from Hospital to Community Based Setting Flashcards
Continuum of care including
Acute
- Intensive care unit (PICU)
- Medical or surgical care unit (special care unit: Cardiac, Hemoc, Pyschiatric)
Inpatient Rehabilitation
Ambulatory or outpatient services
Community based Settings
Acute admission
Child is usually typically developing prior to current referral reason; medical management of symptoms is key focus
Rehabilitation admission
Usually follows acute stay, designed to be a longer time designated on restoring strength, endurance, function and impacted skills in order to return home
Chronic Hospitalization
Admissions occur due to exacerbations of chronic conditions or progression of illness , may need modified continuation of outpatient services
Special program admission
admission of child to a specialized program such as feeding or day rehab program
External influences on pediatric hospital based services
- Health care laws
- Health care costs
- Insurance/ 3rd party reimbursement
- Accrediting agencies
Acute Setting
Goal:
- can be very short
- LTGs usually designed to be met within 1-2 weeks
- STGs usually are designed to be met quickly within a few days.
Goals: Improve client factors: -Improve full active ROM and strength (cognition, swallowing) -Improve safety of swallow -Improve visual perceptual deficits -Improve cognitive/processing functions
Improve occupational level
- Enable child to return to pre-morbid level in school or community.
- Return to age appropriate play and ADL skills
- Support and improve child’s social participation.
Rehabilitation
types of onset-
- accidental injury
- violence
- disease process
- surgical intervention
Types of diagnosis
- TBI
- SCI
- Cancer
- Stroke
- Encephalitis
- Cerebral Palsy
Pediatric Rehabilitation
Traditional Requirements
- 3 hours of therapy per day, 5 days/wk
- fewer hours on weekend
- Evaluations must be completed within 48 hours of admission
- WeeFIM assessments weekly- to show progress is being made.
- Weekly Team Progress Note- Authorization to stay on rehab.
Neuro-Trauma Status
- <3 hours/day of therapy- Justify why they cant (not stable)(may just need parent training, how to position, bath, oral stim, etc)
- Reduced therapy status due to medical severity (tolerance) or due to young age
- May focus on family education.
Pediatric Rehabilitation
Goals-
- Often looking at a 2-8 week stay
- LTG- within 1 month
- STG- within 1 week
Types of OT Intervention
- prevention
- restoration
- Modification/Adaptations for ADL skills
- Equipment evaluation/reassessment- a lot before they leave. what they will need for discharging to home.
- Community re-introduction.
Pediatric Rehabilitation FORs
Biomechanical- ROM, Tone, can they track, sensory stimulation, how body responds
NDT- weight bearing status, synergistic patterns they may have, trunk control (better ability to use extremities)
Sensory Processing- lighting, music, etc. (may not tolerate well) What sensory properties in the room will help calm and organize child.
Visual Information- Processing- able to process what is going on to help with their participation.
Pediatric Outpatient Interventions
- Continuation of rehab or inpatient services (focus on return to pre-morbid function in all occupational areas)
- May start services at this level
- Focus on habilitation and establishing new developmental skills (sensory processing, fine motor skills, strengthening, splinting needs, attention, coordination, feeding)
Pediatric Outpatient Services
Goals:
- Time varies
- LTGs are written for 6 month increments
- STGs are written for 1-2 months (4 to 8 visits)
Frequency of intervention
- varies based on setting and client needs
- outpatient day programs: 3-5x/wk (typically seen for 3-5 hours a day)
- Standard outpatient: 1-2x/wk or 1-2x/month (typically seen for 45min-1 hour/ session)
Community Based- Pediatric settings
Infant Toddle Programs
School based therapies
Pediatric community-based settings
- may or may not charge for OT services
- Consultant- may evaluate current programs and give suggestions for program quality improvement.
OT as part of autism diagnostic group or OT working as a group leader at community substance abuse camp
Work with an educational team at a school to select furniture to support better sitting and movement postures for children with special needs
Community re-integration programs
Therapists work with children in actual childhood environments to better re-integrate them into the community after illness or injury.
Have therapy in McDonald’s McPlay Place to work on child playing in a typical environment or an adolescent work on visual motor integration at a video arcade
Clubhouse model
- Community based facility
- Participants are “members” and have a share in responsibilities to maintenance and operation of clubhouse with staff.
