Continuum of Care

Question 1

Continuum of Care

What does the continuum of care look like for physical disabilities settings?

Identify all of the settings.

Answer 1

1. Inpatient Settings- medicare pt A
2. Community-Based Settings
3. Outpatient Settings

Question 2

What is acute Inpatient setting?

• Acute Care Inpatient Setting
• Inpatient Rehabilitation Setting

Acute Rehabilitation- have to 3hrs a day rehab

Subacute Rehabilitation

• Skilled Nursing Facility

Answer 2

Acute Care Inpatient Setting

• New medical condition or exacerbation of a chronic condition
• Sudden change in client’s context
• Previous social
• roles abandoned
• External stressors
• Loss of control

OT Role:

• 3 roles of OT: reduced/ very limited to a VERY quick 45 min eval of ADLS- where will they go after- mainly a safety check/ eval
• 1. E__ducation Safety precautions, activity analysis
• 2. I__nitiation of the rehabilitation process Initiation of rehab services for clients transferred to a rehab facility
• 3. C__onsultation: Focused on the discharge environment and client needs after leaving the acute care hospital

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Question 3

What is inpatient rehab?

Answer 3

Inpatient Rehab

• Client is able to tolerate several hours of therapy per day.
• Client is deemed capable of benefitting from rehabilitation
• Client is medically stable
• Acute or Subacute
• Pain, if present and affecting client performance, should be addressed in this setting
• Energy expended to perform self-care
• Coordinated services to support client outcomes
• Dress in typical street clothing, eat meals in dining room

Question 4

What is acute and subacute rehab?

Answer 4

Acute Rehab-typically TBI, stroke, SCI. FIM reimbursement is in this setting

• Medically stable and may require some level of acute medical care
• Tolerate 3 hours of combined therapy services 5-6 days per week
• Length of Stay (LOS) is usually 2-3 weeks
• Discharge plan to a lesser level of care
• Process of adjustment to disability has begun
• Client’s deficits and strengths more defined as client begins to participate in areas of occupation
• Improvement in client’s function may have occurred
• New social relationships
• •Interventions are focused on resuming those roles and occupations deemed important to the client’s life- very focused on remedial
• –Remedial- get back to normal
• –Compensatory- compensate for injury/condition/ adaptive equipment
• •Simulated living environments
• •Community access
• Focus is on client performance and goal attainment
• Client’s culture can be compromised in process of rehab
• OT needs to actively participate in discharge plan and recommendation

Subacute Rehabilitation- if you can’t tolerate acute you go here

• Found in Skilled Nursing Facilities
• Do not provide acute medical care
• Focus of intervention continues to address restoring functional abilities but with a slower rate of change
• May also need to focus on Adapting or Modifying the environment to promote occupational performance (because pts don’t progress as quickly here)
• Lengths of stay varies from 1 week to months
• Also known as a short-term SNF admission
• Clients are usually discharged to a lesser level of care
• Pace of intervention varies
• 3 hours of therapy per day is not mandatory
• Client endurance will influence the frequency and duration of therapies
• Convalescing roommates
• Social context does not always support participation in rehabilitation
• Staff may also be more oriented toward skilled nursing care and not rehab goals of independence

Question 5

What are skilled nursing facilities?

Answer 5

Skilled Nursing Facilities

• Meets Medicare or Medicaid criteria for skilled nursing care, including rehabilitation services
• Subacute and short-term rehab programs may be housed in SNF’s
• Long-term skilled programs
• Length of Stay - Months to Years
• Goals directed toward independence and meaningful occupational pursuits and may include fostering engagement in occupations through environmental modifications and adaptations
• Hospice services may be included if appropriate
• Focus is not on rehab, rather palliative care and environmental modifications
• Physical and social environment may impede natural performance of ADL
• Clients often receive additional assistance with self-care to expedite tasks, but this is not focused on fostering engagement in occupational performance
• Extreme variations in disabilities
• Younger adults may feel isolated and abandoned
• Family and friends less likely to visit
• Client may need to actively pursue connections
• OT role to facilitate identification of realistic and meaningful expectations and goals

Question 6

What are community based settings?

