Morocco Final

Running head: HOME EXERCISE PROGRAM FOR CHILDREN WITH CP 1
Development of Client-Centered Occupational Therapy Home Exercise Programs for Children
with Cerebral Palsy: A Program Proposal
Lindsey Ward
University of Utah
HOME EXERCISE PROGRAM FOR CHILDREN WITH CP 2
Development of Client-Centered Occupational Therapy Home Exercise Programs for Children
with Cerebral Palsy: A Program Proposal
The purpose of this program proposal is to conduct a needs analysis of a rural and/or
underserved population in order to develop a program that is based on services that occupational
therapists can assist with. The following needs assessment and program was conducted for the
Moulay Ali Institute for Rehabilitation (MAIR) clinic in Marrakech, Morocco. A clinic that
provides services to those experiencing neurological conditions as a result of congenital or
acquired incidences. The needs assessment involved one-on-one interviews, group interviews, as
well as, graduate student observations of all those involved in the clinic. After the needs
assessment was completed, a literature review was conducted, and an occupational therapy
program was proposed in order to meet the needs and gaps of the MAIR clinic.
Needs Analysis
Description of Setting
Location. Morocco is located in Northern Africa, surrounded by the Atlantic Ocean, the
Mediterranean Sea, and Algeria (Journey Beyond Travel, n.d.; Regional Health Systems
Observatory World Health Organization, 2006; Semlali, 2010). In 2017, approximately 33
million people resided in Morocco (Central Intelligence Agency [CIA], 2018). As of October
2017, five university hospital centers and six military hospitals exist throughout Morocco.
Within the public sector of Morocco’s healthcare, 137 hospitals are available, whereas more than
360 clinics exist in the private sector (Export, 2017). The MAIR clinic is located in Marrakech,
Morocco. Marrakech, also known as the Red City, is the second largest city of Morocco located
at the foot of the Atlas Mountains, with a population of approximately 976,000 individuals as of
2017 (CIA, 2018; Marokko Info, n.d.; The Moulay Ali Institute for Rehabilitation [MAIR], n.d.;
The Telegraph, 2018). Marrakech among other large cities, such as Rabat, Casablanca, Fez, and
Meknes, house the majority of Morocco’s healthcare system (Export, 2017). Further information
regarding the geographic and cultural aspects of Morocco can be found further on in this paper.
History. The MAIR clinic was founded in 2015 by Dr. Mohammed Sbia. Dr. Sbia
obtained his education related to neuroscience through the University of Paris. Once Dr. Sbia
completed his training, he worked at New Jersey Medical School. During this time, Dr. Sbia’s
brother, who was located in Morocco, sustained a traumatic brain injury as a result of a motor
vehicle accident. At the time there were no services to assist Dr. Sbai’s brother in Morocco.
Later, Dr. Sbai traveled with his brother across the world, receiving services first in Paris and
then in New Jersey. In 2007, Dr. Sbai’s brother unfortunately passed away due to medical
complications. Prior to his passing, Dr. Sbai made a promise to his brother to improve access to
healthcare in Morocco. Due to the inspiration of his brother, the project to establish a clinic in
Morocco began in 2009. By 2015 the clinic became a reality, one of the first neurological
rehabilitation centers within the country (M. Sbai, personal communication, May 24, 2018; Your
Mark on the World Center, 2018).
Services. The mission of the MAIR clinic is as follows: “To trigger a neuroplastic change
is the foundation of our therapy, to accomplish maximal recovery is our most important goal”
(MAIR, n.d.). The MAIR clinic provides medical care focused on the area of neuro-
rehabilitation; therefore, the clinic provides services to “children and adults with cerebral palsy
and its complications, traumatic brain injury, spinal cord injury, stroke, multiple sclerosis, spine
and chronic pain” (MAIR, n.d.). In order to receive services, a physician referral is required (M.
Sbai, personal communication, October 8, 2018).

The clinic is 3,000 square feet in size, composed of three rooms with an open concept.
The MAIR clinic is open Monday through Friday, from 8:30 AM to 5:30 PM, and Saturday,
from 8:30 AM to 12 PM. At this point in time, the MAIR clinic is providing services to a total of
60 clients (I. Bentahar, personal communication, October 12, 2018). The clinic typically sees
between 15-25 patients per day, providing a variety of programs; including feeding, cognitive
therapy, range of motion, gait training, balance training, vision therapy, and physical agent
modalities. Each session varies from 45-90 minutes based on the client’s needs. Each client
begins with one session per week for a month and may progress to five sessions per week over
time. The overall length of treatment varies depending on diagnosis, as some individuals that
began attending MAIR clinic in 2015 are still receiving services today (M. Sbai, personal
communication, September 10, 2018).
Target population. In Morocco there are between 36-37 million individuals experiencing
medical conditions. Receiving medical care is a current struggle in Morocco due to a variety of
factors, such as limited health insurance, difficulty accessing healthcare due to remote locations
and poverty. Of those individuals, 2-5 million have a disability of some kind. In particular, there
are 25,000 new cases of cerebral palsy in Morocco each year. Another 20,000-22,000 individuals
are diagnosed with a traumatic brain injury due to traffic accidents. Overall, there are 100,000
new cases of neurological diagnoses per year (Your Mark on the World Center, 2016). Sixty-five
percent of the population served by the MAIR clinic are children, a majority of which have a
diagnosis of cerebral palsy (M. Sbai, personal communication, May 24, 2018).
Funding sources. The MAIR clinic is a not-for-profit organization. In 2009, Dr. Sbai
created the Zahra Charity, a not-for-profit organization in the U.S. to assist in the development of
the MAIR clinic (M. Sbai, personal communication, September 10, 2018). Dr. Sbai has received
multiple grants through Zahra Charity, Neuroworks, the Salt Lake Rotary Club, as well as many
other private foundations over the years (Your Mark on the World Center, 2018). Unfortunately,
in 2017, Neuroworks decided that they no longer wished to contribute to the MAIR clinic. The
Salt Lake Rotary club continues to fund medical training for staff, receiving training both in
Morocco and the United States (M. Sbai, personal communication, September 10, 2018).
The MAIR clinic is currently attempting to transition from a not-for-profit organization to
a for-profit organization. In 2015, when the MAIR clinic opened, 100% of their services were
provided for free. In September 2018, 70% of the patients are receiving services without
payment. Very few patients are paying cash or using their insurance. A therapy session at the
MAIR clinic costs $20 U.S. dollars; however, most paying clients are unable to afford this. An
average wage for an individual working in Morocco is 12.24 dirhams per hour, an equivalent of
$1.51 U.S. dollars per hour (M. Sbai, personal communication, September 10, 2018; The
Economist, 2014). Recently the MAIR clinic has established a partnership with a social worker
to establish a sliding scale payment system for their clients (I. Bentahar, personal
communication, October 8, 2018). In the near future, Dr. Sbai intends to have all clients and their
families contribute some form of payment, as he has found that the families that are paying are
more involved in the therapy process (M. Sbai, personal communication, September 10, 2018).
Staff disciplines. Unfortunately, education within Morocco is limited. The therapists,
called “aspiring neuro-therapists”, have had three years of training following their public
education (Your Mark on the World Center, 2018). Although they identify themselves as
physical therapists, Dr. Sbai reports that in the U.S. their education would be considered a
physical therapy assistant training at best (M. Sbai, personal communication, September 10,
2018). In the past, the MAIR clinic has staffed up to nine therapists; however, due to long-term
contracts, only three therapists are currently employed at the clinic. In addition to the therapists,
there is one individual that runs the front desk, scheduling appointments and filing paperwork.
All employees at MAIR clinic speak both Arabic and English. Interactions with client and staff
are in Arabic, occasionally French. Documentation and interaction between therapists are
completed in English (M. Sbai, personal communication, September 10, 2018).
Factors that Influence Service Delivery
Economic. Morocco is a constitutional monarchy (Regional Health Systems Observatory
World Health Organization, 2006; Semlali, 2010). Key sectors of Morocco’s economy include
“agriculture, tourism, aerospace, automotive, phosphates, textiles, and apparel” (CIA, 2018).
Although these key sectors have assisted in Morocco’s economic progress, many economic
barriers remain. Morocco continues to experience high levels of poverty, unemployment and
illiteracy, especially within rural areas (Arieff, 2013; CIA, 2018). With poverty, unemployment
and illiteracy, people are often limited in their ability to access healthcare, either through the lack
of funds or lack of knowledge of the available services provided in Morocco. If an individual is
able to receive services, illiteracy may lead to a misunderstanding of the reasons for therapy and
a lack of participation in home programs.
A large disparity exists between the rich and poor within Morocco. According to the
World Bank, one in four Moroccans live in poverty (Arieff, 2013; Semlali, 2010). In 2017,
Morocco had an unemployment rate of 10%, with a high percentage of these individuals being
women with diplomas (Arieff, 2013; CIA, 2018; Semlali, 2010). Unemployment is also a
common factor among young people, as the job market has not grown in relation to the growing
population (Arieff, 2013). In addition, illiteracy is another economic barrier. Although primary
education for children up to the age of 15 years old is required and free, illiteracy is still
common. Illiteracy is most common in women because they typically stop attending school to
contribute to family roles (Regional Health Systems Observatory World Health Organization,
2006). According to the Central Intelligence Agency (CIA) in 2015, it was reported that only
68.5% of the total population over the age of 15 could read and write (CIA, 2018).
To put things in perspective, in 2014, an individual typically brought home 2,333 dirhams
or $288 per month in U.S. currency (The Economist, 2014). Health insurance in Morocco is
mandatory, as will be discussed in the following section; however, insurance typically covers
only 50-80% of the healthcare costs, leaving the client to pay the difference (Export, 2017). A
typical cost to see a specialist is 150 dirhams (US $28), two days worth of Moroccan individual’s
pay (Ruger & Kress, 2007). Overall, low socioeconomic status and unemployment can impact
access to healthcare.
Professional. To become a physical therapist in Morocco, one attends private school for
three years following their high school diploma. Each month the student pays $300 U.S. dollars
to attend the program (C. Elghazi, personal communication, October 5, 2018). During the three
years of training, the students receive approximately three hours of neuro-rehabilitation training
(M. Sbai, personal communication, October 8, 2018). Even though all therapists at the MAIR
clinic have a physical therapy license, their neuro-rehabilitation training is limited. The main
purpose of the MAIR clinic is to provide neuro-rehabilitation therapy; therefore, most therapist
training is completed on the job through collaboration with other therapists and Dr. Sbai.
Another important factor is the limited number of health personnel within Morocco.
Morocco is one of the leading emigration countries in the world (de Haas, 2014). Not only does
the limited healthcare personnel affect the economic system of Morocco, but it also limits the
availability of healthcare for those that continue to reside in the country. At this time, the MAIR
clinic has three full-time aspiring neuro-therapists. These therapists have signed a 10-year
commitment to the clinic. This commitment is a unique contract to the MAIR clinic, established
by Dr. Sbai in order to prevent individuals from working a short time at the clinic and then
seeking work elsewhere. The therapists are paid $800 U.S. dollars per month, well above the
average income within Morocco. In an attempt to recruit more therapists, the MAIR clinic has
put out hiring ads. When recruiting therapists, Dr. Sbai looks at the therapist’s credentials, the
ability to speak English, a value of honesty, and the drive for long-term commitment to the
MAIR clinic (M. Sbai, personal communication, October 3, 2018).
In January 2018, Rabat, the capital of Morocco, opened the first occupational therapy
program in the country. This program is a six-semester program focusing on anatomy,
psychology, neurology, as well as the foundations and models of occupational therapy. Eight
internship opportunities are provided throughout the program in order to help establish clinical
reasoning around evaluation and intervention (Ispits, 2017). Dr. Sbai reports that this program is
based on the French model, a model that is focused on an individual’s disability. This model
establishes the idea that nothing can be done to improve the individual’s skills and independence
level; therefore, a maintenance program is put into effect to assist the caregiver. As a result, Dr.
Sbai is unsure of how this program will impact rehabilitation services in Morocco. Dr. Sbai
believes that a U.S. medical perspective should be taken into effect in Morocco, a model that
promotes client skills and improves independence; a model that closely aligns with the mission
statement of the MAIR clinic (M. Sbai, personal communication, October 5, 2018).
Policy. The Moroccan healthcare system is divided into two sectors, the public sector and
the private sector. When a client receives services, they pay directly out-of-pocket. After services
have been provided, the client then files a claim through their insurance to obtain reimbursement.
With a basic, private health insurance plan, a client may be reimbursed up to 50 percent. With a
higher-level insurance plan, within the private sector, the client may be reimbursed up to 80
percent (I. Bentahar, personal communication, October 8, 2018). Covering the remaining 20-
50% of the medical costs can be a difficult task for clients and their families.
When billing insurance there are no therapy codes defining the type of therapy services
provided; therefore, insurance either accepts the therapy services as a whole, regardless of
intervention, or therapy services are declined (M. Sbai, personal communication, October 8,
2018). Without billing codes, the type of therapy intervention is not typically established,
decreasing the ability to justify the cost of services. Imane Bentahar reports, “Sometimes a client
would be reimbursed for services one week and not the other” (I. Bentahar, personal
communication, October 8, 2018). Therefore, the reliability on insurance paying for a portion of
the services is nonexistent, causing more individuals to rely on free services.
In terms of the MAIR clinic, Dr. Sbai is attempting to develop an official agreement that
clients and their families will sign at the time of evaluation, ensuring their participation in
therapy. Dr. Sbai is developing this agreement from an example piloted from Intermountain
Healthcare. Since the agreement is not yet in place, the clinic is struggling for clients to arrive on
time or arrive at all to sessions, participate in home programs, and being honest about their
ability to pay for services (M. Sbai, personal communication, October 8, 2018).
Political. In an attempt to improve healthcare within Morocco, the government
implemented two reforms in 2005. The first reform is payroll-based health insurance that is
mandatory for public and private-sector employees. With the second reform, it creates a fund
paid by the government to cover services for the poor (Ruger & Kress, 2007). Although these
reforms have been made, among others, a large percentage of the population still does not have
healthcare insurance, limiting accessibility. Healthcare financing is typically in favor of
wealthier individuals within the population as compared to those of a lower socioeconomic status
(Arieff, 2013). The 2011 Constitution and the World Health Organization continue to strive for
equality of access to healthcare (Semlali, 2010; Zemouri, 2018). The Minister of Health, Anas
Doukkali, proposes to implement a health insurance system that will cover 90% of the Moroccan
population by 2021 (Koundouno, 2018).
Morocco continues to strive to provide individuals with disabilities equal access to
education and employment. Although policies have been established to improve the rights for
individuals with disabilities, the policies continue to be criticized by society and are not being
carried out sufficiently by the government. Therefore, children with disabilities continue to be
excluded from education with their peers and adults with disabilities continue to be unemployed
(United Nations Human Rights Office of the High Commissioner, 2017). Access to the
community through public transportation and access to public buildings presents as another
barrier (Country Reports, n.d.a). Depending on an individual's location, rural versus urban, and
their mode of transportation, access to healthcare may be limited. Legislative laws need further
development within Morocco in order to improve access for individuals with disability.
Geographic. Morocco spans 172,413 square miles, with the capital city, Rabat, located
northwest of the country. To the north is Tangier. In the center of Morocco lies the business
capital, Marrakech (Nations Encyclopedia, n.d.; Semlali, 2010). Morocco is in the process of
moving towards urbanization (Regional Health Systems Observatory World Health
Organization, 2006). In 2016, it was reported that 39.92% of the total population resided in rural
areas (Trading Economics, n.d.). Although the number is small in retrospect, the individuals
residing within this rural population are limited to healthcare access; with 59% of the rural
population living between 5 to 10 km (3.1-6.2 miles) from healthcare facilities. However, within
the urban areas, individuals have access to healthcare facilities less than 5 km (3.1 miles) away
(Arieff, 2013; Regional Health Systems Observatory World Health Organization, 2006).
Therefore, geographical location can play a key role in accessing healthcare.
Another important geographic factor that may limit access to healthcare is road
conditions and driving within Morocco. Within urban areas of Morocco streets are paved and
consist primarily of highways; however, it is common for traffic lights to not function or they are
difficult to view. In rural areas of Morocco, the streets are often narrow, unpaved and could be
windy or steep. Driving at night is strongly suggested to be avoided due to poor lighting. While
there are public transportation options, such as taxis and buses, the operators often demonstrate
poor driving habits. Buses are also typically overcrowded (Country Reports, n.d.b). Therefore,
getting around Morocco can be a chore based on geographic location and transportation means.
Demographic. Within Morocco, 99.1% of the population is composed of Arab and
Berber ethnic groups (CIA, 2018; Semlali, 2010; World Population Review, 2018). The
remaining percentage of the Moroccan population is composed of Jews, Europeans, Haratin, and
Africans (Countries and their Cultures, n.d.; World Population Review, 2018). Of this
population, between 42-45% are under the age of 24 years old, whereas 42% of the population is
between the ages of 25 and 54. Only 7% of the population is between the ages of 55 and 64, and
just 6% is 65 years and older. Thus, the median age of an individual in Morocco is 27 years old
(CIA, 2018; World Population Review, 2018). These statics support the MAIR clinic’s focus on
the pediatric population.
Social. Due to the majority of the population being composed of Arabs and Berbers, the
official language of Morocco is Arabic (Semlali, 2010). Within the rural areas of Morocco, the
common dialect is Berber, as the rural areas such as the mountains are where the Berbers
continue to reside. Two unofficial languages also exist across Morocco; French is spoken when
discussing government related topics and Spanish is common across the northern coastline of
Morocco (Regional Health Systems Observatory World Health Organization, 2006). The people
of Morocco are known to be warm, welcoming and hospitable; however, their views of disability
are quite different from those in the United States (Olivier, 2017). When a child with a disability
is born, it is common for the family to view the disability as a curse due to cultural influences.
Due to the negative stigma associated with disability, these children are typically not allowed in
schools; therefore, limiting their education and success within the Moroccan society (M. Sbai,
personal communication, September 21, 2018).
Today, Marrakech is reported as one of the most liberal cities within Morocco; however,
many social aspects may still be considered conservative (The Telegraph, 2018). The Moroccan
society is patriarchal by nature. Men work outside the home; whereas, women stay within the
home to care for the family. Women rely on their husbands for financial support, while the
husband relies on the wife to take care of the children and provide adequate meals. Within their
society, men are considered socially and economically valuable; therefore, their needs come first.
Women often eat last, eating less protein and less nutritious meals (Batnitzky, 2008). Girls are
often taken out of school to take part in family responsibilities so that boys are able to gain the
education they need to become employed (Olivier, 2017). Due to cultural influences, the mother
is the key role taker in caring for children with disabilities, in addition to other daily roles. The
mothers often experience burnout as a result.
Future Plans for Program Development

