Part 1 of 4 in a series: SNF vs Homecare: An examination of the distinction in the provision of clinical services between SNF vs homecare settings
The distinction between clinical services in SNF vs Homecare lies between 4 main points: the number of key providers within the patient’s immediate care plan, the source of reimbursement, the time frame between start of care and discharge, and the environmental scope of a patient’s rehabilitation.
This multi-part series aims to examine each of these points of distinction with a focus on Occupational Therapy.
The Distinction Between Key Rehabilitation Providers and Their Roles in SNF vs Homecare Settings – Part 1 of 4 (Key Providers)
Occupational therapists (OTs) play an important role as part of a patient’s interdisciplinary team, however that role often changes as a patient’s recovery and rehabilitation shifts from acute to sub-acute and post-acute care. The changing role of an OT along this continuum of care is most evident along three main points: the disciplinary emphasis and number of direct healthcare providers within the course of a patient’s care, the types of treatment procedures utilized within a plan of care, and the environment within which a patient’s treatment is performed. OTs may work in different clinical and non-clinical settings throughout the course of their careers, and it is important to understand the distinctions of their role along the continuum of care and the changing environments within which they provide their services.
Although this blog aims to focus on the role of OTs within a skilled nursing facility (SNF) during the sub-acute phase of patient care in contrast to their role in the post-acute phase of homecare, an OT’s role may shift throughout any phase of the continuum of care and within any environmental setting that they may work.
The Role of OT in a SNF
Similar to their role within acute hospital-based care, occupational therapists (OTs) work closely alongside certified occupational therapist assistants (COTAs), physical therapists (PTs), physical therapy assistants (PTAs), speech language pathologists (SLPs), and nursing staff in a SNF to provide inpatient sub-acute services. Sub-acute care is often considered “transitional care”, as a patient transitions from being medically unstable and requiring intensive acute medical management from a multidisciplinary team, usually provided within a hospital, to that of a more stable condition requiring less-intensive care within a SNF. This shift is most notable in the following ways: 24-hour physicians may no longer be on site, a patient receives less overall therapy time throughout the course of the day, and a patient’s length of stay within a sub-acute facility is expected to be longer. The focus of care within a SNF shifts from medical management to rehabilitation, with the aim to prepare the patient for a return to home, or another level of care.
Rehabilitation services within a SNF address a patient’s functional ability in basic activities of daily living (ADLs), walking, bed mobility and “out of bed” (OOB) transfers. These services are often limited to the environmental confines of the patient’s room or the common and rehabilitation areas of the facility.
Because OTs work closely alongside other team members within a SNF, there are often strict delineations and guidelines regarding which disciplines provide which services to be provided at specific intervals and timelines throughout the day. For example, a SNF facility may request that clinicians “divide” up the body and treatment procedures between PT and OT, requiring that PT’s focus specifically on lower body strengthening, transfers and walking, while OTs focus specifically on upper body strengthening, dressing, toileting, and bathing. Treatment may have to work around nursing and clinical schedules, and may also be divided up between morning and afternoon sessions.
OTs also play a role in providing consultation services for the maintenance of functional abilities in a SNF’s long-term residents, those who may no longer have the potential to care for themselves and will be unable to live alone. Consultations may include providing suggestions and educating nursing staff regarding possible adaptations for the long-term comfort and safety of the patient, such as bed or wheelchair positioning, adaptive feeding equipment, or resting hand splints.
The Role of OT in Homecare
Homecare therapy may be provided by OTs, PTs, and SLPs. Homecare sessions occur within a patient’s home environment and sometimes can extend into their community. Upon referral from a patient’s primary care physician, homecare OTs may find themselves as the sole provider of rehabilitative services during a given period of time, and thus the scope of their services widens beyond that of basic ADLs, bed mobility, walking, and OOB transfers to more complex instrumental activities of daily living (IADLs) and community re-entry.
Whereas all patients work toward maximizing their functional potential in basic ADLs throughout the continuum of care, homecare patients seek to maximize their ability to function within independent living situations. Activities that are instrumental to independent living may include: management of medications and finances, meal preparation, household maintenance, personal shopping, doing laundry, organizing and maintaining a personal schedule and appointments, accessing public transportation, and much more.
