Focus: Montreal Cognitive Assessment (MoCA)
The College is aware of the new mandatory online training and certification program required by the developers of the Montreal Cognitive Assessment (MoCA). The following scenario and questions were developed for the Annual Continuing Competency Review (ACCR), but since that was deferred for the 2019/20 year, we thought it might be helpful to publish the question as a case study for your reflection.
An 86-year-old female presents to the emergency department by ambulance following a fall in the house where she lives alone. Staff are concerned because in addition to her soft tissue injuries, she is demonstrating symptoms of cognitive impairment. She is admitted to the hospital and transferred to an acute care unit for a full medical workup.
The physician makes a referral to the occupational therapist with an order to administer the Montreal Cognitive Assessment (MoCA). What is the best first step for the occupational therapist to take in response to the physician’s referral? (Select 1)
- Accept the referral and complete the MoCA because the occupational therapist should follow the physician’s order.
- Discuss the purpose of the referral with the physician and determine how it relates to the client’s occupational performance.
- Decline the referral because it is within the physician’s scope of practice to administer the MoCA.
- Complete the MoCA and assess the client’s cognition in relation to her ability to complete activities of daily living (ADLs).
The College’s preferred response is B.
Per Competency A3, specifically A3.3, occupational therapists must determine the clients’ needs and goals for occupational therapy services and decide whether occupational therapy services are appropriate at this time (ACOTRO, ACOTUP, & CAOT, 2021, pg. 10). By clarifying the purpose for the referral, the occupational therapist can better understand the nature of the request and determine if occupational therapy services are warranted at this time and if there are additional occupational therapy assessments or interventions that may be appropriate.
A is not the best response. Occupational therapists are autonomous health care professionals, and as such, are accountable for their professional judgement and decision-making. While occupational therapists collaborate with other health care professionals to provide safe, effective, ethical, and client-centred occupational therapy services, if an occupational therapist has questions or concerns about a referral, they should clarify these prior to proceeding if possible.
C is not the best response. As stated above, the occupational therapist should clarify the expectations of the physician regarding the referral and determine if occupational therapy services may be indicated.
D is not the best response. While the occupational therapist may determine that the MoCA and an assessment of the client’s abilities to complete ADLs are appropriate as part of a broader cognitive assessment process, the best first step is for the occupational therapist to determine the purpose of the referral and communicate with the physician.
The occupational therapist is very experienced using the MoCA in her practice. However, she is aware that as of September 1, 2019, a new online training and certification program (with a cost of $125 US) was implemented by the developers of the MoCA.
The developers state that completion of the training and certification is mandatory, to ensure standardization of the testing procedures. The website states: “If you wish to continue using the MoCA Test without being officially trained and certified, you will be at increased risk for administration, scoring and interpretation errors which could lead to misdiagnosis and liability” (MoCA, 2019). The developers require clinicians to complete a disclaimer should they choose to use the MoCA without the training and certification.
The occupational therapist has not completed this training, but believes that she has the competence to continue to use the MoCA, given her familiarity with its appropriate application and many years of experience using it in clinical practice.
What is the best action for the occupational therapist to take in relation to administering the MoCA? (Select 1)
- Complete the training and certification program and continue to administer the MoCA when it is appropriate in relation to the client’s occupational performance.
- Recommend that the physician request that a resident or neuropsychologist administer the MoCA because they are exempt from the training.
- A change in practice is not required because the occupational therapist’s employer does not require the MoCA training and certification.
- Complete the disclaimer and administer the MoCA when clinically appropriate, given the occupational therapist’s individual competency.
The College’s preferred answer is A.
The occupational therapist demonstrates a commitment to continuing competence by completing the training and certification and continuing to use the MoCA in clinical practice. Doing so helps to foster the trust that clients have in knowing that the occupational therapist has the necessary training and competence to use the MoCA correctly.
It is also helpful to consider this scenario in the context of the following from the Competencies for Occupational Therapists in Canada:
D1. Engage in ongoing learning and professional development
- D1.1 Develop professional development plans.
- D1.2 Engage in professional development activities to improve practice and ensure continuing competence.
- D1.3 Enhance knowledge, skills, behaviour, and attitudes.
- D1.4 Ensure that skills are adequate to meet practice needs.
D3. Monitor developments in practice
- D3.1 Stay aware of political, social, economic, environmental, and technological effects on occupational therapy practice.
- D3.2 Keep up to date with research, guidelines, protocols, and practices.
- D3.3 Appraise evidence related to knowledge and skills for practice.
- D3.4 Integrate relevant evidence into practice.
- D3.5 Consider the social, economic, and ecological costs of care.
The MoCA is one of many cognitive screening tools. The occupational therapist may decide to administer an alternative cognitive screening tool based on the intended population and psychometric properties of such tools, the occupational therapist’s clinical reasoning and the client’s presenting occupational performance issues.
D is the next best response. The occupational therapist can choose to complete the disclaimer, acknowledging the developer’s stated risks. Using the MoCA without the training and certification ultimately involves the occupational therapist’s accountability. If choosing this option, the occupational therapist should carefully consider the context within which the MoCA is being used and what the potential impacts and risks are of not completing the training and certification. As stated in COTBC’s Code of Ethics, occupational therapists “are fully responsible for their practice and are obligated to account for their actions” (2006, p. 5). If choosing not to do the training, the occupational therapist needs to consider the risks to their own competence, as well as the possible implications related to fostering trusting relationships with their clients and others (e.g., fee payers, colleagues, acceptance as an expert witness in occupational therapy, etc.).
Occupational therapists should also consider any employer or health authority policies regarding the use of the MoCA. The MoCA is a copyrighted screening tool; therefore, the occupational therapist is required to follow applicable copyright laws.
B is not the best response. As stated above, occupational therapists are fully responsible for their practice and are obligated to account for their actions. While residents and neuropsychologists are exempt from the training and certification, the occupational therapist’s focus should be on determining the need for occupational therapy services. As such, the occupational therapist should clarify the expectations of the referral and determine what occupational therapy services may be indicated.
C is not the best response. As noted above, the MoCA is a copyrighted screening tool. Per COTBC’s Code of Ethics, occupational therapists must “practise within the scope of the profession, with knowledge of, and adherence to, national and provincial legislation, regulations, standards of practice and policies relevant to the practice of occupational therapy” (2006, p. 4). The occupational therapist should complete the disclaimer and not rely solely on the employer’s policy, even if that policy does not require the MoCA training and certification.
ACOTRO, ACOTUP & CAOT. (2021). Competencies for occupational therapists in Canada. https://cotbc.org/wp-content/uploads/Competencies-for-Occupational-Therapists-in-Canada-2021-Final-EN-HiRes.pdf
College of Occupational Therapists of British Columbia. (2006). Code of Ethics.
Montreal Cognitive Assessment. (2019). https://www.mocatest.org