The future plan for the MAIR clinic is to grow into an excellent neuro-rehab facility, one
that provides services based off of medical models and standards of care that are similar to those
in the United States. He hopes that one day, the MAIR clinic will be recognized as the best
neuro-rehabilitation clinic in Morocco, as well as all of Africa. (M. Sbai, personal
communication, September 10, 2018). In order to meet these goals, Dr. Sbai realizes that first,
the therapy staff needs to improve their education regarding patient care and current evidence-
based practice. The clinic then needs to transition from a not-for-profit organization to a for-
profit organization, by demonstrating positive outcomes through quantitative data and achieving
goals (M. Sbai, personal communication, September 10, 2018).
Dr. Sbai plans on purchasing an abundance of land in order to develop a 10,000 square
foot clinic and a university to educate current and future therapists. A guest house will also be
built for those clients that live in remote areas and are unable to pay for a hotel, as well as, for
health professions from the U.S. to stay while visiting and contributing to the needs of the MAIR
clinic. He intends to have 15-20 therapists staffed at the new clinic, allowing the clinic to serve
125 patients per day (Your Mark on the World Center, 2018).
Data Collection Regarding Current Programming Strengths and Areas for Growth
In order to gain a greater understanding of the MAIR clinic in terms of strengths and
weaknesses, a variety of interviews were completed with key stakeholders, clinical staff, mothers
of the clients, and clients themselves. In addition, over the course of the two weeks at the MAIR
clinic, thorough observations were completed by the graduate student.
Stakeholders. A one-on-one semi-structured interview was conducted with the founder
of the MAIR clinic. Dr. Sbai reported that the greatest strength of the clinic is the skills of the
staff as compared to other medical workers in the country of Morocco. As a result of the staff
skills, success stories and positive results for multiple patients have occurred. In addition, the
reputation of the MAIR clinic is growing within the local community, even the medical setting is
beginning to recognize and refer patients to the clinic (M. Sbai, personal communication,
September 10, 2018). In terms of weaknesses, Dr. Sbai mentioned that admission is a nonexistent
process within the clinic. He acknowledges the need to establish a comprehensive process for
client evaluation, financial assessment, client scheduling, establishing goals and therapy
guidelines, documentation, and discharge (M. Sbai, personal communication, September 10,
2018).
Clinical staff. Group interviews and one-on-one semi-structured interviews were
conducted with the three aspiring neuro-therapists working at the MAIR clinic. One of the
greatest strengths reported by the staff is their ability to know all clients. Each therapist carries
their own caseload; however, they know all of the clients and client goals in order to meet their
needs if a therapist is sick or a change in schedule occurs (S. Berrada, personal communication,
October 5, 2018). Another strength is the therapists’ ability to push and engage the mother of the
client to participate in all aspects of therapy. The therapists train the mothers to perform
stretching and range of motion. The mothers also learn how to assist in positioning the child into
the stander and the locomotor training unit (C. Elghazi, personal communication, October 5,
2018). Overall, the clinical staff expresses strengths in providing therapy related to standing and
walking (I. Bentahar, personal communication, September 17, 2018).
In terms of weaknesses, the therapists report that they are limited in their ability to work
on communication with their clients. They also report that they would like to incorporate more
occupational therapy type exercises into their therapy sessions. Cognition is the largest area that
the therapists would like to improve upon, particularly attention and focus (S. Berrada & C.
Elghazi, personal communication, October 5, 2018). In terms of general diagnoses, the therapists
feel that they would benefit from further education related to stroke, cerebral palsy, and autism
(I. Bentahar, personal communication, September 17, 2018).
Clientele and families. Semi-structured interviews were completed with the mothers of
the children engaging in therapy at the MAIR clinic, with an aspiring neuro-therapist acting as
the interpreter. Through these interviews it was discovered that the most common goals that
parents wanted to address during therapy were as follows: (1) sitting, (2) standing, (3) walking,
(4) balance, (5) talking, (6) hand grasp, (7) dressing, (8) using the bathroom, (9) eating, and (10)
going to school (Parent 1, Parent 2, Parent 3, Parent 4, Parent 5, Parent 6, personal
communication, October 8-10, 2018; Support Group, personal communication, October 12,
2018). Although majority of the clients were children and were nonverbal, three adult clients
were able to participate in the interview process. In terms of adult clients, most common goals
were (1) going back to work, (2) being able to pray, (3) to use the bathroom, (4) to be able to use
their affected hand for functional tasks, and (5) to garden (Client 1, Client 2, Client 3, personal
communication, October 4-8, 2018).
Extensive research regarding formal assessments was completed in an attempt to find an
assessment that was relevant to the clients in order to gather further data. After a few semi-
structured interviews, it was apparent that no formal assessment would be completed for this
needs analysis due to a variety of factors. For one, the aspiring neuro-therapists were very busy
and did not have the time to sit down with the student therapist and the client and/or client’s
mother to fill out a formal assessment. Secondly, when translation occurred, the meaning of the
question was often changed to better meet the understanding of the individuals; therefore, even
semi-structured questions were often misunderstood or misinterpreted. Lastly, formal

occupational therapy assessments in relation to the pediatric population often asked what
occupations the child was able to complete independently and which ones they needed assistance
with. Due to the severity of the client’s conditions, more than half of the clients were dependent
on all activities of daily living (ADLs). Due to the client’s low level of function, participation in
ADLs were not yet a priority for goals, as noted by the top three goals reported above.
Typical interests for pediatric clients included television and music. A few non-dominant
interests included playing with phone cables, make-up, and cooking (Parent 1, Parent 2, Parent 3,
Parent 4, Parent 5, Parent 6, personal communication, October 8-10, 2018; Support Group,
personal communication, October 12, 2018). Interests for adults, included praying, shopping,
housework, and gardening (Client 1, Client 2, Client 3, personal communication, October 4-8,
2018). Strengths of the clinic that were reported by mothers and adult clients, include proactive
therapists, the opportunity for mothers/clients to collaborate with therapists, the equipment
available at the clinic, the home exercises that are recommended, and punctuality of services
(Support Group, personal communication, October 12, 2018).
Parents reported that the biggest weakness of the clinic was their inability to address
speech and communication. Limited access to other therapy services and equipment, such as a
TheraSuit® and hydrotherapy, was also reported. A TheraSuit® is a dynamic orthosis consisting
of multiple attachments connected through elastic bands that are applied to the head, chest,
knees, and shoes. The TheraSuit® is used in combination with an intensive exercise program in
order to accelerate a client’s progress in therapy; particularly clients with cerebral palsy
(Therasuit LLC, n.d.). Multiple parents reported that when asked about weaknesses of the clinic
it was impossible for them to answer as they were unaware of services that were available
outside of MAIR clinic (Parent 1, Parent 2, Parent 3, Parent 4, Parent 5, Parent 6, personal
communication, October 8-10, 2018; Support Group, personal communication, October 12,
2018).
Graduate student perspective. Through a variety of interviews, open communication,
and continuous observation, I was able to gain an understanding of the MAIR clinic.
Observations of evaluations, various treatment interventions, and home evaluations were
completed. Present strengths of the clinic and the staff include their relationships with the clients
and their mothers. It is apparent that the therapists take the time to get to know the client and
their family situation. Each therapist is knowledgeable of their own caseload as well as the other
therapist’s caseloads. Every morning the therapists set aside a half an hour to talk with one
another, going over their client’s goals, barriers, successes, and discussing their daily caseload.
In terms of therapy services, the aspiring neuro-therapists are effective in providing
therapy services related to trunk control, head control, stretching and range of motion, walking
with the use of the locomotor training unit, and mirror therapy for upper extremities. In addition,
the therapists spend a tremendous amount of time educating the mothers on stretching exercises
that they can perform at home. The therapists strive to have each client perform their home
program on a daily basis, as well as educating the client and mother on the importance of follow
through. Lastly, the therapists are able to provide therapy services to the same client multiple
times per week; a factor that may influence the time frame of rehabilitation and outcomes.
Due to the fact that the MAIR clinic is only three years old, continuous work is being
done to improve the establishment of the clinic; as a result, multiple areas of growth are possible.
Based upon an observation of an initial assessment, information and data collected during this
time is limited. During the initial evaluation the client’s personal information and data history is
gathered (Sbia, 2018). No physical assessment or engagement in an occupation is completed at
this time. Dr. Sbai reports that assessments are conducted; however, this was not observed.
Documentation is another area of weakness. The therapists typically spend five minutes
on one note. Notes often report what the client did during the therapy session, for example:
“AROM, walking on LT for 15 min, stretching the UP and LE, push communication, balance
exercises” (Sbia, 2018). A child’s progress is often documented through videos that parents take;
however, therapists do not transform the video files into a format that can be included in the
client’s file. Due to their form of documentation, progress towards goals and outcomes measures
are currently nonexistent. This also develops a conflict in determining when a client should be
discharged from services. The clinic has only discharged a handful of clients since its opening in
2015. The lack of discharge planning is causing the clinic to see clients that may no longer
benefit from services. In turn, this is causing future paying clients to remain on the waiting list.
Due to the severity of the conditions, clients often do not participate in occupations. The
demand of the therapist during a therapy session is too high to engage the client in an occupation.
When providing services to the children, the therapist’s hands are full, while attempting to
support the child’s head, trunk, and promoting proper positioning of the lower extremities.
However, occupations are being addressed with adult clients through prayer and cooking.
Continuous improvement can be made to help develop occupation-based therapy interventions
for the pediatric population, and to enhance the adult occupation-based interventions.
Other weaknesses include overscheduling clients and time management, limiting the
ability for the therapists to work one-on-one with their clients. Home evaluations and
modifications are not common practices carried out by the MAIR clinic. Lack of sustainable
resources is also a barrier in supporting the clinic as a not-for-profit organization.

