Part 4 of a series: SNF vs Homecare: An examination of the distinction in the provision of clinical services between SNF vs homecare settings.
As discussed in the previous 3 parts to this 4 part series, there’s a balance between our roles of transitional versus preventative care (Part 1, Roles of Key Providers), the services we can and cannot provide based on the limitations of benefit coverage (Part 2, Source of Reimbursement), and the patient’s time on program as well as professional time frames we must consider (Part 3, Time Frame Between Start of Care and Discharge). The final part to this series considers the environmental scope of a patient’s rehabilitation.
Setting the Stage for Activity and Engagement in a Treatment Environment
For two exhilarating hours, I experienced elation and a kinetic energy throughout body and soul, though I remained seated in one place. I was transported from Tsarist Russia to Paris of the 1920s with the help of media projections of maps, photorealistic country sides, castles and theatrical stage sets of ballrooms and cityscapes while listening to “Anastasia”. As I luxuriated in the vast and elaborate visual display, I considered the role of the set designer as related to the role of an occupational therapist in creating an environment within which activity and engagement can be inspired.
A set designer must first consider the show’s “design concept”, a cohesive overview of the show’s overall style, the various scene locations that will be presented, and a plan for transitioning from one setting to another.
An occupational therapist (OT) must design a session plan in much the same way: by considering the treatment plan as related to the patient’s goals, the various locations in which interventions may occur, and the methods and supports needed in transferring from one treatment environment to another.
Oftentimes there are practical problems that must be resolved. Probably one of the most impressive examples of this was a production of “Dead End”, a play which is seldom produced because its script requires the actors to perform entire scenes while diving and swimming in New York City’s East River. The set designer filled the theater’s orchestra pit with 10,000 gallons of water, and yes there was an audience “splash zone”— so needless to say, this rare production made quiet a splash!
Now, I relish a challenge and the opportunity to inspire when considering patient-centered interventions. Recently, one of my patients had progressed from years of being unable to sit unsupported and being dependent in all out-of-bed transfers with the use of a hoyer lift, to sitting with contact guard assistance at the edge of her bed, and transferring to various surfaces with maximum support of one person.
Yet, despite her gains, she continued to be sponge bathed in bed. It was her goal, and that of her care team, to take a shower. The luxury of being able to enjoy her scented soaps, and return to an occupation that she used to love was the inspiration. My patient was no longer as challenged by sitting or standing balance or dependent in transfers, however there was still one remaining and seemingly insurmountable obstacle.
The challenge was one of impracticality– the patient’s claw foot porcelain tub was simply too high and too deep for transfers with a shower bench. If my patient transferred onto her shower bench, which could be adjusted to accommodate the high bathtub edge, the bottom of the tub was too deep for her to reach with her feet in order to scoot along the bench. To resolve this situation, I needed to find a platform surface for the patient’s feet when sitting on the bench, one that could bear enough weight to allow for scooting along the bench to get into and out of the tub. Furthermore, I needed to find a platform that would be narrow enough to fit within the shower bench legs and tub, and one that wouldn’t move around on a wet surface, and would be able to withstand typical bathtub moisture pre- and post- shower. After measurements and internet searches, I found a durable plastic step with a slip-resistant top and rubber feet that was the right size for this particular bathtub.
Just as a set designer must collaborate with the lighting and sound designers as well as the director, so must the occupational therapist collaborate with the patient and care team in order for a plan to run smoothly. In this example, I needed to assess if, in fact, the step really did solve the problem of safe shower transfers. I needed to consider the level of support that my patient would need in transferring on and off the bench and sliding across it to get into and out of the tub, which verbal and tactile cues would most efficiently and effectively communicate to assist my patient’s motor planning for the safest hand and foot placement and weight shifting. Lastly, and most importantly, I needed to educate the patient’s care team on my findings, assess their demonstrated understanding of the support and cues needed, as well as ensure that they understood the importance of caring for the platform step and allowing it to thoroughly dry in between showers to avoid mildew and wear. The long-term goal was for this plan to run smoothly on a regular basis, when I am no longer present.
The “production” – or treatment plan went smoothly: the patient-centered goal was designed, obstacles and challenges considered, the necessary “props” or equipment for a safe environment was obtained, and most of all, the “cast and crew”– the patient and care team– were thoroughly engaged and inspired to work toward attainment of the goal. My patient has been enjoying her regular showers for a couple of months now, the burden of care on her aides has been greatly diminished, and her entire care team is astounded by her ability to attain what many of them had previously thought impossible.
