological assessment.

The Role of Asset Owners in the Market for Investment Research: Where are the Fiduciary Capitalists?

Fiduciary capitalists, such as leading pension plans and endowments, can be influential in aligning the interests of asset management firms with their clients. In the market connecting investment professionals with the information they need to meet client goals, we identify numerous conflicts of interest, but find little action has been taken by asset owners. Interest in the obscure practices surrounding the use of dealing commissions for research has heightened since 2014 due to regulatory scrutiny in the UK and the impending implementation of the second Markets in Financial Instruments Directive (MiFIDII) in Europe. The authors make recommendations to guide asset managers and asset owners through a complex information market during this time of dramatic change.