Summary of Needs Analysis
Data collected from key stakeholders, clinical staff, clientele and their families, as well as
observations completed by the graduate student revealed a wide variety of needs and areas for
potential growth for the MAIR clinic. With a very limited number of discharges performed since
2015, the MAIR clinic continues to provide services to clients that have been receiving services
for three years and who are no longer demonstrating a significant change in function that needs
to be addressed in the clinic. The lack of discharge planning prevents new clients with more
critical needs from being admitted. The difficulty of determining the appropriate time of
discharge appears to be due to the current form of documentation within the MAIR clinic. Initial
evaluation, progress towards goals, and measurable outcome data is significantly limited. The
therapists believe that many of the current clients need to continue therapy services, as they are
still progressing. This statement is true, but the approach to reaching the client’s maximal
recovery can be addressed through a different means.
Although the clients and their families currently participate in home exercise programs
(HEPs), the HEP is limited to joint range of motion. HEPs targeting ADLs and enhancing client
participation within the home environment is essential to promote client progress towards desired
outcomes. Development of client-centered occupational therapy HEPs, especially for the cerebral
palsy population, will promote positive outcomes within a shorter time frame and enhance the
time the client spends in therapy. By encompassing HEPs into treatment, the clinical staff will
improve outcomes and promote timely discharge, with a program in place to maintain client
performance after discharge. In addition, HEPs can be provided to clients on the wait list as they
wait for hands-on therapy services to become available at the MAIR clinic. HEPs will assist the
MAIR clinic in obtaining outcomes, establishing an appropriate discharge plan, improving the
number of clients served, and assist in the transition to a for-profit organization.
Literature Review
In order to gain a comprehensive understanding of the occupational needs of the MAIR
clinic and its clientele, a literature review was conducted. PubMed, American Journal of
Occupational Therapy (AJOT), Google Scholar, CINAHL, and University of Utah (U of U)
Library were databases used to compile the ensuing literature review. The following terms were
used in various combinations in order to gather relevant articles: occupational therapy, rural
setting, underserved population, third world countries, Africa, outpatient therapy, pediatric
setting, outpatient setting, neurorehabiliation, rehabilitation, home exercise programs, task-
specific training, task-oriented training, occupation-based, activities of daily living,
compensation, remediation, rehabilitation, cerebral palsy, and factors influencing care. The
majority of the articles were found through Google Scholar searches; however, to access the full
article, the U of U Library and the student’s login were used. Originally, articles were only
included in the review if they were published within the last five years in order to ensure the
most current elements of best practice. However, due to limited research in respects to home
exercise programs as well as research regarding the country of Morocco, the time frame was
expanded to include articles that were published within the last 15 years. The decision to keep or
discard an article was based on its relevance to the program proposal and the comprehensive
information provided within. Eighteen articles were used to compose the following literature
review.
Prevalence of Disability in Morocco

It is estimated that one billion people residing on Earth are living with a disability, with
80% of these individuals living in developing countries (Hajjioui, Fourtassi, & Nejjari, 2015;
Khan, Amatya, Mannan, & Rathore, 2015). In order to gain a better understanding of the number
of individuals experiencing a disability within Morocco compared to the rest of the world,
literature was obtained. According to Boutayeb (2006), Morocco’s population was composed of
30 million individuals in 2006 (p. 1). In 2004, a National Disability Survey was conducted in
Morocco revealing that 1.5 million individuals live with a disability, or 5% of the Moroccan
population (as cited in Hajjioui et al., 2015). When the Moroccan Ministry of Health conducted a
similar survey a few years later, data showed that 18.2% of the individuals in Morocco were
experiencing at least one chronic disease (as cited in Hajjioui et al., 2015).
Rehabilitation Services for an Underserved Population in a Rural Setting
Although the MAIR clinic is located in Marrakech, a major city of Morocco, the clinic
provides a large amount of resources to families that are underserved and commuting from rural
areas outside of Marrakech. According to Dr. Sbai, clients are commuting to the MAIR clinic
from approximately 75 km away (M. Sbai, personal communication, October 3, 2018). As
previously mentioned, 39.92% of Morocco’s population continues to live within rural areas
(Trading Economics, n.d.). Therefore, due to the makeup of the clinic’s clientele, literature
regarding underserved populations and therapy services in a rural setting was collected.
Due to illiteracy, unemployment, geographic locations, slow economic growth, the cost
of healthcare and a ratio of one doctor for every 2,100 individuals, access to healthcare is
significantly limited in Morocco (Boutayeb, 2006; Hajjioui et al., 2015; Khan et al., 2015). In
addition to limited access to healthcare, access to rehabilitation services is even more scarce.
Although a large number of those residing in Morocco live with a disability, physical and
rehabilitative medicine is limited. In 2011, only five hospital beds within Morocco were devoted
to physical and rehabilitative medicine (Hajjioui et al., 2015). Even with five hospital beds
available, an individual’s greatest limitation to services is access. In developing countries, it is
common for healthcare to focus on prevention and curative aspects of disease; therefore,
rehabilitation is less of a priority. Additionally, a developing country’s statistics on its population
is often an approximation. Consequently, the data does not provide adequate information to
determine the type, setting, and intensity of rehabilitation services needed (Khan et al., 2015).
Both occupational therapists (OTs) and physical therapists (PTs) that work within the
rural setting have been found to have a high level of autonomy due to limited resources, poor
access to recent medical developments, and the remoteness from other disciplines or members
within their own discipline. Due to the limited number of therapists within the rural setting, high
caseloads containing a variety of diagnoses are common. OTs and PTs are often considered
generalists within the rural setting. Therefore, rural OTs and PTs are found to have a higher level
of problem-solving, communication, networking, understanding their scope of practice, as well
as the ability to improvise (Roots, Brown, & Banbridge, 2014).
In order to gain a better understanding of the roles that PT and OT play within the rural
setting, Roots et al. (2014) conducted a qualitative study to gather therapist perspectives. The
therapists were found to be generalists, stretching their role as therapists within their scope of
practice in order to meet the needs of their clientele. Due to a variety of factors, the definition of
health that they learned in practice was often modified to encompass the larger definition of
health (Roots et al., 2014). A similar principle has taken place in Morocco, as the definition of
rehabilitation is different from that in the United States. Khan et al. (2015) reports that the term
‘rehabilitation’ to the individuals residing in Africa often contains misleading connotations and
implies patient dependency.
Occupational therapy in Africa. At this time, it is uncommon for an OT to practice in
Morocco (Béguin, 2013). However, as mentioned in the needs analysis of this paper, Rabat, the
capital of Morocco, established an occupational therapy program in January of 2018. Slowly, the
practice of OT is gaining attention in Northern Africa (Nafai, 2015). In Algeria, a large country
east of Morocco, only 26 OTs are licensed and actively practicing. In West Africa, psychiatric
rehabilitation is the most common setting for OT practice. An occupational therapy school,
educating students on a bachelor’s degree level, is located in East Africa. Here, OTs commonly
work in nursing homes, psychiatry, prisons, military hospitals, and within the community. In
South Africa, it is common for OTs to work in clinics for HIV/AIDS to assist with management
of the disease. The model of human occupation, biomechanical, neurodevelopmental,
psychosocial, behavioral, and rehabilitative approaches are the most common treatment
frameworks used by OTs within Africa (Béguin, 2013; Kielhofner, 2009).
Neurorehabilitation. The MAIR clinic strives to provide valuable neurorehabilitation
services; therefore, relevant literature was obtained in order to understand the components of this
focus and the role of OT within this setting. Neurorehabilitation is a process that enhances
clients’ independence and participation within society. The belief is that neurorehabilitation can
leave lasting effects to all patients by providing services that are focused on the individual and
their goals for social participation and well-being within their environment (Donaghy, 2011;
Khan et al., 2015). Neurological conditions are those that affect the nervous system within one’s
body. Common examples include: spinal cord injury, traumatic brain injury, multiple sclerosis,
Parkinson’s disease, and cerebral palsy. Typical treatments in neurorehabilitation include: motor
control, mobility training, task-specific training, visual feedback, cognitive rehabilitation,
constraint-induced movement therapy (CIMT), and use of technology such as neuromuscular
electrical stimulation and virtual reality (Doucet, 2012; Gillen, 2010).
Within America, OT has recognized its role in neurorehabilitation; however, limitations
within practice exist. There is a lack of high-level research in OT practice in relation to
neurorehabilitation treatments. In addition, the literature that is available for OT practitioners
provides shortfalls in the link between neurorehabilitation treatment and its effect on enhancing
occupational performance (Gillen, 2010). Therefore, in order to justify the need for OTs within
neurorehabilitation, education, collaboration, and choosing outcomes that measure occupational
performance are imperative to remain in the practice of neurorehabilitation (Doucet, 2012;
Gillen, 2010).
Although the MAIR clinic provides services to a wide range of neurological conditions,
for the purpose of this paper, the focus is placed on children with cerebral palsy (CP). The
diagnosis of CP was chosen due to the prevalence within Morocco. Sixty-five percent of the
MAIR clinic’s population is children, a majority of which have a diagnosis of CP (M. Sbai,
personal communication, May 24, 2018).
Cerebral palsy. According to Morgan et al. (2016), the prevalence of CP worldwide is
2.1 per 1,000 live births, a number that has remained fairly stable since 2009 (Novak, Cusick, &
Lannin, 2009). In the United States in 2009, it was estimated that 550,000-764,000 individuals
were living with CP, with a prevalence of 3.6 per 1,000 live births (Novak et al., 2009; Salem &
Godwin, 2009). The term CP defines a group of neurodevelopmental disorders that result in
motor impairments which therefore limit participation in daily activities (Salem, & Godwin,
2009; Schnackers et al., 2018). On the other side of the world in Morocco, it is estimated that
25,000 new cases of CP occur each year. The cause of this widespread problem within Morocco
is unknown but hypothesized to be a result of a lack of access to healthcare, lack of resources
within healthcare, lack of financial resources, and geographical location (Hajjioui et al., 2015;
Nafai et al., 2017).
Neurorehabilitation has been found to be the most common approach to improving
mobility function and to manage the presentation of CP (Salem & Godwin, 2009). In a
systematic review conducted by Morgan et al. (2016), it was found that children with CP by the
age of five years old, have reached 90% of their gross motor development. The first two years of
life are the most pertinent for children with CP, as the most gains and potential for improvement
exist within this time frame (Morgan et al., 2016).
Home Exercise Programs for Cerebral Palsy
To supplement neurorehabilitation services provided in a clinic, a therapist could
establish a home exercise program (HEP). HEPs are used around the world to provide clients
opportunities for repeated practice of a task, to improve functional performance and to promote
participation within the home environment (Milton & Roe, 2017; Novak & Cusick, 2006;
Novack, Cusick & Lannin, 2009). HEPs can include task-specific training as well as many other
treatments that are incorporated within neurorehabilitation. Therefore, HEPs can transition the
valuable neurorehabilitation services provided within the MAIR clinic into the home
environment.
Even though OT may have limitations in providing neurorehabilitation services at this
time in America, OT provides a valuable contribution when implementing HEPs. OT provides a
holistic approach when providing services to a client. As an OT, one looks at the environment,
the person, the occupation, as well as any other factors that may contribute to occupational
performance. A major focus of OT is to improve client performance and satisfaction related to
their daily occupations. Occupations are everyday life activities that the client engages in
(American Occupational Therapy Association [AOTA], 2014). Additional information regarding
OT and HEPs will be presented, supporting the link between providing therapy services within
the home environment in addition to services provided at the MAIR clinic.
Home exercise programs. HEPs involve therapeutic activities that are carried out within
the home environment, with the parent acting as the faciliatory of the program (Novak, Cusick,
& Lowe, 2007). Therapeutic activities defer from exercise, as therapeutic activities are often
components of an occupation. Therapeutic activities hold meaning and relevance to the client as
they relate back to an occupation; whereas, exercise may not hold an inherent purpose and
cannot be considered a stand-alone entity (AOTA, 2014). From an OT perspective, home
programs are individualized to the client in order to target a specific body structure, a specific
activity, or to increase participation as identified by the caregiver and therapist (Milton & Roe,
2017; Novak et al., 2009).
In order to establish an individualized HEP, Novak and Cusick (2006) conducted a
literature review and through use of clinical-reasoning and experience, they developed what they
believed to be one of the first formal processes for HEP development with relation to CP. Little
research was available to assist an OT in the evaluation, development, and implementation of a
HEP for children with CP, but Novak and Cusick believed that enough information was provided
to assist in the development of an effective HEP protocol. To begin, an OT must establish a
service approach and a model to work from. In terms of HEPs, a family-centered approach is
considered the ‘gold-standard’ (Novak & Cusick, 2006; Schnackers et al., 2018). Common OT
frame of references and theories used to support this approach include the person-environment-
occupation (PEO) model, the motor control/motor learning, and neurodevelopment treatment
(NDT) (Law et al., 1996; Morgan et al., 2016; Novak & Cusick, 2006).
After appropriate models are established, Novak and Cusick (2006) suggest the following
five phases of action: “(i) establishing a collaborative relationship with the child’s
parent/caregiver; (ii) collaborative goal setting; (iii) constructing the home programme; (iv)
supporting the programme implementation; and (v) evaluating the outcomes” (p. 260). The
research conducted by Novak and Cusick was the first reference related to incorporating and
establishing HEPs for children with CP. More recently, Schnackers et al. (2018) presented
another method for establishing HEPs based on implicit and explicit learning. In summary,
Schnackers et al. (2018), proposes two phases for developing a HEP. The first phase includes
preparation, a needs assessment, goal setting, introductory meetings with involved professionals,
designing an individualized program, educating the parents on the HEP, and conducting a home
visit. The second phase implements the home-based training, including: caregiver training, video
recordings to document the HEP, daily logs, as well as coaching through telehealth and home
visits. When focusing on an explicit motor learning process, conscious aspects of the motor
process are targeted. On the other hand, when implementing an implicit motor learning HEP,
focus is on the non-conscious components of motor learning (Schnackers et al., 2018).
Based on current literature, the time spent on a HEP in order to reach targeted outcomes
varies from different researchers. In a double-blind, randomized, controlled trial conducted by
Novak et al. (2009), it was found that a HEP should be implemented for an average of 16.5
minutes per session for 17.5 times per month in order to achieve parent satisfaction and change
in function for children with CP. Conversely, literature obtained by Schnackers et al. (2018),
supports implementation of a HEP for 3.5 hours per week for a total of 12 weeks. In a pilot study
determining the impact on HEP for 20 children with CP, the typical time spent per day was 14.22
minutes, completing the HEP for an average of 27 days each month (Novak et al., 2007).
A variety of intervention methods for CP are supported within the HEP literature.
Modified CIMT and bimanual therapy were found effective intervention approaches for
improving upper limb function during HEPs for children with CP (Novak et al., 2009). In Novak
et al. (2009), 36 children were randomly assigned to an OT HEP for four or eight weeks or
received no home program. All children who participated in a HEP improved in upper limb
function, regardless of the intervention approach used. Although upper limb function improved,
Novak et al. (2009) found that the HEP had no impact on daily participation. Interventions
included handwriting task training, behavior support, recreation therapy, adaptive equipment,
play therapy, and CIMT. Morgan et al. (2018), also discovered that child-initiated movement and
environmental modification were effective means in improving motor function in children with
cerebral palsy as a result of their systematic review.
Salem and Godwin (2009) conducted a randomized controlled trial on the effects of task-
oriented training on mobility for children with CP. The children within the experimental group
completed task-oriented training as opposed to the control group who received typical PT
intervention. Task-oriented training included activities that were similar to mobility tasks that
were completed during everyday activities, such as completing sit-to-stands, walking, and
climbing stairs. After five weeks, it was found that the children who completed task-oriented
training improved in functional outcomes to a greater extent that individuals in the control group
(Salem & Godwin, 2009). Task-specific intervention was also supported as an appropriate
intervention in a systematic review conducted by Morgan et al. (2009), and when establishing
both an implicit and explicit model of learning for HEPs (Schnackers et al., 2018). Therefore,
task-specific/task-oriented training has proven to be an effective intervention approach for motor
learning during HEPs over time.