- Focus on function and interdependence
- I-ADL training (social development, self care education/training, job training, healthy leisure exploration, time management)
community setting
- Roles and goals of OT may vary depending on nature of community based agency
- Advocacy for children and families
- Encouragement of improved function within naturalistic environment
- Types of intervention (promote/creation, maintenance, establish/restore, prevention, adaptation/modification)
Evaluations
- Start with biomechanical evaluation (ROM, head control, sitting balance, cognitive awareness)
- Progress to functional skills as able (ADL’s, fine motor skills, feeding/swallow, social skills)
- Standardized tests (MMT, Bailey, Peabody, HELP)
Sensory stimulation
- Visual input: eyes open, tracking, locating objects on command
- Auditory input: turn to sounds, tolerating tv or music, following commands
- Tactile input: Tolerating touch, providing different sensations that are soft/rough/textured, holding an object or tactile exploration, tolerating handling for positioning
- Smells: providing various familiar smells and watching for reactions: vanilla, orange, peppermint, cinnamon, chocolate
- Vestibular Input: Tolerating position changes
ROM and strengthening
Begin strengthening from day 1
Provide passive stretch where movement is limited
- Tenodesis stretch- to facilitate grasp for SCI
- Consider splinting
Eating
- Assess safety of swallow
- Often experience change in hunger
- If UE’s are not affected then progress feeding from an inclined bed, to eating in w/c, to standard chair.
- Assess pace of eating (initiation of bites and swallows), FM skills for eating, and need for set-up of meal.
Grooming
-Adaptive equipment
suction tooth brush if needed universal cuff brush cuff long handled brush bath mitt
Dressing
UE easier than LE
- progress based on patient’s overall balance and trunk mobility.
- may need one handed technique
Bathing
- begin with bed baths
- dependent lift or use of Hoyer lift to reclining bath chair or supine bath cart.
- Begin bathing on transfer tub bench.
Toilet Transfers
It is difficult independently complete slide board transfer onto a commode unless it has swing away/drop down arms
Recommend use a Stand Pivot Transfer, Hoyer Lift, or 2 person dependent lift instead
Recommend toilet transfer board to start
Public restrooms and home bathrooms often have limited space (see video)
Patients will need to have advanced dressing skills to dress in a w/c or in standing to be independent with toileting on a toilet.
SCI cathing
-taught by nursing staff
OT’s role
- Guide and teach positioning techniques (abduction of legs, recline in w/c)
- Recommend adaptive equipment as necessary
- Clothing management.
Home Accessibility
Accessible entrance with ramp as needed
Two accessible exits in case of an emergency
Bathroom
Width of door
Space to access tub/shower and toilet with appropriate equipment and transfer
Bedroom
Carpet height if propelling wheelchair
Accessing closets
Height of bed for transfer
Kitchen
Difficult to access counter tops and sink
Accessing items from refrigerator and cabinets
Meal prep training begins as an inpatient
Environmental control
Rehabilitation Institute of KC
Coalition for Independence – telephone access
Community Re-integration
Community outings begin during inpatient stay -Considerations: Transportation Child’s interests Time restraints Cathing/feeding/medicine schedules “To go bag”!
-Setting goals Community mobility Social interaction Confidence Money management Endurance
-Home visit to prep for discharge
Driving Evaluation and Training Program > Rehabilitation Institute of Kansas City
No state requirements
Eval and driving time not covered if adaptive transport nearby
Two hand control vendors
Low profile floor mount system
Traditional steering column mounted system
Placing wheelchair into car for SCI – wheels off
Lean front seat back and pull chair over to front seat
Pull wheelchair into back seat – suicide doors
Back to school accommodations
cathing
Plan for if bowel or bladder accident occurs
Pressure relief at beginning and end of each class
School books
Accessing backpack or bag on wheelchair
Cafeteria
Adaptive PE
Navigation
Desk in each room that is wheelchair accessible
Priority Seating
Transportation to school and fieldtrips
Testing accommodations
Wheelchair skills
Wheelchair skills: assisted to independent
- Opening doors
- Ramps
- Wheelies – clearing rise in sidewalks
- Curbs
- Stairs
- Floor wheelchair transfer
Sports and Leisure
- Swimming: goal progression
- floatation and assist level: static vs swimming
Wheelchair Sports and events
- Mid-America Games, Day at the Lake
- Kansas City wheelchair sports teams
Sports Wheelchair
-Cambered/angled wheels
Special Olympics
Psychosocial impact of hospitalization
Shields
- significant stressor to family
- Acute phase: family in shock, overwhelmed with feelings of guilt
- Change or loss
Kuntz-
-Isolation (children are away from typical childhood environments.
Thurber
-Homesickness
Fear
-Young children may have distorted views of why they are being hospitalized-punishment or causal result of being bad.
Clatworthy
-Anxiety (a new environment and a lot of people around you that you don’t know and people saying things that the kid may not understand. )
Hospitalization and play
Kielhofner
- Decreased opportunities for play
- Decreased levels of playfulness among hospitalized children
- Lack of designated play space
Gariepy and Howe
-Less expansive play routines
Play and Hospitalization
Ryan and Ryan-bloomer and Candler
-Qualitative study evaluating how children play in the hospital
-Quantitative studies assessed how playfulness varied between home and hospital
-Findings:
-Playfulness is similar in the hospital and home if children are well enough to engage in play
-Playfulness can improve over time in the hospital
-Playfulness may be more influenced by personal attributes
OT can collaborate to promote best match between client factors and environmental demands
