The Sensory Modality Assessment and Rehabilitation Technique (SMART) is an extended and detailed assessment and investigation of behavioural responses for people with prolonged disorders of consciousness (PDOC) following severe brain injury. Conducted by specialist clinicians, the assessment provides measurable therapeutic interventions and/or a management strategy for the individual in PDOC.
Elinor Jordan-Bennett, Specialist Occupational Therapist (OT) at Adderley Green Care Centre in Staffordshire, has recently qualified as an Advanced Accredited SMART Assessor after completing extensive training and gaining practical clinical experience, which includes the fulfilment of 10 SMART assessments with patients. As an advanced assessor, this now means she is authorised to mentor other professionals who are also undertaking the rigorous training to become accredited.
In this EveryExpert article, we catch up with Elinor and discuss the benefits of the SMART assessment, its principles and ways of working for both the individual receiving care and the clinical team supporting them.
Hi Elinor, Great to speak with you today. Could you tell us more about your involvement with SMART and your team at Adderley Green?
Elinor: “Of course, here at Adderley Green we have a team of four OTs within a wider therapy team of approximately 25 clinicians. We currently have 15 individuals that present in PDOC. Some people come to us having already had extensive assessments, and they’ll have a diagnosis. Others will come without an assessment because they’ve been in a hospital where it wasn’t possible. We can then do the assessment for them.
“I’m now a qualified Advanced Assessor for the SMART assessment and my colleague Hangsa Limbu is currently working towards her accreditation. She is due to be qualified by October, and I’m mentoring her through the SMART accreditation process, whilst also acting as her clinical supervisor. I encouraged Hangsa to earn her accreditation because not only is it an incredibly important assessment to offer the individuals we care for, but the key skills you learn as a practitioner enhance every area of your work. So that’s specialised skills for assessment, treatment and long-term management. As soon as our other two team members are ready, I will encourage them to begin the training so that the SMART principles and ways of working can be fully embedded across our team.
“Elysium Neurological invest in our training and provide the space and time to complete all the work and observations, which is fantastic. It’s all part of the wider ethos here; we want residents to receive the most appropriate expert care at every stage of their care journey, and that, of course, also applies to individuals who are in PDOC. As a service, we now receive referrals from commissioners for individuals who require a SMART assessment or other specialist PDOC assessments.”
What are the benefits of the SMART assessments for individuals in PDOC?
Elinor: “There are many, many benefits. Firstly, individuals get the opportunity to have a specialist observing them, within optimised conditions, giving them the best opportunity to respond. Optimising the environment can mean something simple, such as making sure there’s not too much noise in the room or that the temperature is optimal, not too hot or too cold. But simple adjustments have the potential to make a big difference to response levels.
“A SMART assessment is conducted over an extended period of time, so the individual is observed on multiple occasions, all focusing on giving the person the best opportunity to respond. During that time, the assessor will get to know the individual as well as possible, so the assessments become personalised, and that’s why we also involve family or close friends. This is really important because they know that person the best, or sometimes they might observe things that the professional hasn’t. Family members can often spot meaningful things that are happening, which are important for us to know as assessors.”
SMART assessments were traditionally completed within hospitals, but here at Adderley Green, you complete them within a rehabilitation setting. Are there particular benefits to conducting the assessment in a neuro-rehab service?
Elinor: “Yes, historically SMART assessments were conducted in a hospital setting, but more are completed within neuro-rehab settings now (of course, some of those can be based in an overall hospital). The big benefit of this is the familiarity and continuity of the setting, surroundings and the people involved in the assessment. For example, if you conduct the assessment within someone’s own room, it’s a familiar environment where they are surrounded by their own possessions and items. Plus, there’s more flexibility, and it’s easier for us to control the environment. For example, we can usually minimise disturbances so that the environment fully supports the assessment, and we can work very closely with the unit staff and the family.
“When I do assessments, often I’ll be the treating OT anyway, so I’m already supporting that individual through that whole kind of pathway. I get to know important details about that person and their family, and this information plays a vital role in the assessment. I can observe in more informal situations, I can watch therapy sessions, or I can watch the individual with the family. If I didn’t know the family, this would be quite intrusive, but we try to do it in the least intrusive way possible.
“I always involve family members as much as possible in the assessment. I keep them up to date with progress, and they share with me what they have observed. Sometimes, they’ll send me videos, or they’ll actually show me what they’ve been doing with their loved one.”
When a clinician undergoes SMART training and gains SMART skills, it must benefit multiple patients, regardless of whether or not they’re having an assessment, because they can spot things and they can implement treatment more effectively?
Elinor: “Absolutely. The SMART training really helps develop and progress many clinical skills and hugely increases the depth of knowledge for the PDOC specialism. It’s more than just observing, it’s about optimising every element of care, and your practice is enhanced holistically. For example, there’s a set of criteria that needs to be completed before the SMART assessment can begin, and even if an individual is not having an assessment, this way of working becomes naturally embedded throughout the care. We always consider whether a person has got positioning guidelines in place. For example, has this person got the best seat in place?
“Once you are satisfied everything has been optimised, then the emphasis is on educating the carers and the family around that person. Even if they’re not there for a SMART assessment, it’s about using those skills to better the treatment for the other individuals anyway. And as part of an MDT, we involve other disciplines too, including Speech and Language therapists or other clinicians. When we all work together, including the SMART principles in our care, then we achieve better outcomes for the individuals we support.”
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