Summary of Needs Analysis and Literature Review
The mission of the MAIR clinic is “To trigger a neuroplastic change in the foundation of
our therapy, to accomplish maximal recovery is our most important goal” (MAIR, n.d.). By
implementing this mission statement into daily treatment, the MAIR clinic is fighting to
eradicate the negative connotation that the term ‘rehabilitation’ has in Africa. They hope to
reestablish the greater meaning of ‘rehabilitation’, one that promotes independence and positive
change (M. Sbai, personal communication, October 5, 2018). Cerebral palsy is a physical
disorder which limits physical movement and posture; therefore, limiting participation in
activities of daily living (Milton & Roe, 2017). The MAIR clinic strives to redefine rehabilitation
in relation to children with CP by providing training to the clients’ mother and
neurorehabilitation services to the children. The MAIR clinic engages children with CP in
locomotor training, joint range of motion, and trunk control activities during therapy sessions
within the clinic. The clinic also promotes mothers’ engagement in daily range of motion in both
upper and lower extremity joints. However, there are no resources in place to establish HEPs that
target task-specific training and participation in daily occupations.
In order to promote outcomes within a shorter time frame, enhance the time the child
engages in therapy, and to even provide therapy services when hands-on therapy is not available,
the MAIR clinic would benefit from a program focusing on establishing OT HEPs (Novak et al.,
2009). Based on semi-structured interviews completed with key stakeholders, clinical staff, and
mothers of the clients, a variety of goals exist. Goals established by mothers with children with
CP include: (1) sitting, (2) standing, (3) walking, (4) balance, (5) talking, (6) hand grasp, (7)
dressing, (8) using the bathroom, (9) eating, and (10) going to school (Parent 1, Parent 2, Parent
3, Parent 4, Parent 5, Parent 6, personal communication, October 8-10, 2018; Support Group,
personal communication, October 12, 2018). Individualized HEPs encompassing occupation-
based and task-specific training, in addition to the already established joint range of motion,
could assist in achieving these goals to enhance occupational performance and participation in
activities of daily living. The goal of HEPs are to meet desired goals within a shorter time frame
and to increase the number of clients discharged from one-on-one therapy services. In addition,
HEPs could be established for those clients that are currently on the waiting list. This would
allow these clients to participate in meaningful activities at home as they wait for their one-on-
one treatment sessions to become available.
As a result of the needs assessment and the literature review, a strong argument has been
established regarding the need for a program targeting development and implementation of HEPs
for children with CP. This program will fill a need established by all those involved as well as
graduate student observation, allowing integration of therapy services and goals into the home
environment, while simultaneously supporting the mission of the MAIR clinic.
Program Proposal
Program Overview
As a result of the gaps discovered during the needs analysis, a program that focuses on
the development of a comprehensive and individualized HEP for each child with CP is proposed.
There are three physical therapists employed at the MAIR clinic. Every day the therapists strive
to trigger a neuroplastic change and to accomplish maximal recovery in their clients (MAIR,
n.d.). By understanding movement problems as a result of a disease or injury, the physical
therapists work to improve or restore mobility in order to allow their clients to improve their
overall quality of life. As the therapists strive to increase mobility through stretching and
walking inside the clinic, a need exists to engage clients in task-specific and occupation-based
activities within the home environment. This program will provide supplementary services to
children with CP to reach desired outcomes in a shorter time frame, to increase the number of
clients discharged from one-on-one therapy services, and to provide an intervention for the
children that continue to reside on the wait list. A focus on task-specific and occupation-based
activities will ensure that the HEPs are meaningful to the child and their families, allowing
occupational engagement within the home environment and within their daily routine.
This proposed program places on emphasis on the home environment, meaningful
activities, and the caregiver as the provider of services. Currently, parents are being provided the
education required to complete daily range of motion mobility stretches in upper and lower
extremity joints, but the current HEP established for these children lacks functionality and
meaning to the children. The development of client-centered OT HEPs for children with CP will
merge the MAIR clinic practices into the home environment.
Development of the client-centered occupation-based HEPs will occur in the five phases
of action established by Novak and Cusick (2006). Desired outcomes will be identified through
collaboration between the therapist and the caregiver with relation to the information obtained
from completed assessments. A home evaluation will be conducted to gain an understanding of
the influence that the home environment will provide on the HEP. Education and training will be
provided to the parent in order to assist in carry-over from the clinical setting to the home
environment. Follow-up visits through telehealth conferencing or home visits will occur to
ensure that the needs of the client are being met and the HEPs are being adjusted as the skills of
the client improve. Assessments will be conducted to monitor progress and improvement in the
client’s performance skills and client factors over time.

In an ideal situation, an occupational therapist would complete home evaluations, as well
as the development and implementation of client-centered HEPs. However, due to a variety of
factors affecting the MAIR clinic, hiring a full-time occupational therapist is not feasible at this
time. Therefore, an OT will be hired for consultative and indirect services to educate and train
the aspiring neuro-therapists to implement this program. Initially, the OT will play a strong role,
as the OT will model elements of the home evaluation, goal development and HEP development.
As time goes on, the OT will transition to consultative services, allowing the aspiring neuro-
therapist to play a key role in evaluation and development of HEPs, reaching out to the OT when
needed.
Population. Sixty-five percent of clients served by the MAIR clinic are children. A
majority of the children served have a diagnosis of CP. With 25,000 new cases of CP in Morocco
each year, CP is an important diagnostic focus within the MAIR clinic (Nafai et al., 2017). Due
to the abundance of CP diagnoses present within the MAIR clinic, the development of client-
centered OT HEPs will focus on children with a CP diagnosis. The HEPs will be developed for
children with CP currently receiving hands-on therapy services at the MAIR clinic, as well as
those on the MAIR clinic’s wait list. In the beginning, HEPs will be established for all children
with CP, regardless of age. As time progresses, the goal is to develop HEPs for children prior to
the age of five, as most gross motor development occurs between birth and five years of age
(Morgan et al., 2016).
Program value. This program aims to merge the practices that are carried out in the
clinical setting to those carried out within the home environment. By providing HEPs, caregivers
will learn the knowledge and skills necessary to competently implement a home program for
their child over a period of time. The program will assist the caregivers in understanding the
importance of participation in occupations and meaningful activities. In addition, the program
will allow children with CP to maintain certain performance skills and allow other skills to grow
and develop. Over time, it is anticipated that the HEP will take over one-on-one therapy services
as outcomes are reached and discharge planning is performed.
The development of client-centered OT HEPs will allow children with CP additional
therapy services outside of the clinic or provide some form of therapy while waiting for hands-on
therapy while on the clinic’s wait list. A goal of the HEPs is to improve clients’ performance
skills and client factors in order to enhance occupational performance throughout daily activities.
Depending on when the HEP is established, the program may focus on improvement of desired
skills or maintenance of current skills. The mission of the MAIR clinic is “To trigger a
neuroplastic change is the foundation of our therapy, to accomplish maximal recovery is our
most important goal” (MAIR, n.d.). The development of client-centered OT HEPs aligns with
the MAIR clinics mission as it will implement treatment that supplements neurorehabilitation
and strives to reach maximal recovery within each child that the HEPs will serve. HEPs will not
only complement the MAIR clinic’s mission, HEPs will also address occupational injustice.
Occupational justice. Individuals have unique occupational needs, routines, and
capacities. Each individual has the right to exercise their occupational capacities in order to
maintain and improve their overall wellness and quality of life (Durocher, Gibson, & Rappolt,
2014). This program addresses occupational injustice by allowing clients the opportunity to have
their occupational needs met through participation and engagement. Through development of
client-centered OT HEPs, a number of occupational injustices are prevented. Specifically, this
program addresses occupational deprivation and occupational alienation.

