|
|
Going Home
Home » News » Going Home |
Therapy is finished and the patient is discharged from the nursing home. It’s a happy day for all, but as he or she drives off into the sunset, what lies ahead in the new environment? Can Mr. Jones, who walked 250 feet on a shiny linoleum floor, safely navigate on carpet and throw rugs? Will Mrs. Smith be able to drive safely to the grocery store? Can Miss Brown stand up long enough to prepare her meals alone?
“Discharge planning is often not as comprehensive as it could be,” says Mark Richards, national director of clinical services at Aegis Therapies. “We need to know the environment the resident is going to return to. Is the caregiver prepared, and has he or she been part of the treatment process? Sometimes we discharge patients to home and they really struggle. We never know that.”
To make the discharge transition go more smoothly, therapists must understand the environment to which the patient is being discharged, whether home or to another facility. A home (or facility) evaluation can determine any obstacles to the safety of the patient—a steep stairway, for example, or the need for a grab rail in the shower. The visit should be scheduled far enough in advance to make any necessary corrections. “Without a home evaluation, a therapist might spend a great deal of time teaching a patient to wheel himself to the bathroom and transfer to the toilet, but the first time the patient goes to the bathroom at home, the chair won’t fit through the door,” says Mark Besch, vice-president of clinical services, Aegis Therapies. “That means the therapist has failed that patient.”
There’s more, however, to good discharge planning than simply making sure the physical environment is safe. Both the patient and the caregivers must be prepared for new roles. One way to monitor the patient’s independence and educate the caregiver is to ramp down therapy as the patient approaches discharge. For example, Safe Transitions, a partnership between facilities and Aegis Therapies, creates a three-week predischarge period of decreasing therapy and of evaluation involving the patient and future caregivers. The program incorporates not only the discharge goals of therapy, but of the patient and family, as well. “We want the patient to practice with her caregiver the skills she has learned in therapy so therapists can audit and adjust what’s happening before discharge,” says Linda Riccio, former Aegis Therapies regional vice-president.
The partnership between Aegis and the facility requires agreement between facility staff, the patient, and family to commit to the transition period. During this time, the patient will demonstrate that he or she can manage safely and independently whatever the skill or goal worked on in therapy. “It takes awhile to build the culture,” says Riccio. “It has to happen from oversight and director of nurses right down to the CNA.” To make the partnership work, the facility must have a stable staff and be willing to do in-service.
A Safe Transitions Committee, made up of a licensed nurse, a therapist, the nurse’s aides, a social worker, and an activities person, focuses not on what the patient can do with the therapist, but what he or she can do with the caregiver. “The caregiver may be a family member or a nurse’s aide, depending upon where the patient is being discharged to,” notes Riccio.
The committee sets weekly goals for the transition. For example, a goal might be for Mr. Jones to walk to the dining room without a nurse’s aide. “Therapy will provide verbal cues, observations for safety, and encouragement,” explains Riccio. “Once he can do it on the first shift, we want to see if he can do it for three meals a day and then to all his activities. If he can do it five times a day in those last weeks of therapy, we’ve made him safe for going home.” Goals are put into the medical charts so that nursing, CNAs, or restorative nursing can document against the goals and measure performance.
Riccio says it’s an easy mistake for a therapist to assume that because Mr. Jones can walk 250 feet once a day in ideal conditions, he can do it at home with a change in flooring or when he’s tired. “So we establish the goals in a tapering off of therapy,” says Riccio. “It’s ideal to have all disciplines of therapy represented, because a PT might offer walking goals or certain ways to transfer and change positions, an OT would have dressing, hygiene, or mealtime goals, and a speech therapist will have communication or swallowing goals.” If it’s not possible for all three to attend, the therapist on the committee can bring notes from the other disciplines.
“Safe Transitions involves a level of commitment from the facility to put the systems in place to monitor the goals for the patient,” says Riccio. “I would suggest that the Safe Transitions meeting take place at the end of the Medicare meeting that the team holds to determine who is on caseload, who is coming in, who is discharging.”
Admittedly, the Safe Transitions program is above and beyond the requirements. But that’s what good patient-focused care is all about. “It’s easy for therapy, admissions, nursing, and social work to operate separately from each other,” says Riccio. “Too often a therapist might be ready to discharge Mr. Jones on Friday after recommending grab rails in his home bathroom and a removal of throw rugs. The social worker will set it up, and Mr. Jones is sent on his way. But have we truly assessed Mr. Jones’s safety? Have we taught the caregiver to give the proper help? We have found that patients have new challenges when they go home the first couple of weeks. They are at increased risk for falls. It becomes unsafe and very stressful for the patient and family.”
Facilities that are focused on the patient don’t close their doors once the patient has been discharged. “We follow up within the first week of discharge to make sure the patient is doing well,” says Vickie Cortner, senior community relations representative for Beverly Healthcare‘s District 33. Often patients return for outpatient therapy, and after skilled services are no longer needed, they enroll in a community wellness program if offered by the facility. At Heritage Square Healthcare Center in Greendale, Wisconsin, Wellness Coordinator Jenny Zimpel says that 70% of patients discharged from the facility return to the wellness program. “I think the residents see how the Nautilus equipment they used in our Freedom Through Functionality program during their inpatient therapy has really made them stronger,” she says. “After discharge, they are motivated to come back and use it.”
Discharge planning, like raising children, is about preparing individuals for the best possible independent life. Therapy and the nursing home can work together to ease the transition out of the nest.
|
|
|
|
|