An OT must strive to apply the most suitable environment and context for the most applicable and patient-oriented intervention, within the limitations of their patient’s environment. This is perhaps the biggest challenge an OT faces, and what differentiates between an uninspired plan versus an engaging and inspirational plan worthy of “rave reviews”.
The Conscious and Subconscious Influences of Environment on Patient Intervention
A study published in 2015 in the journal of Physical and Occupational Therapy in Geriatrics[i] considered whether the environment played a subconscious role in therapists’ clinical reasoning when deciding which treatment interventions to use and where interventions took place. The study was based on qualitative interviews and observations of three OTs as they provided care for each of their 4 patients over the course of 16 months within a Midwestern rehabilitation hospital that housed a therapy gym, a home-like space (practice apartment), and a combination room consisting of a therapy gym and a kitchen.
Three patterns emerged as a result of the study: Therapists chose a particular environment out of habit, therapists chose the environment first and allowed the environment to influence which intervention to use, and therapists chose treatment environments where they felt safe and supported by their colleagues.
Due to productivity pressures and time constraints, the therapists reported that often it was easier to rely on predictive patterns, daily habits, and even self-described “ruts” when determining the environment for their interventions. They admitted that this was not necessarily a patient-centered approach, and that relying on habits put them at risk for being inattentive and “zoning out” during the treatment session, and by not opting for the most suitable environment, there was a potential for reduced patient outcome. As one therapist reported on the study, “I think that (the patients) have such trust and confidence in what we are going to do with them and it’s almost like they don’t know what they’re missing”. Those habits were broken when the therapists took the time to plan interventions in advance, and often such planning resulted in interventions being more occupation-based and patient-centered. The therapists admitted that they spent more time planning occupation-based, patient-centered interventions when they were mentoring a student.
The second pattern most commonly observed was the therapists choosing an environment based on ease of accessibility, and then basing the intervention around what was accessible within the environment. Therapists reported that it was easier to see equipment that was ready-to-use for potential interventions in the gym area, whereas equipment in the home-like space wasn’t as easily visible. They acknowledged that when equipment wasn’t as readily visible, it wasn’t as commonly used. They also reported that the gym setting required less pre-intervention set-up and preparatory work prior to treatment, whereas the use of a home-like setting required a bit more time for consideration of adaptations and equipment needed. When considering how the environment choices affected their clinical decisions regarding intervention approaches, the therapists felt that the gym equipment lent a more biomechanical approach to interventions, but that it was easier to pursue occupation-based interventions in the home-like setting. All the therapists agreed that the combination environment was valuable because the ease of obtaining equipment and accessibility paired along with the home-like familiarity assisted in boosting the morale of their patients with the visual reminder that returning to home was the goal.
The third pattern was opting for an environment that offered the therapist support, safety, and camaraderie from their fellow colleagues. By accessing the most commonly used gym environment, therapists felt more reassured that they’d be able to obtain immediate assistance with a difficult patient transfer, if they had any questions or needed a morale boost, or if they needed to ensure patient safety when momentarily walking away to obtain a new piece of equipment. Although it is nice to have the camaraderie, physical, and emotional support of the other practitioners, there are drawbacks to be noted. Rehab gyms can get busy, and establishing organization among the rehab team is important, especially during peak hours. Without a clear delineation between the disciplines, roles between physical and occupational therapists in the gym setting can become unclear. Therapists also reported that the therapy gym, the most common environment for interventions, lent itself to many distractions for both patient and therapist.
While this study was limited to the point of view of only three OTs, there is a common resonance in their patterns of environmental choice that anyone who has worked in a clinical facility would recognize. The further removed from occupation-based settings, the further the risk of losing sight of occupation-centered interventions, the essence of what separates us from other disciplines. The environment is the final key to creating inspirational, occupation-based, client-centered care plans. Environmental barriers and obstacles provide OTs the opportunity to consider practical solutions for challenging or supporting a patient’s engagement. Through the use of adaptive or compensative equipment or strategies within the environment, as well as the interactions and relationships within that environment, OTs are able to mastermind a plan of care that sets the stage for patient success.
[i] Skubik-Peplaski, Camille, et al. “Occupational Therapists’ Perceptions of Environmental Influences on Practice at an Inpatient Stroke Rehabilitation Program: A Pilot Study.” Physical & Occupational Therapy in Geriatrics, vol. 33, no. 3, Sept. 2015, pp. 250-262.