Occupational deprivation is the state of inability to complete daily occupations due to
factors outside of a client’s control (Durocher et al., 2014). Through the development of HEPs,
the aspiring neuro-therapists will be trained to adapt the environment and task to meet the
demands of the client. HEPs will be established within the home environment, regardless of
geographical location. The client’s needs and goals established to create the HEP will focus on
allowing clients the opportunity to participate in occupations that are meaningful or necessary,
regardless of external factors. Due to cultural influences, the mother spends a tremendous
amount of time performing daily occupations for children with CP rather than encouraging client
participation. By implementing client-centered OT HEPs, the focus will be on maximal
participation from the client and less demand on the caregiver. Not only will this program
increase client skills, but it will also improve independence in ADLs.
Another form of occupational injustice is occupational alienation. Occupational
alienation is a prolonged absence of personal belonging. When an individual is unable to
participate in occupations, the individual experiences isolation, lack of self-identity,
disconnectedness from society, or may even experience no meaning in life (Durocher et al.,
2014). Due to the severity of the CP diagnoses within Morocco, a large degree of occupational
deprivation occurs. As a result of not being able to participate in meaningful occupations as a
result of external factors, occupational alienation occurs. From the graduate student’s
perspective, children were found sitting in the living room while the mothers were working in the
kitchen and children were out playing in the neighborhood. The child was left in the corner
without toys or any form of engagement. With little or no interaction with family, the
community, or siblings, the child does not gain a sense of belonging. This program strives to
enhance occupational engagement and awareness for children with CP. HEPs will be developed
to engage the child in occupations, activities, or tasks that provide a sense of participation within
their family environment to improve their occupational engagement and sense of belonging.
Influence of the population’s health. By addressing occupational injustices described
above, a variety of outcomes will follow. Client occupational performance and participation will
improve. Their health and wellness, well-being, and quality of life will improve as they will be
involved in more activities than ever before. The clients will begin to develop an understanding
of their role in performing an occupation as opposed to the caregivers. Children with CP for
which HEPs will be provided, will improve their mental and physical health as they establish an
identity, discovering meaning and purpose to daily activities within the home environment.
Level of prevention. As this program focuses on maximal recovery, improving
independence level of participation in occupations, and maintenance, a focus is placed on tertiary
prevention. The children that the HEPs will be established for already have a diagnosis of CP,
regardless of whether the diagnosis is recent or one that they have had for many years. The
attempt of implementing a HEP that can be incorporated into the family’s daily routine through
participation in occupations and task-specific training, is to maximize function for these children.
Although some of these children will never be independent with all ADLs, this program strives
to reach the highest level of participation possible to increase independence and decrease
caregiver burden. The program works to increase quality of life by reducing the symptoms
associated with CP. In addition, by participating in HEPs, the children will remain active and
healthy, avoiding secondary health conditions or complications.
Preventing secondary conditions. Through participation in HEPs, a number of health
risks or secondary conditions will be prevented. Health risks or secondary conditions include, but
are not limited to: feeding and swallowing, poor nutrition, respiratory issues, and contractures.
Due to CP, children may experience oral motor control deficits, making it difficult to manipulate
food once in the mouth and to swallow effectively. By addressing feeding to those children who
need it within their HEP, feeding and swallowing complications will be prevented. For example,
the therapist could provide oral motor exercises in addition to carrying out the actual task of
feeding. Poor nutrition can occur on both ends, rather it be obesity or emaciation. Obesity could
occur due to a sedentary state, as a result of a lack of engagement in daily activities. Emaciation
could occur as a result of an inappropriate diet or oral motor control deficits. Through a client-
centered OT HEP, poor nutrition can be prevented on a case-by-case basis through a variety of
interventions. Respiratory issues result from aspiration or positioning. Through physical therapy
and OT collaboration, positioning can be a factor addressed during daily occupations to prevent
these respiratory issues. Lastly, due to the current lack of engagement for children with CP in
Morocco, contractures of the fingers, wrist and hand are occurring. By enhancing client
participation, contractures will be prevented when a HEP is established early on. Overall,
through the development of client-centered OT HEPs, a number of secondary conditions will be
prevented. The health risks will be identified and addressed on a case-by-case basis, ensuring
that each child’s needs are met.
How Factors Influenced Service Delivery
Based on the geographical location of the MAIR clinic, the clinic serves individuals that
are underserved as well as those living in a rural area. Due to the MAIR clinic being in
Marrakech, Morocco, it is considered that the clinic is in a developing country. As Morocco is a
developing country, and a large disparity exists between the rich and the poor, this program will
be implemented through grants (Arieff, 2013). At this time, a large number of clients receiving
services at the MAIR clinic are not paying; therefore, it is unrealistic for this program to expect
an income based on clients and their families that are paying out-of-pocket or using insurance.
The number of OTs within Morocco is limited, as well as all other healthcare personnel.
As of January 2018, the first OT program was established in Rabat; however, it will be some
time before these students graduate, allowing them to practice in a number of areas throughout
Morocco. Even with an OT program within Morocco, the stakes of these students leaving to
practice outside of Morocco are high, as Morocco continues to be one of the leading emigration
countries in the world (de Haas, 2014). Based on geographical and professional domains, the
implementation of this program is more feasible if applied by those already on staff, the aspiring
neuro-therapists. The aspiring neuro-therapists are trained to be physical therapists; therefore, the
lens in which they practice is different from that of an OT. To ensure that all essential pieces of
the program are applied to the best of the therapists’ abilities, training will be provided by the OT
to shed light on their unique role and perspective within neurorehabilitation. The following
section supports the need for an OT to effectively establish and implement this proposed
program.
Rationale for an Occupational Therapy Role
An OT would be best suited to implement a program related to HEP development
through a holistic approach. An OT is sufficiently trained to assess individuals as a holistic
entity, including the environment, the occupation, and the individual’s functional abilities.
Within OT, it is important to consider the individual’s routine, home environment, and skills in
order to identify appropriate strengths and barriers related to occupational engagement. A
holistic approach will also assist in development of client-centered goals that target occupational
performance and participation in ADLs within the clients’ physical and social environments
(Milton & Roe, 2017; Novak & Cusick, 2006; Novak et al., 2009). This program would assist
clients in meeting desired goals by targeting specific body structures and participation problems
identified by parents through engagement in meaningful activities (Milton & Roe, 2017). By
reaching goals, the clients will have greater gains towards occupational success, leading to
discharge from outpatient therapy services.
As previously mentioned, it would be ideal for an OT to complete home evaluations and
develop all HEPs; however due to the factors discussed above, an alternative means will be used.
Within this program, an OT will provide consultative and indirect services for the MAIR clinic’s
staff, including education on the importance of developing a HEP, how to conduct a home
evaluation, as well as the development process for goal writing. Additionally, they will be taught
how to create activities that align with the client’s abilities. The OT will be a strong presence as
the HEPs begin to develop for the MAIR clinic’s clientele. As the skills of the aspiring neuro-
therapists improve, the OT will transition to more of a consultation-based practice model,
allowing the therapists to reach out when in need.
To ensure that the HEPs are occupation-based, an OT will play a key role in
development. Occupations, or everyday life activities, are the primary lens that OTs evaluate and
provide therapy through (AOTA, 2014). As a part of neurorehabilitation, task-specific training is
common. Task-specific training focuses on activities or components that make up daily activities
(Salem & Godwin, 2009). Occupations and task-specific training will be the primary focus for
development of all client-centered OT HEPs. An OT is essential to carry out the training of this
program as an OT will provide a holistic approach by incorporating the following models and
frame of references.
Theoretical foundation. Within the occupational therapy discipline, models and frame
of references are used for development and implementation of therapy services. The theoretical
foundation helps an OT support and guide services based off of theoretical assumptions,
postulates of change, and associated outcomes. The theories and foundations influence the
assessments chosen for evaluation and the means an OT uses to develop appropriate
interventions. At least one occupation-centered model is needed to ensure the primary focus of
this discipline. It is then common to use complementary models to assist with assessment and
evaluation. This section discusses the occupation-centered model, as well as the complementary
model and the family-centered practice approach chosen for the development of individualized
HEPs.
To provide occupation-based services, an occupation-centered model is essential. The
person-environment-occupation (PEO) model provides this occupation-centered focus. The PEO
model focuses on establishing a congruent relationship between the person, the occupation, and
the environment. Based on this model, the person, the occupation, and the environment are
factors that influence one another, impacting occupational performance. As this program
establishes HEPs for children with CP, the key environment is within the home. The PEO model
will allow the OT and aspiring neuro-therapists to evaluate the home environment to understand
how the environment influences the child’s behavior, as well as how the environment can be
used as a modality within the HEPs (Law et al., 1996).
The PEO model allows individuals to be seen holistically through assessment and
intervention. Due to the cultural differences between the U.S. and Morocco, it is critical that each
person’s life experiences, spiritual qualities, and cultural background are carefully taken into
account so that assumptions are not made. The PEO model also allows therapists to consider the
unique skills and factors that come with each individual (Law et al., 1996). To gather this
information, the Canadian Occupational Performance Measure (COPM) will be used. The
COPM will serve as a qualitative and quantitative means, gathering data related to client
performance and satisfaction with performance in areas of daily living. Areas discussed within
the COPM include: self-care, productivity and leisure. The COPM then identifies the top five
clients’ occupational performance problems. Performance and satisfaction are obtained based off
a 10-point Likert scale (1 = not able to do it/not satisfied at all to 10 = able to do it extremely
well/extremely satisfied). Due to the vast use of the COPM worldwide, the COPM can be
purchased in Arabic, allowing it to be used easily between therapists, clients and caregivers. To
view an English version of the COPM, see Appendix D (Law et al., 2014).
Within the PEO model, the activity, task or occupation are considered through task
analysis. Task analysis is the ability to break down the demands of the task into a set of steps or
skills that the client requires in order to carry out the desired scenario. By assessing the activity,
task, or occupation, the therapist is able to get a thorough understanding on how each step
influences occupational performance among clients (Law et al., 1996).
The PEO model perceives the environment and the person to be dynamic entities. Key
aspects from the person, the environment, and/or the occupation can influence performance. The
person, environment, and occupation transact continuously over time and space; therefore, it is
essential to optimize congruence to assist in optimal occupational performance. Within the PEO
model, barriers are perceived to be created by social attitudes, the medical model, laws, policies,
and the built environment. Optimal congruence is created by removing these barriers and
establishing changes within the person, the environment, or the occupation as needed (Law et al.,
1996).
To supplement the PEO model, the motor skill acquisition model will be used. The motor
skill acquisition model focuses on clients with central nervous system deficits which contribute
to difficulty in executing voluntary motor movements. This model is used as a complementary
model to PEO because it also strives to maximize personal and environmental factors in order to
enhance performance. When using the motor skill acquisition model, the therapist works to grow
the problem-solving skills the of the clients. This will assist the client in finding solutions to
challenges presented outside of the treatment setting. Overall, the motor skill acquisition model
strives to enhance purposeful movements, increase client problem-solving abilities, which in
turn, allows the client to complete a task in the most efficient way possible (Kaplan, 2010).
Lastly, the family centered practice (FCP) was a topic that was brought up time and time
again in the literature that was found when addressing children with CP and establishing a HEP.
Based on this approach, it is best to address the client’s needs within their family. Services
should be focused on engagement, involvement, and support within families. Due to the culture
in Morocco, the FCP is an essential element to the HEPs. The mothers play a key role in therapy
and meeting the needs of their children. The FCP will assist the therapist in engaging the mothers
and other family members in therapy by developing an understanding of their child’s needs. The
family will play a central role in the determining the needs and goals of the client, as well as
what activities should be addressed during the HEP (The University of Iowa, n.d.).
Goals and Objectives
The primary goals and objectives of this program are related to training the aspiring
neuro-therapists into skilled professionals that can effectively and efficiently carry out a home
evaluation and HEP development based on client needs. The following are goals and objectives
to support the program.

Goal 1: To improve therapists’ knowledge regarding the benefits and outcomes of implementing
a home exercise program that correlates with desired patient outcomes.
Objective 1: Within six months, 2/3 aspiring neuro-therapists will independently provide
an informal education session to at least five clients and their caregivers supporting the need for
these clients to participate in an individualized home exercise program to improve client
occupational performance in daily life activities.
Objective 2: Within one year, 2/3 aspiring neuro-therapists will independently identify at
least two performance skills that the child has improved upon as a result of their home exercise
program, in at least 75% of the clients.
Goal 2: To enhance the therapists’ abilities to modify the task or environment within home
exercise programs to meet the functional abilities of all clients.
Objective 1: Within two months, 2/3 aspiring neuro-therapists will use principles of task
analysis to modify at least one step within an occupation to improve a client’s performance
during their home exercise program with no more than five direct verbal cues.
Objective 2: Within eight months, 2/3 aspiring neuro-therapists will modify at least one
environmental factor in at least 10 client homes to improve client performance in their home
exercise program with less than three indirect verbal cues.
Once the training is complete and the aspiring neuro-therapists are able to implement this
program, a number of goals and objectives can be created in order to allow program evaluation
to occur and to ensure program outcomes are met. The following are an example of goals and
outcomes that can be established by the aspiring neuro-therapists in relation to this program.
Goal 1: To increase client participation in task-specific and occupation-based home exercise
programs in order to improve client’s independence in activities of daily living.

Objective 1: Within four months, 85% of clients will participate in at least one step of a
daily occupation during their individualized home exercise program with Min A.
Objective 2: Within one year, 80% of clients and their mothers will independently
participate in an individualized home exercise programs at least four times a week for an
average of 10 minutes per session.
Goal 2: To improve caregiver’s knowledge and commitment in carrying out individualized home
exercise programs for their child with cerebral palsy.
Objective 1. In six months, 8/10 mothers will demonstrate the individualized home
exercise program within the home environment will less than five verbal cues.
Objective 2. In ten months, 70% of mothers in the support group will independently
identify at least one benefit of participating in an individualized home exercise program
with their child.
Client-Centered Home Exercise Programs for Children with Cerebral Palsy
The development of client-centered OT HEPs for children with CP is a program that will
complement the MAIR clinic’s mission in multiple formats. For one, the program will provide
further education related to clinical reasoning, intervention development, as well as an exposure
to the principles of occupation-based treatment, implementing programs within the home
environment and principles of task analysis. The main goal of the MAIR clinic is to reach
maximal recovery of each and every individual through neurorehabilitation. Additional time
participating in a variety of activities, including but not limited to occupations, exercise, and
task-specific training within the home environment will enhance client potential to reach this
goal. This program will also expose the aspiring neuro-therapists to the importance and place for
adaptation to occur within the neurorehabilitation process.

