Staff in-service · Adult neuro & cognition

Executive Function in IADLs

An in-service for OTs on helping patients carry executive function strategies out of the clinic and into real life: medications, meals, bills and errands.

Audience
OTs on adult neuro teams
Setting
Adult neuro rehab
Format
In-service + session planning template
Pairs with
MS Training Sheet, Clinical Reasoning Sheet

The project

Problem

Patients with stroke, brain injury, MS or early dementia often do well on tabletop cognitive tasks, then struggle to manage medications or pay bills at home. Strategies practiced in one setting don't carry over on their own, and many standard tests miss real-world executive function problems.

Solution

An in-service that teaches therapists to plan for generalization from day one: use real IADLs, teach one strategy across many contexts, build the patient's awareness, fade cues on purpose, and document progress in a way that shows skilled need.

Outcome measured

A five-question knowledge check before and after the session, a session planning template staff can reuse, and a follow-up chart audit of how generalization is documented in therapy notes.

The project · Executive function in-service

The in-service

Learning objectives

By the end, participants will be able to

  • Name the executive function skills each common IADL demands.
  • Describe the four levels of transfer, from near to very far.
  • Plan a session that moves one strategy across at least two contexts.
  • Use a cueing hierarchy and record cue level to show progress.
  • Write a note that shows generalization and skilled need.
Agenda45 min
  1. 0–5
    Pre-check and warm-up caseFive-question knowledge check
  2. 5–15
    Why strategies don't transferExecutive function in daily life; awareness; the transfer continuum
  3. 15–25
    Assessing real-world performancePerformance-based tools and what to observe
  4. 25–38
    Small-group session planningEach group plans one IADL with the template below
  5. 38–43
    Cueing and documentationTurning observations into skilled notes
  6. 43–45
    Post-check and feedbackSame five questions, plus a short evaluation

Transfer continuum

One strategy, four contexts

Practicing the same task until it's perfect doesn't mean the skill will show up at home. Keep the strategy the same and change the task and setting step by step, so the patient learns when to use it. Example strategy: a written checklist.

Near transfer

Same task, small changes

One or two surface details change.

Sorting a week of practice pills, then the same with a different organizer.

Intermediate

Similar task

Several details change; the steps stay alike.

Using a checklist to set up the patient's own medications in the hospital room.

Far transfer

Different task, same idea

The task looks different but needs the same strategy.

Writing and using a checklist to make a simple meal in the therapy kitchen.

Very far

Real life, on their own

The patient chooses to use the strategy, uncued.

Making a grocery list before shopping, reported by family at follow-up.

ClinicHome & community

Group activity

Session planner

During the in-service, each small group uses this template to plan a session for one IADL. Choose an IADL below to see a completed example.

Grade it down

    Grade it up

      Strategy to teach

        Carry it forward

          What to observe

            Safety and team

              Sample note

              Building awareness

              Before, during, after

              • Before: predict

                "How do you think this will go? What might be hard?"

                The patient predicts performance and picks a strategy. The gap between prediction and result builds awareness.

              • During: self-check

                "How are you keeping track? How's it going so far?"

                Use the least help needed. Let small, safe errors happen so the patient can notice and fix them.

              • After: compare and bridge

                "How did it go compared with what you expected? Where else could this help you?"

                Compare the prediction with what happened, then name a real situation at home where the strategy fits.

              Cueing hierarchy

              • 1
                General verbal"What's your plan?" "Check your work."
              • 2
                Specific verbal"Look at your checklist for the next step."
              • 3
                Visual or gesturalPoint to the checklist or the missed item.
              • 4
                DemonstrationShow the step, then let the patient try.
              • 5
                Hands-onGuide the step physically.

              Start at the top and move down only as needed. Record the number and level of cues each session: fewer and more general cues over time is the evidence of learning that payers and teams look for.

              Given before and after

              Knowledge check

              The same five questions open and close the in-service. Try them.

              Pre/post score

              Average change on the five questions for each group of attendees.

              Session rating

              A short form: how useful, how clear, and one thing participants will use this week.

              Template use

              How many therapists use the planner with a patient in the next month.

              Chart audit

              A sample of notes checked for cue level, context and carryover before and after.

              Built on

              Cueing levels and documentation wording should match the department's standards and payer requirements.