It is important to note that while all therapists working within the realm of homecare should address a patient’s potential for safely pursuing these activities within the evaluation, not all insurance benefits will cover actual treatment toward these specific pursuits. For example, some insurance providers will allow for the provision of short-term post-acute homecare therapy that may sometimes be provided in as little as 2 weeks or even just a few sessions. These sessions are limited to a patient’s household (and immediate entry-way of their building), as they are also considered “Transitional Care” from a sub-acute phase to a post-acute homebound phase. Such services are useful for patients who will be receiving 24-hour home health aide services. Upon the patient’s return from a hospital or SNF, the homecare therapist will evaluate the patient’s level of support required within the home environment and educate the patient and aides regarding strategies for maintaining patient’s safety, positioning, and hygiene.
Other insurance providers will reimburse for treatments related to broader IADLs and community re-entry on a wider environmental span. Usually, these insurance benefits consider such treatments “Risk Prevention”, and therapy sessions are provided over a longer period of time to ensure that the patient is not at risk of falling within their home or community, or to minimize risk of chronic but preventable conditions. For example, a patient with a dual diagnosis of mild cognitive impairment and Type 2 diabetes, who lives alone with no support, may have the goal of independent shopping and meal preparation. Ongoing treatments may include educating and assisting the patient at the grocery store with making healthier food choices, lifting and carrying techniques, education regarding which protective shoes to wear while walking and general safety education for community re-entry, as well as education and adaptations within the kitchen during meal preparation. In this example, it is clear that the benefit of long-term therapy sessions would have the potential to reduce risk of unhealthy blood glucose levels due to dietary choices, to reduce the chance of injury, skin infection, or falls during community excursions, and to reduce the potential for injuries within the kitchen, thus all the above treatments would be considered “risk prevention”.
Because a homecare therapist may be the only service a patient receives during a long-term period, the line between PT and OT treatment procedures may blur. For example, regardless of who is providing care, both homecare PTs and OTs will address strengthening of a patient’s entire body, sitting, standing, and walking balance, activity endurance, as well as home safety. A homecare OT may find themselves working with a patient on lower body strengthening, working on climbing stairs and decreasing a patient’s antalgic gait in order to reach the patient’s goal of throwing away their recycling in their apartment’s downstairs basement bin. Likewise, a homecare PT’s responsibility to address a patient’s fall risk may require treatment intervention for upper body strengthening to facilitate a sliding board transfer from wheelchair to bed.
A Shifting of Focus
A 2010 article in Stroke American Heart Association Journal discussed interdisciplinary shift along the continuum of care:
“Whereas initial acute management focuses on pathophysiological processes at the body structure and function level, subacute and chronic phases tend to shift the focus to improving performance of functional tasks at the activity level and to facilitating community integration, including addressing vocational and avocational needs, at the participation level.”
In other words, acute and sub-acute services, usually provided in hospitals, SNFs, or immediately following a patient’s homecoming from a facility, have an emphasis on medical management and transitional care with short-term intensive rehabilitation. Homecare provider services emphasize maximization of a patient’s long-term functional ability, or the education and training of the patient’s family and long-term support staff, as well as risk-preventative rehabilitation, and thus may be provided within a patient’s own environment and community.
As the continuum of care progresses, both a rehabilitation therapist and a patient’s focus may develop beyond maximization of functional ability in basic ADLs to that of a desire to pursue further vocational and avocational goals. However, rehabilitation therapists must be cognizant of the limitations within which the patient’s post-acute insurance benefits apply, as often these limitations dictate which treatment procedures will be reimbursed and which patient goals can be addressed.
There are a few ways a therapist can increase patient satisfaction within the limitations of insurance benefits. One is to educate patients about the continuum of care: what they can expect from their rehabilitation treatment within their current phase, as well as what they can expect in the next phase of their rehabilitation plan. Another is to engage patients in advocating for the appropriate goals along all phases. Lastly, a therapist can provide referrals and resources to other supports that can assist patients with further attainment of their avocational goals upon discharge.
Miller, E. L., L. Murray, L. Richards, R. D. Zorowitz, T. Bakas, P. Clark, and S. A. Billinger. “Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient: A Scientific Statement From the American Heart Association.” Stroke 41.10 (2010): 2402-448. American Heart Association Journals. Web. 28 July 2017.