Based on the formality of the situation, an OT will train all aspiring neuro-therapists
within the MAIR clinic. Once training is completed, HEP development will be performed by all
aspiring neuro-therapists, proving HEPs to all children with CP. The purpose of this program is
to serve all children with CP that have contact with the MAIR clinic, this includes: children
actively receiving services, those preparing for discharge, and those on the wait list. HEPs will
be completed between aspiring neuro-therapist, caregiver, and the client, with 24 hours of
consultation services being provided by the OT each month. The program timeline section will
break down the components of the process and how it will unfold over time.
Program timeline. For the purposes of this program, a two-week training will be
provided to all aspiring neuro-therapists employed at the MAIR clinic. The training will cover
two-weeks as it will be providing education over time, allowing the aspiring neuro-therapists to
process and reflect on material provided. The development of client-centered OT HEPs program
will highlight the following topics when educating the aspiring neuro-therapists.
The program will begin with the OT discussing the importance of HEPs. The therapist
will iterate the importance of going beyond joint range of motion by increasing client physical
engagement within home activities to promote desired outcomes. The presentation will go on to
discuss what interventions can be included within a HEP. The next presentation will provide the
aspiring neuro-therapists education related to home evaluations. The OT will discuss why a
home evaluation is performed and what is typically looked for in a home evaluation.
Once all of the background information is provided by the previous two presentations
discussed, the OT will begin educating the aspiring neuro-therapists on determining components
of a HEP. During this presentation, the OT will define the difference between an occupation, an
exercise, an activity, and a task. The OT will then discuss principles of task analysis in order for
the aspiring neuro-therapists to have a basic understanding of how to adapt an activity to the
client’s abilities. Lastly, the presentation will discuss how to determine an appropriate
occupation, an exercise, an activity, or a task based on the client’s abilities, age, and
development. The OT will use the five phases of program development established by Novak
and Cusick (2006), to educate the aspiring neuro-therapists on program development. All phases
will be discussed in depth during implementation of the program. According to Novak and
Cusick (2006), the five phases are: “(i) establishing a collaborative relationship with the child’s
parent/caregiver; (ii) collaborative goal setting; (iii) constructing the home programme; (iv)
supporting the programme implementation; and (v) evaluating the outcomes” (p. 260).
The fourth and final educational presentation will discuss methods of data collection. The
OT will educate the aspiring neuro-therapists on the Canadian Occupational Performance
Measure (COPM), with practice opportunities to perform the COPM. The aspiring neuro-
therapists will then be educated on the home evaluation and HEP development form that the OT
has developed for their clinic (see appendix E). Goal writing will also be included within this
presentation, providing the therapists with information on how to develop measurable goals that
will identify outcomes. This will not be a large focus of this program, as goal writing could be a
program in its own. Discussing goal writing as a part of this program only provides exposure to
detailed goal writing, allowing them an opportunity to view a different means to goal writing. All
of the educational PowerPoints will be provided during the first week of the training.
Week one will conclude by beginning the final phase of the program, putting the skills to
practice. The aspiring neuro-therapists will have the opportunity to observe the OT perform a
home evaluation and development of a HEP based on one client receiving services at the MAIR
clinic. The entire process will occur within the client’s home, reiterating the importance of the
home environment. Once the observation of the OT is complete, the OT will provide each
aspiring neuro-therapist with a case study to work on independently over the weekend. To begin
the second week, the OT and aspiring neuro-therapists will sit down and go through the case
study, discussing the difficulties of establishing a HEP, comparing HEPs between therapists, as
well as a variety of other factors. After the case studies are complete, each aspiring neuro-
therapist will have the opportunity to perform a home visit and develop a HEP on their own. The
OT will join the aspiring neuro-therapist on the home visit in order to observe and provide
immediate feedback on performance. Once all three home visits are completed and the HEPs are
developed, the two-week training will end by gathering as a group, allowing the aspiring neuro-
therapists to present their HEPs, discussing personal challenges and providing an environment
for final questions for the OT, as well as for group collaboration and problem-solving to occur. A
visual overview of the program is presented in Appendix B.
Time requirements. Due to the composition of the program, a two-week training will be
provided to all aspiring neuro-therapists. A total of 44 hours will be required for completion of
the training (15 hours of preparation + 1-hour presentation + 2-hour presentation + 5-hour
presentation + 3-hour presentation + 18 hours of application = 44 hours). The OT will complete
all preparation for the two-week program prior to arriving at MAIR clinic. A total of 11 hours
will be presentations conducted by the OT during the first week of training. The first week will
end with the OT conducting a home evaluation and HEP development, allowing the therapists to
observe the entire process. Including the observation and case study, 18 hours will be dedicated
to the second week of training for application of learned skills. To view the time requirements in
relation to the training, view Appendix B.

The following is a proposal of the time required to implement HEPs for all children with
CP by the aspiring neuro-therapists. The MAIR clinic is open Monday-Friday from 9 am-12 pm
and 1-5 pm, as well as on Saturdays from 9 am-12 pm. For the purposes of the HEPs, services
will be provided Monday-Friday following the times mentioned above. Home visits will be
performed Monday-Friday, with Saturday providing the therapist time to catch up on
documentation and development of HEPs as well as to complete any additional collaboration
with the OT. It is estimated that two hours will be required to complete a comprehensive initial
evaluation. An initial evaluation will include a home evaluation, completion of the COPM, as
well as evaluation and observation of the client.
For each home visit, 60 minutes of transportation is allotted roundtrip. Approximately 2-3
hours is required for consultation and development of client-centered OT HEPs. A handout with
pictures and essential descriptions is included within this time frame. The therapist will then
complete an additional 90-minute home visit to provide caregiver education and training related
to the client’s HEP. Every six months thereafter, a 45-minute home visit or telehealth conference
will be completed to conduct a follow-up, complementing the COPM again and changing the
HEP as needed.
The MAIR clinic is currently providing services to 60 clients, 65% of which are children.
Therefore, 39 are children, a majority of which have a diagnosis of CP. For the purpose of this
paper, 60% of the children will have a diagnosis of CP, or 23 children. The MAIR clinic’s wait
list is composed over 100 individuals, 30-40 of which have a diagnosis of CP. For this paper, 35
individuals will be considered on the wait list with a diagnosis of CP. Numbers are based on an
approximation gathered by Dr. Sbai, as there are no current statistics regarding the exact number
of children with CP being served and those on the wait list (M. Sbai, personal communication,
November 15, 2018). Overall, there are currently 58 children receiving services from the MAIR
clinic or waiting to receive hands-on therapy services.
For initial evaluation and development of a HEP, it is anticipated that it will require an
average of five and a half hours per client (120 minutes for initial evaluation + average of 60
minutes for commute + average of 150 minutes for consultation and development of the HEP =
330 minutes). To complete all 58 HEPs, 319 hours is required (5.5 hours per client x 58 clients =
319 hours). To teach the HEP, two and a half hours are required per client/caregiver (60 minutes
for commute + 90 minutes for home visit = 150 minutes). Therefore, a total of 145 hours is
required to complete all educational home visits (2.5 hours per client x 58 clients = 145 hours).
After the clients’ HEPs have been implemented for six months, 45-minute follow-up visits will
occur (45-minute follow-up visit + 60 minutes for commute = 105 minutes). This will require
one hour and 45 minutes per client or 101.5 hours overall for follow-up visits (1.75 hours per
client x 58 clients = 101.5 hours). To save time for the aspiring neuro-therapists, six-month
follow-up visits can be completed through teleconferencing.
Overall, to serve all children with CP receiving services from the MAIR clinic or those
on the wait list, 464 hours is required for initial evaluation as well as development and
implementation of the HEP (319 hours for initial evaluation and HEP development + 145 hours
for educational home visit = 464 hours). Every six months, 101.5 hours will be required to
complete follow-up visits and provide changes to HEPs on a case-by-case basis. Again, the time
required for follow-up visits may vary, depending on the number of visits conducted through
teleconferencing versus those completed during a physical home visit.
Program criteria. The development of client-centered OT HEPs will specifically target
children with CP who are currently receiving services or are on the wait list for services at the
MAIR clinic. To ensure that the HEP is developed holistically, considering the person, the
environment, and the occupation, the home environment is an essential component to the
program. Therefore, the program will be provided to all children with CP, regardless of
geographic location, as many of the clients and their caregivers are commuting from rural areas
outside of Marrakech.
Due to the abundance of CP being addressed within the MAIR clinic, HEP development
will focus on this diagnosis. Therefore, all other diagnoses will be excluded from this program. It
is anticipated that the program will expand to include individuals with varying diagnoses. This
expansion will be reliant on program outcomes and capabilities of the MAIR clinic and its staff.
How the program addresses factors relevant to the setting. A large percentage of the
population served within the MAIR clinic is children with CP; this factor influences the focus of
the development of HEPs to those with a diagnosis of CP. The development of client-centered
OT HEPs will provide clients additional potential to reach maximal recovery, allowing them to
participate in desired ADLs. By reaching maximal recovery through neurorehabilitation
approaches, such as task-specific training, this program supplements the MAIR clinic’s mission
statement.
Staff involvement. Based on the situation of the MAIR clinic, a full-time OT is not
feasible at this time. As a result, an OT will be hired for consultative and indirect services. The
OT will be used to prepare and implement the two-week training for this program. The two-week
training will be completed on-site, using both the MAIR clinic as well as clients’ homes. After
training is complete, the OT can then be reached through teleconferencing for 24 hours of
consultation each month. The OT will provide the aspiring neuro-therapists the skills they need
to sufficiently complete a home evaluation and HEP development by emerging occupational

