As an OT, I’ve found that our role varies significantly between settings, facilities/ companies, and communities. In the SNF, I helped my patients plan at discharge, how they were going to logistically survive from day to day once they left our facility.
For example, I worked with a lady that experienced an MS exacerbation who’s only possible discharge plan was to return to her apartment on the 7th floor in an urban area (based on her supervision level of functioning with ADLs and based on her finances she did not qualify anywhere else). She could function within her apartment, but there were many more factors that had to be considered for an optimal discharge home, such as grocery shopping, paying bills, medication management, ensuring that she could alert rescue personnel if she fell, and transportation to her doctors’ visits.
I helped her locate a grocery delivery service so she had access to the healthy foods she needed to maintain strength/ endurance gains she’d made. I helped her order a medical alert system since she didn’t have a cell phone that would easily allow her to call for help if she was in a medical emergency. I also suggested that she have her friends and family check on her a minimum of once per day to prevent the episode that brought her into the hospital originally, which resulted from a fall and laying on the floor unable to get help for days at a time. I helped set up a medication management system for her involving a company that delivers her medications in pre-packaged containers for each day of the week. I gave her information on resources of MS support groups in our area. Finally, I assisted her in ordering adaptive equipment and durable medical equipment that would maximize her discharge home to prevent readmission to the hospitals.
The previous example occurred for a large percentage of my patients within the SNF setting in an urban area. We had social workers, but they were responsible for more funding concerns with insurance, finding proper discharge placement, follow-up appointment scheduling, and logistics of transportation for each patient home. I’ve learned in changing settings that my role in discharge planning is significantly different, in the sense that the social workers are responsible for a lot of the planning that was mentioned in the example above.
I find that there are a lot of factors that affect our role as OTs for our patients, some of those are staffing needs in our department, staffing needs in our colleagues department, openness/ willingness to provide a transdisciplinary approach for our patients, and resources available within a specific community. Generally speaking, I make an effort with every patient to have them make a daily and weekly routine list, including what fills their day and what his or her needs are from the time they wake up each morning to the time they go to bed. Based on the list/ routine they provide me, I make sure that they have considered all of the details for their optimal safety prior to discharge.
Often times, patients have been provided for over the last few weeks or months with regards to medications, meals, clean laundry, clean up within their immediate environment, and they stop taking these things into consideration for life at home. A lot of my colleagues refer to this concept as “institutionalization”. I feel that it’s very important to transition my patients back into the daily living mindset of not having multiple nurses, multiple CNAs, multiple therapist, social workers, doctors, nurse practitioners, physician assistants available to check on them throughout their days. In the days prior to his or her discharge home, I want them to simulate their daily routines from home at the SNF to optimize their discharge home. I want them to identify and request their medications, prepare meals, have more independence with planning their daily routine.
I want them to be mentally prepared for caring for themselves, because often times patients underestimate the difficulty in the transition back home. They’ve been in a system that provides everything for them for weeks or months. They’ve been told when to eat, when to get dressed, when to take medication, when to sleep, and there is a lot of safety in that for them. It is sometimes a shock to return home where they may have very little socialization and assistance in his or her everyday life. A lot of times, my patients live a fairly isolated life, so just as it was a transition to adjust to having so much attention and so little privacy, it is a major transition going back to a life where they have little social interaction and little daily living support.
With that being said, I also make an effort to introduce the idea of older adult living communities when it is appropriate, such as independent living facilities, assisted living facilities, and adult day care programs. I provide education on this topic for patients and their families, because I want them to know that there are communities of people that are in the same place in life as they are. In the geriatric population, people may have lost a spouse, may have lost life-long friends, may be experiencing a decline in physical health, may have recently had their license revoked, which are stressful psychosocial factors to cope with. We all need social engagements to process and accept things that occur in our lives, as we age that becomes more and more difficult. It may not be a proper fit for every older adult, but with education and direct conversations with friends and family it may be a better fit that will improve his or her quality of life. Everyone is different and some are more receptive than others, but there are a lot of benefits to living in a community that better supports the geriatric populations needs than living alone with little support within their community.
In closing, as an OT make sure that you know your community’s resources, because it may make the difference in a safe and sustainable discharge home versus readmission to the hospital in the upcoming weeks or months.