Answer 6

Community-Based Settings

• Home- and Community-Based Settings
• Intermediate Care Facilities (Residential Care)
• Assisted Living Units or Residence
• Home Health
• •Therapist has access to client’s natural physical, social, and cultural environments.
• •Services provided at this level can foster skill acquisition and habit formation and engagement in occupations in context
• •Client is not hospitalized

Home- and Community-Based Settings

• Alternative to acute inpatient rehab program for clients with traumatic injuries, such as head or spinal cord injuries.
• Comprehensive rehab services
• Client acquires functional skills in daily activities in normal environments of home, school, work site, and community.
• Enhances likelihood of a successful and functional outcome.
• Home- and Community-Based Settings (different from home health- HH they must be homebound)
• Scheduling is within control of client
• Intervention sessions vary in length and frequency depending on goals
• Rehabilitation technician or therapy aide provides practice necessary for goal attainment

Question 7

What are intermediate care, home health and assisted living units?

Answer 7

Intermediate Care Facilities (Residential Care)

• Closely resemble home situations
• Residence is permanent or transitional
• Similarities in the age of residents, their disability status, and diagnosis
• Clients do not require ongoing intensive medical care
• Facilities are staffed with care providers 24 hours a day due to clients’ need for safety and supervision
• Frequency of OT services vary from weekly to monthly consultation
• Rehab technicians may implement the unskilled portions of the intervention plans addressing ADLs, select IADLs, and leisure.
• Therapist can identify key performance issues in this context.

Assisted Living Units or Residence

• Health services in a cooperative living setting
• Client lives in an apartment or cottage
• Client receives 1 or more meals daily, medication management as needed, and 24 hour support as needed
• Usually age restrictions of 55 and older
• Client owns or rents space
• Social and environmental support
• OT services foster and enhance habits and routines necessary to remain in this environment
• OT focus is on ADL, simple IADL, and leisure activities
• OT needs to know what services are provided at the ALU prior to designing an intervention

Home Health- OT cannot start case, only PT or RN

• Services provided within client’s home
• Provides most natural context for intervention
• Resumption of life roles at home
• Focus of OT intervention is to support participation in roles
• Therapist is a guest in patient’s home
• Client and family in control of the home environment – must ask permission
• Daily schedules established by client and family
• Appointments should support family routines and schedules
• ADL and IADL and leisure tasks evaluated in home environment identify challenges that client meets daily
• Familiarity of items promotes orientation and task performance, however, changing things may increase confusion and decrease orientation skills
• Home Assessment –
• Environmental adaptations and modifications
• Ethical dilemmas involving safety
• OT can see social and family support
• Caregiver assistance and caregiver burden

Question 8

What are outpatient, work site therapy, and day treatment?

Answer 8

Outpatient Settings

• Outpatient OT Service
• Day Treatment
• Work Site Therapy Settings

Outpatient Rehabilitation-medicare B (no overnight)

• Provided in hospitals and fee-standing clinics
• Clients are medically stable, able to tolerate a few hours of therapy, and can travel
• New disability and long-standing disability
• Frequency varies - several times a week to 1 time every few months
• Clients have more control over schedule compared to inpatient
• Assessing ADL
• Physical design and equipment
• Social Context

Day Treatment

• Community-based intervention setting
• Intensive interdisciplinary intervention
• Clients are not hospitalized and usually live at home
• Clients may still have decreased independence with ADL and IADL
• Frequency varies from daily to weekly
• Team approach
• Recovery of functional skills following an acute injury or illness or a progressively deteriorating disorder
• Allows participation in occupations through environmental modifications and adaptations.
• Length of stay varies from months to years
• Time constraints are not common
• OT can perform community outings and work site assessment and intervention sessions
• OT evaluation and intervention in natural environments

Work Site Therapy Settings

• Industrial Rehabilitation
• Context of employee’s work
• Address work injury related therapy needs
• Intervention focuses on occupational performance required for work setting
• Focus on prevention of injury
• Transition from patient role to role of worker
• Team can include the employer and insurance company
• Reasonable and necessary work modifications