therapy practices into that of physical therapy. The OT will play a supportive role initially, as the
program is being established. Over time, it is anticipated the OT role will diminish as the
aspiring neuro-therapists take on a larger role within the program.
Community resources. As the focus of this program is HEP development, the entirety of
the program will be completed within the community, specifically within the clients’ homes. The
home environment is the focus of this program; therefore, no community resources outside of the
clients’ homes will be recommended.
Space requirements. Due to the composition of this program, space requirements will
vary. The space that will be allotted for the HEP is composed of the home environment;
therefore, space will vary from family to family and house to house. Equipment within the space
will also vary depending on the activities, tasks, or occupations incorporated into the HEP. For
example, if a child is working on oral hygiene, the location of the activity will be performed near
a sink, either in the bathroom or the kitchen. The child may be able to stand independently next
to the sink or will require supported seating based on trunk control. Through home evaluation
and implementation of the person-environment-occupation model and the motor skill acquisition
model, space requirements will be established according to client needs and skills. The
evaluation and intervention will both be completed within the home environment. The COPM
will most likely be completed between therapist, caregiver, and client seated in the living room.
The home evaluation form will be completed as the therapists assesses the home environment.
Within the MAIR clinic, a storage space of 15 square feet will be allocated for ADL kits for the
HEPs. A number of ADL kits will be stored in the therapists’ vehicle at all times, being
restocked by the kits within storage as needed. The therapist may use a small office space within
the MAIR clinic, the client’s home, or the car in order to complete documentation.
Budget. In addition to the other requirements discussed previously, a budget is needed to
propose yearly cost and income. To see the proposed budget in its entirety, see Appendix C. This
section will discuss the need for the items proposed in the budget.
An OT will be hired to develop the training and curriculum prior to arriving in
Marrakech, Morocco. Cost of the travel, including airfare and hotel stay, are included for the OT
within the budget. The OT will then be paid for the hours spent providing training during the
two-week training to educate the aspiring neuro-therapists on HEP development. Lastly, the
budget also includes the cost for OT consultation services, allowing consultation to be provided
up to 24 hours per month. At this time, the MAIR clinic has three aspiring neuro-therapists. As
Dr. Sbai wishes, all therapists are trained to implement this program; therefore, three therapists’
yearly wages were also included within the budget. Benefits of all aspiring neuro-therapists were
also taken into account.
Each HEP will require various supplies based on the targeted performance skills and
desired client outcomes established by the therapists and the caregiver. Examples of supplies
included in an established HEP include: handouts with written and pictorial information
regarding the HEP, ADL kits (such as a bathing kit or oral hygiene kit), as well as client and
family toys and furniture. Client and family toys and furniture were not considered in the budget,
as the therapists will incorporate items already present within the home environment. ADL kits
will be distributed on a case-by-case basis, depending on the occupations assigned within a
client’s HEP.
Initial start-up cost will include a transportation vehicle. A car is needed for the aspiring
neuro-therapists to travel to the clients’ homes. A mobile printer will be installed within the
vehicle and a laptop with Microsoft Office will be purchased to support development and
printing of home evaluations and HEPs on the go. Direct costs to support HEP development
includes office supplies, including ink and paper for the printer, as well as pens. Assessments for
this program include the Canadian Occupational Performance Measure (COPM) in the Arabic
language as well as a free home evaluation and HEP development document created by the
graduate student. Both assessments tools will assist the aspiring neuro-therapists in the
development of HEPs through interview, observation and assessment of the client, and the home
environment. Mileage reimbursement is an additional direct cost included within the budget.
Costs that indirectly affect the program include car maintenance, storage of ADL kits, and
internet.
A few of the items included within the budget are considered in-kind due to the MAIR
clinic already owning or paying for these materials. These items include: the yearly wage of
three aspiring neuro-therapists, storage within the MAIR clinic, and internet. Due to the MAIR
clinic being a not-for-profit organization at this time, as well as the limited number of clients that
self-pay or pay through insurance, an estimate was made on the income for the purpose of this
budget.
Marketing. No formal marketing needs to occur for this program, as marketing of this
program will be completed in-house. The development of HEPs for children with CP will be a
supplemental program provided to all children with CP receiving services at the MAIR clinic,
children preparing for discharge, and those on the MAIR clinic’s wait list. Therefore,
communication between aspiring neuro-therapists, caregivers, and clients will occur during one-
on-one therapy sessions or through a phone call for those on the wait list. Word of mouth has
continued to be one of the leading ways for the MAIR clinic to receive clients and is effective for
marketing this program. A personal selling relationship will occur between the aspiring neuro-
therapist and the caregivers of children with CP. The therapists at the MAIR clinic will be the
ones educating the family about a home visit and recommending that a HEP be established for
their child. This selling relationship will be effective for this program, as the therapists on site
already have strong relationship with all caregivers. Future effort will be taken to properly
document the number of children with CP receiving services as well as those on the wait list. By
gathering this data, appropriate effort can be made to ensure that all children with CP are being
provided the opportunity to participate in the program.
Program Funding
Audit trail. To support implementation of this program, a number of funding sources
were reviewed to discover realistic funding services. To obtain funding options, a number of
resources were used. Through the U of U Eccles library, research databases were accessed, and
the following search engines were used: foundation directory online and funding institutional.
The following key terms were used in various combinations in order to search the funding sites:
health (subject area), Morocco (geographic focus), Africa (region), cerebral palsy,
rehabilitation, and program and projects (funding type).
Funding options. The Bill & Melinda Gates foundation was the first funding source
found that would be realistic in terms of funding this program. This foundation focuses on
providing equality across all individuals, allowing them to live healthy lives. Within developing
countries, the Bill & Melinda Gates Foundation seeks to improve health and living for all
individuals. Within the U.S., this foundation strives to provide access to opportunities individuals
need to succeed in life, especially those with few resources (Foundation Directory Online,
2018a). Overall, the missions of the Bill & Melinda Gates Foundation are to (1) ensure that
people survive and thrive, (2) empower the poorest, (3) combat infectious diseases, and (4)
inspire others to take action (Bill & Melinda Gates Foundation, n.d.). Funding interests for the
Bills & Melinda Gates foundation include: community and economic development, program
development, children and youth, and individuals of a low socioeconomic status. A large amount
of the Bills & Melinda Gates foundation currently serves Africa. In 2016, a total of
$4,280,463,865 was distributed for grants from this foundation. Grants from this foundation
currently range from $5,000 to over $1 million. Funding provided by this foundation tends to be
on the higher end, providing funds from $500,000 to $1,000,000 but it is not to say that the
source would not be willing to fund this program (Bill & Melinda Gates Foundation, n.d.;
Foundation Directory Online, 2018a).
The MAIR clinic is a not-for-profit organization. At this time, the MAIR clinic is
primarily receiving grants from the different branches of Rotary International, such as the Salt
Lake Rotary Club. The mission of the Rotary International is to “provide service to others,
promote integrity, and advance world understanding, goodwill, and peach through our fellowship
of business, professional, and community leaders” (Rotary International, n.d.). Although Rotary
International was not found during the grant search, the MAIR clinic is currently receiving
funding from this source, making it a realistic funding opportunity for this program. In terms of
the MAIR clinic, Rotary International focuses on providing education to the aspiring neuro-
therapists. At this time, Rotary International provides $70 million dollars in grants each year;
however, an application for a specific grant from this foundation was not found to determine how
much this organization could fund the program (Rotary International, n.d.).
In the past, the MAIR clinic has also received grants from the Sorenson Legacy
Foundation. The Sorenson Legacy Foundation was established by James LeVoy and Beverley
Sorenson to provide education and community development from a scientific domain all the way
to an art domain. The foundation is based in Salt Lake City, Utah, but provides services across
the world. Funding interests include: diseases and conditions, family services, continuing
support, and program development with a population focus on children and youth, economically
disadvantaged people, as well as those with a low socioeconomic status. In 2016, $35,167,550
was given in grants from the Sorenson Legacy Foundation, varying the number of funds
distributed per organization based on the number of dollars needed. Most of the funding
provided by the Sorenson Legacy Foundation tends to range between $10,000 to $25,000 with a
number of other donations ranging between $25,000 to $500,000. Based on the typical funding
distributed, the Sorenson Legacy Foundation may be a more appropriate option for this program
as compared to the Bill & Melinda Gates Foundation (Foundation Directory Online, 2018;
Sorenson Legacy Foundation, n.d.).
Program Evaluation
To ensure funding and growth of the program, program evaluation and outcomes are
expected. The following section will discuss the expected outcomes of the OT providing the
aspiring the neuro-therapists training, as well as the outcomes expected as a result of
implementation of this program. This section will continue by discussing how these outcomes
can be evaluated.
Expected outcomes. As a result of this program, all aspiring neuro-therapists at the
MAIR clinic will have the training they need in order to conduct a home evaluation and develop
a client-centered, occupation-based HEP. In addition, the therapists will gain a knowledge
related to the importance of HEPs that go beyond stretching, allowing desired client outcomes to
be met in a shorter time frame. This program also provides the therapists with an education
regarding the COPM, a different assessment from those already in place at the MAIR clinic.
Also, the program introduces the therapists to a more comprehensive form of goal writing and
documentation in order to monitor and identify patient outcomes as a result of HEPs. Another
essential outcome of this program is providing the education needed to use compensation as just
as an effective means as that of rehabilitation. Compensation has its time and place, just as
rehabilitation does, allowing the therapists to gain the knowledge and reasoning behind
compensation will allow the method to be applied appropriate and effectively across clients and
settings.
From the client perspective, this program will provide additional time for the clients to
engage in services that will assist in the development, as well as maintenance, of client factors
and performance skills. This program serves as the beginning step in obtaining maximal recovery
and serves as a program that can be implemented after discharge to ensure maintenance of client
skills. Through education provided by the aspiring neuro-therapists, the caregivers of the clients
will learn the importance of a HEP and how to be the facilitator of an effective HEP. In turn, this
program will eliminate occupational alienation and deprivation, allowing the clients the right to
participate in their desired ADLs.
Evaluation. Both quantitative and qualitative data will be gathered to determine the
effectiveness of the program and ensuring that the expected outcomes are obtained. After the
two-week training course is complete, a case study will be presented to all aspiring neuro-
therapists. The case study will serve as both a qualitative and quantitative means, as there will be
right and wrong answers, as well an opportunity for some of the answers to vary across
therapists. The case study will ensure that the aspiring neuro-therapists obtained the necessary
information during the training provided by the OT to effectively complete a home evaluation
and HEP development.

Another means that could be used to ensure the aspiring neuro-therapists learned the
essential information for home evaluation and HEP development would be to create a test. The
test would consist of a variety of multiple-choice questions, providing a small case and allowing
the therapists to choose the best possible answer. This test would serve as quantitative data, as
there is a correct and incorrect answer for each question. In terms of quantitative data over time,
the follow questions can be used to gather data related to program outcomes:
1. How many home evaluations were completed? How many home evaluations were
performed through teleconferencing or a narrative format within the MAIR clinic?
2. How many home exercise programs were developed?
3. How many specific exercises did the aspiring neuro-therapists implement in the
HEPs?
4. What was the most common occupation used for the home exercise programs?
Options are: bathing, feeding, eating, toileting, dressing, functional mobility, personal
hygiene.
5. Were there any instrumental activities of daily living implemented into the home
exercise program? Yes/No What was the most common? Options are: care of pets,
religious and spiritual activities, and meal preparation and clean-up.
In terms of qualitative data, the following questions can be asked to gather program
outcomes related to the training provided by the OT:
1. What was the most beneficial piece of information you learned during the two-week
training provided by the OT?
2. As the therapist, what did you find the most challenging about establishing a HEP for
your clients?
3. What information do you wish the OT would have provided during the two-week
training that was not discussed in relation to the home environment and HEP
development?
4. What additional training would help you implement a comprehensive HEP for your
clients?
5. How do you plan to take the information you have learned from this two-week
training and implement a program focusing on client-centered HEP development
within the home environment?
6. From your own perspective, how is an occupational therapist’s role different from
that of a physical therapist’s role?
For the aspiring neuro-therapists, once they have completed the OT training and
implementation of the program has occurred, the following quantitative and qualitative data can
be used to gather information relevant to the program’s outcomes. The COPM will be used as a
quantitative measure to identify outcomes, as it will provide numerical data as to how the
caregiver’s/client’s satisfaction and performance numbers have improved over time through use
of the HEP. The scoring section of the COPM is based on a 10-point Likert scale, ranging from 1
(not able to do it/not satisfied at all) to 10 (able to do it extremely well/extremely satisfied) (Law
et al., 2014). For qualitative data, various forms of the following questions can be asked to the
parents by the therapists:
1. What benefits has the HEP provided for you and your child?
2. What do you find most challenging about a HEP?
3. What was something that the therapist educated you on that you found helpful for the
HEP?
4. How has the HEP helped your child in becoming more independent?
5. What other focus areas, activities, or interventions do you wish were included in the
HEP for your child?
Summary
Overall, the needs analysis conducted at the MAIR clinic led to the development of a
comprehensive HEP for clients to engage in. This HEP targets occupations and task-specific
training to improve client performance, participation, and satisfaction across a variety of areas. A
literature review was conducted to gather literature about HEPs related to the MAIR clinic’s
most prevalent diagnosis, CP. Through evidence-based literature and clinical reasoning, the
graduate student created a program proposal to develop client-centered OT HEPs for clients
receiving services at the MAIR clinic as well as those on the wait list. This program proposal
provides an in-depth guideline to the development and implementation of such a program for the
MAIR clinic. This project has been a delight to work on over the course of the semester, as the
staff at the MAIR clinic are delightful individuals to work with. Dr. Sbai and the aspiring neuro-
therapists work hard to provide what is best for the clients that they serve at the MAIR clinic. It
is my pleasure to present them with this program proposal in hopes to increase the number of
clients served through an alternative means.

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Appendix A: Interview Questions
Questions related to Occupational Therapy

• What does a typical day at the clinic look like?
• What diagnoses are included in your caseload?
• What is the most common diagnosis?
• Are there any diagnoses that you do not work with in the clinic?
• What ages are included in your caseload?
• What is the most common age range receiving services at the clinic?
• What is the caseload for a therapist at the clinic each day?
• What is the frequency of services?
• What other health professionals do you work with outside of the clinic?
• Do you understand the role of occupational therapy?
• What occupations do you address the most during therapy sessions?
• What programs would you like to implement into the clinic?
• What is the involvement of the parents like?
• What do the parents most commonly ask about during therapy sessions?
• What are the primary goals of the parents?
• What does the discharge process look like?
Questions for Dr. Sbai

• What qualifies a patient for services?
• How do patients find out about the MAIR clinic? Is a physician referral required for
treatment?
• What is the scheduling process at the clinic?
• What is the evaluation process?
• What is the goal writing process?
• What is the documentation process?
• How do you fund the services that the clinic provides?
• What barriers limit the services that are provided at the clinic?
• How does the Salt Lake Rotary Club contribute to MAIR clinic?
• What is the Zahra Charity?
• How many therapists are on staff?
• What is the education background of the therapists?
• What other members are on staff?
• How do you prioritize and organize the waiting list?
• What is the distance that patients are traveling to receive services at the clinic?
• How many patients are paying for services? How are they paying?
• How do you envision this occupational therapy team contributing to your clinic?
• What are your plans for the future?
• What is the plan for making the clinic sustainable?
• What is working well for the clinic at this time? What aspects need improvement?
Questions for Staff

• What programs do you currently implement at the clinic?
• What programs would you like to implement at the clinic?
• What are current strengths of the services provided?
• What are the weaknesses of the services provided?
• What are your current strengths as a clinician?
• What are your current weaknesses as a clinician?
• What are current limitations that are impacting the services provided at the clinic?
• What does your current documentation process look like?
• How long do you typically spend on documentation?
• If you had unlimited funds for the clinic, what would you want to buy or implement?
• How do you establish goals for your patients?
• What are you doing in terms of Telehealth?
Questions for Patients and their Families

• What are your goals for yourself or your child?
• How did you learn about the MAIR clinic?
• What do you enjoy the most about the clinic?
• Are there any services that you wish the clinic would provide?
• What do you wish that you or your child could do independently at home that they are
currently not independent in?
• What are your or your child’s interests?
• What would you like for your child in the future?
Appendix B: Outline of Two-Week Training Course
• The importance of HEPs (1 hour)
o Why is joint range of motion not enough in a home exercise program?
• Home evaluation (2 hours)
o What to look for in a home evaluation
o Why a home visit may have better outcomes than a caregiver narrative
• Determining the components of a HEP (5 hours)
o Occupation vs exercise vs activity vs task
o Determining whether the activity is age appropriate
o Principles of task analysis
• Gathering data (3 hours)
o Canadian Occupational Performance Measure (COPM) (Appendix D)
o Home evaluate and HEP development (Appendix E)
• Putting these skills to practice (18 hours)
o Observation of OT home evaluation and HEP development (4 hours)
o Case study (3+ hours on the aspiring neuro-therapists own time)
o Individual home evaluations and HEP development (9 hours)
o Reflecting on personal experiences (2 hours)

Week One:
Monday Tuesday Wednesday Thursday Friday Saturday
Presentation Presentation Presentation Finish Observation Time allotted
One: The Two: Home Three: Presentation of OT to therapists
Importance Evaluation Determining Three: completing a working on
of HEPs the Determining home case study
Components the evaluation
of a HEP Components and HEP
of a HEP development
Presentation
Four:
Gathering
Data
Week Two:
Monday Tuesday Wednesday Thursday Friday Saturday
Finish and Group
review case reflection on
study in home
Time allotted to therapists to complete individual home
group evaluation
evaluation and HEP development
and HEP
development
experience
Appendix C: Proposed Budget
Source of Specific costs or sources of income Cost

Start-up
Costs
Transportation Vehicle x 1 $13,500
• Small SUV
• Used, 2008
• Diesel
(Qri3a.ma)
Laptop w/Microsoft Office x 1 $598
$499.00
(Walmart)
Microsoft Office 365 for Business x 1
$8.25/month x 12 months = $99/year
(Microsoft)
Mobile Print x 1 $129.99
$129.99
(Best Buy)
Total= $14,227.99
Direct Costs
One Occupational Therapist $13,420
Training therapists
• Preparation for Training Session
$35/hour x 15 hours = $525
• Travel
$1,000 for plane ticket + $800 for hotel = $1,800
(KLM – Royal Dutch Airlines)
(Le Printemps by Blue Sea Hotel)
• 2-week Training Course
(1-hour presentation + 2-hour presentation + 5-hour
presentation + 3-hour presentation + 18 hours of
application = 29 hours)
$35/hour x 29 hours = $1,015
One occupational therapist will be paid for indirect and

consultation services after training is complete.
$35/hour x 24 hours per month x 12 months = $10,080
In-kind Aspiring Neuro-Therapist x 3 $48,000
Mo reports that he pays the therapists $800 per month

(M. Sbai, personal communication, October 13, 2018).
This includes insurance and a gym membership.
Although this may not seem like a lot of money in the
US, in Morocco, this would convert to approximately
160,000 dirhams, which is well above average for
yearly income.
$800/month x 12 months x 3 aspiring neuro-therapists
Office Supplies $102.94

Ink: Canon 35 Black Ink Cartridge $14.99 x 2
Canon 36 Multicolor Ink Cartridge $18.99 x 2
($14.99 x 2) + ($18.99 x 2) = $67.96
(Best Buy)
1 Package of Paper: 500 Sheets $28.99
1 Package of Pens: 60 Pens $5.99
(Office Depot)
ADL Kits $618.61
• Oral Care
o Toothpaste, toothbrush, floss
o $0.50 per toothbrush when purchased in
bulk x 72 kits = $36
o Crest Toothpaste .85 oz (quantity 72) =
$24.99
o $3 per floss when purchased in bulk x
72 kits = $216
• Bathing
o Soap, shampoo, deodorant, hair brush
o $1.03 per bar of soap when purchased in
bulk x 72 = $74.42
o $0.99 per 3 fl oz of shampoo x 72 =
$71.28
o $1.47 per 0.5 oz deodorant stick x 72 =
$105.84
o $2.53 per brush set (comes with one
brush and one comb – brushes will be
given to girls and combs will be given
to boys) x 36 = $91.08
(Smile Makers, Walmart)
Assessments $82.21
• Canadian Occupational Performance Measure
o $15 translation fee into Arabic
o $18.38 for 1 pack of 100 forms
o $48.83 for manual, 5th edition

 $82.21
(thecopm.ca)
• Home Evaluation and HEP Development
o Free, see Appendix E
Mileage Reimbursement $551.20
Average: 20 miles per day (32.19 km)
Rate of reimbursement: $0.53 per mile
($0.53 x 20 miles x 52 week)
(IRS Standard Mileage Rate)
Total= $62,774.96
Indirect
Costs
Car Maintenance $1,681.50
Maintenance was based on an average cost found on
the following website.
(moneyundeer30.com)
In-kind Storage $195

A six-foot-wide closet with a depth of 30 inches would
be ideal. This closet space would be used to store ADL
kits for the HEPs.
Square Footage = Length (ft) x Width (ft)
6 ft x 2.5 ft = 15 square feet
$13.00/square foot x 15 square feet
In-kind Internet $489
$35/month for 70 GBs
Initial startup cost for equipment is $69
$69 initial cost + ($35/month x 12 months)
(Maroc Telecom)
Total = $2,365.50
Income Grant(s) $0
Insurance/Self-pay clients $150
In-kind In-kind $48,684
Total= $48,834
Budget Summary
Total costs $79,368.45
Total income $48,834

or in-kind
contributions
Net cost of $30,534.45
program
Appendix D: Canadian Occupational Performance Measure

Appendix E: Morocco Home Evaluation
Home Evaluation and HEP Development

Background Information
Name of Client:
Address
Date of Evaluation
Type of Evaluation Initial Home Evaluation Follow-up
Client Information
Client Presentation
-Type of CP, Tone (if present), etc.
Range of Motion Upper Extremity:

Right:
Left:
Lower Extremity:
Right:
Left:
Hand Dominance Right

Left
Ambidextrous
Sitting Tolerance
-Does the client require supported seating?
-How long can the client sit unsupported?
Standing Tolerance
-Can the client stand independently?
-Can the client ambulate? With or without
assistance?
-Note balance here
Endurance
-How long can the client participate in a
task before demonstrating fatigue?
Is the client participating in any activities
outside of the home?
(Example: Attending school, school sports)
Is the client able to communicate? Yes
No
Psychosocial Diagnosis Yes
No
Description:
Household Members
Provides
Number of client
Relationship to the Hours Spent assistance?
Name Age Client Job at Home (Yes/No)
Primary Caregiver
Who provides care/assistance most frequently for the client?
What activities are the caregivers assisting the client with?

How much assistance is the caregiver providing?
Details of the Home Environment

*Note: Under description of each room, include: general layout, furniture present, type of
flooring and any other information pertinent to establishing home exercise program, such as
caregiver comments.
Description of the Home
-type of home (apartment, 2-story)
-floor plan (ex. bedrooms upstairs, living
room downstairs, kitchen on terrace)
Description of Client’s Bedroom
Description of Parent’s Bedroom

-Where is it located in relation to client’s
bedroom?
Description of Living Room
Description of Kitchen
Description of Bathroom
Description of Outdoor Area (if present)
Where does the client spend most of

their time?
Have there been any adaptations made

to the home to assist the client? If so,
what?
-Example: Ramp, grab bar
Materials within the Home

What toys exist within the home?
-What is the client’s favorite toy/object?
What cooking equipment is in the

home?
What other material is in the home that

can be incorporated into the client’s
HEP?
What items are in the house that can be

used for multiple purposes?
-Personal observation
Does the client have any activity of

daily living equipment?
-Bathing items
-Oral hygiene materials
What furniture is available in the
home?
Is there any furniture/equipment in the

home that is specific for the client?
-Example: Wheelchair, stander, etc.
Client
What are the client’s interests?
What does enjoy doing?
What is the daily/weekly

routine of the client?
Other Notes:
Goals/Outcomes
What are the caregiver’s
goals?
What are the client’s goals?

(If they can contribute)
What are the therapist goals?
Client Factor Addressed

Mental Functions Sensory Functions Joint Range of Motion Strength
Endurance Control of Voluntary Movement
Performance Skills Addressed
Positions Reaches Bends Grips Manipulates Moves Lifts
Walks Endures Paces Coordinates Uses Initiates
Continues Terminates Sequences
Performance Skills – Social Interaction:
Starts Disengages Speaks Fluently Turns Toward Looks Replies
Discloses Expresses Emotion Takes Turn
Top Five Areas of Growth

*Note: Can be obtained from the Canadian Occupational Performance Measure
Occupational
Performance
Problems Performance Satisfaction Notes
Adaptations
How can the environment be changed to

enhance client performance?
How can the person be changed to enhance

client performance?
How can the occupation be changed to

enhance client performance?
Goals
*Note: Goal Outline – “By [Date], client will demonstrate improved/increased [performance
skill or client factor] in order to [do what occupation] with [assistant level and/or specific
condition]” (Woolley, 2017).
Example Long-Term Goal: “Within 6 months, Jeremy will independently finger feed himself and
drink finishing 80% of meal in a 20-minute session on 4/5 trials when seated in a high chair and
given 2-handled cup with a lid” (Woolley, 2017).
Example Short-Term Goal: “Within 3 months, Jeremy will use a pincher grasp to independently
feed himself finger foods 8/10 tries within 10 minutes on 4/5 consecutive days, when seated in a
high chair during snack” (Woolley, 2017).
Long-Term Goal:
Short-Term Goal 1:
Short-Term Goal 2:
Long-Term Goal:
Short-Term Goal 1:
Short-Term Goal 2:
Long-Term Goal:
Short-Term Goal 1:
Short-Term Goal 2:
Home Program Outline
What should be included in this client’s HEP?
Activities of Daily Living (ADLs)

Bathing Toileting Dressing Feeding Eating Functional Personal
Mobility Hygiene
Instrumental Activities of Daily Living (IADLs)

Meal Preparation and Cleanup Religious and Spiritual Activities Care of Pets
Education
Description (example: colors, shapes)
Play
Play Exploration – “Identifying appropriate play activities, including exploration play,
practice play, pretend play, games with rules, constructive play, and symbolic play” (American
Occupational Therapy Association [AOTA], 2014).
Play Participation – “Participating in play; maintaining a balance of play with other
occupations; and obtaining, using, and maintaining toys, equipment, and supplies
appropriately” (AOTA, 2014).
*Note: Remember to consider the following:

• What key parts of the task will the client be participating in?
• How will the caregiver assist during the activity?
• Repetitions/Sets – How many times per day? How many times while engaging in
activity?
• Are you going to focus an entire occupation or a specific part of the occupation?
• Task-specific training focuses on activities or components that make up daily activities.

o For example: standing up from a chair (sit-to-stands) (Salem & Godwin, 2009).
o
Other Notes:
*Adapted from Australian Government Comcare (2018, August 8). Home assessment
(occupational therapy) report template.
References for the Morocco Home Evaluation Form
American Occupational Therapy Association [AOTA] (2014). Occupational therapy practice
framework: Domain & process (3rd Ed). American Journal of Occupational Therapy, 68,
s1-s51.
Australian Government Comcare (2018, August 8). Home assessment (occupational therapy)
report template. Retrieved from
https://www.comcare.gov.au/Forms_and_Publications/forms2/claims_forms2/claims_f
orms/home_assessment_occupational_therapy_report_template
Salem, Y., & Godwin, E. M. (2009). Effects of task-oriented training on mobility function in
children with cerebral palsy. NeuroRehabilitation, 24, 307-313. doi:10.3233/NRE-2009-
0483
Woolley, H. (2017). Intervention process: Goals, GAS in EI setting [PowerPoint slides].

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Running head: HOME EXERCISE PROGRAM FOR CHILDREN WITH CP 1

Development of Client-Centered Occupational Therapy Home Exercise Programs for Children

with Cerebral Palsy: A Program Proposal

Development of Client-Centered Occupational Therapy Home Exercise Programs for Children

with Cerebral Palsy: A Program Proposal

provides services to those experiencing neurological conditions as a result of congenital or

Observatory World Health Organization, 2006; Semlali, 2010). In 2017, approximately 33

Mark on the World Center, 2018).

Sbai, personal communication, October 8, 2018).

communication, September 10, 2018).

The MAIR clinic is currently attempting to transition from a not-for-profit organization to

Staff disciplines. Unfortunately, education within Morocco is limited. The therapists,

completed in English (M. Sbai, personal communication, September 10, 2018).

Factors that Influence Service Delivery

Economic. Morocco is a constitutional monarchy (Regional Health Systems Observatory

of funds or lack of knowledge of the available services provided in Morocco. If an individual is

a lack of participation in home programs.

MAIR clinic (M. Sbai, personal communication, October 3, 2018).

program in the country. This program is a six-semester program focusing on anatomy,

the services is nonexistent, causing more individuals to rely on free services.

Political. In an attempt to improve healthcare within Morocco, the government

healthcare insurance, limiting accessibility. Healthcare financing is typically in favor of

population by 2021 (Koundouno, 2018).

Morocco continues to strive to provide individuals with disabilities equal access to

moving towards urbanization (Regional Health Systems Observatory World Health

Therefore, geographical location can play a key role in accessing healthcare.

Demographic. Within Morocco, 99.1% of the population is composed of Arab and

the pediatric population.

personal communication, September 21, 2018).

mothers often experience burnout as a result.

Future Plans for Program Development

neuro-rehabilitation clinic in Morocco, as well as all of Africa. (M. Sbai, personal

goals (M. Sbai, personal communication, September 10, 2018).

clinic, thorough observations were completed by the graduate student.

Stakeholders. A one-on-one semi-structured interview was conducted with the founder

Clinical staff. Group interviews and one-on-one semi-structured interviews were

walking (I. Bentahar, personal communication, September 17, 2018).

(I. Bentahar, personal communication, September 17, 2018).

going to school (Parent 1, Parent 2, Parent 3, Parent 4, Parent 5, Parent 6, personal

communication, October 4-8, 2018).

Extensive research regarding formal assessments was completed in an attempt to find an

semi-structured questions were often misunderstood or misinterpreted. Lastly, formal

(Support Group, personal communication, October 12, 2018).

Graduate student perspective. Through a variety of interviews, open communication,

Observations of evaluations, various treatment interventions, and home evaluations were

In terms of therapy services, the aspiring neuro-therapists are effective in providing

gathered (Sbia, 2018). No physical assessment or engagement in an occupation is completed at

Continuous improvement can be made to help develop occupation-based therapy interventions

resources is also a barrier in supporting the clinic as a not-for-profit organization.

Summary of Needs Analysis

recovery can be addressed through a different means.

number of clients served, and assist in the transition to a for-profit organization.

In order to gain a comprehensive understanding of the occupational needs of the MAIR

Occupational Therapy (AJOT), Google Scholar, CINAHL, and University of Utah (U of U)

setting, outpatient setting, neurorehabiliation, rehabilitation, home exercise programs, task-

specific training, task-oriented training, occupation-based, activities of daily living,

Prevalence of Disability in Morocco

Rehabilitation Services for an Underserved Population in a Rural Setting

from approximately 75 km away (M. Sbai, personal communication, October 3, 2018). As

available, an individual’s greatest limitation to services is access. In developing countries, it is

rehabilitation is less of a priority. Additionally, a developing country’s statistics on its population

of problem-solving, communication, networking, understanding their scope of practice, as well

as the ability to improvise (Roots, Brown, & Banbridge, 2014).