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Short-term rehab plans for the newly discharged

Renee Kinder
Renee Kinder

Short-term rehabilitation programs are designed to promote and ease individuals' return to home environments and assist with re-entry into the community within a relatively short period of time. Individualized treatment plans for short-term care may be established for a variety of medical conditions from joint replacement surgeries to cerebrovascular accidents.

In order to promote patients' return to community following a course of rehabilitation services, there must be active collaboration and education of all interdisciplinary team members. This includes the resident and caregivers and should begin at the start of care and continue thru the end of care. This is to allow for a fluid transition to least restrictive environment. Ideally, this is a setting in which the individual resided prior to functional declines which necessitated skilled care.

Promoting return to prior living environment requires that therapists obtain upon initial evaluation vital information regarding the individual's desired discharge location, prior functional abilities for higher level cognitive/physical tasks and instrumental activities of daily living, and then compare these to baseline/current levels of function. 

For example, let's look at a resident admitted for short-term care following a cerebrovascular accident. This changed her ability to comprehend written text. Prior to the CVA, she was an active volunteer at the local community center, tutoring children in after-school programs. She would need a plan which included increased ability to comprehend written language. 

In another example, a patient admitted for short-term care following knee replacement surgery — who lives in a split level home with laundry on the lower level — will need a plan that specifically addresses the ability to climb stairs while carrying objects.

Establishing a checklist as part of treatment planning can provide a guide to clinicians and a sense of motivation to patients. In addition, creating an established list of needs can promote more effective planning for the home assessment, during which abilities are evaluated within the patient's preferred discharge environment.

To begin, in order to perform higher level instrumental activities of daily living in a home environment cognitive and physical abilities must work in harmony to achieve the following: 

 

  • Medication management including fine motor skills for administration and executive function abilities for recall
  • Organization and planning of med schedule
  • Management of finances and follow-up appointments including bill pay
  • Ability to create and keep a schedule/calendar use
  • Meal preparation including selection of proper therapeutic diet and safest texture and viscosity
  • Housework, including laundry and cleaning, which may including lifting and carrying objects
  • Safety awareness within tasks including awareness of limitations
  • Need for energy conservation for individuals with compromised respiratory systems or reduced muscle endurance
  • Ability to use phone during emergencies
  • Proper gait pattern for negotiating obstacles, curbs, uneven surfaces and climbing stairs
  • Upper extremity range of motion when reaching upward to retrieve items from cabinets or downwards to pick up items from the floor
  • Upper extremity strength and overall balance for opening doors
  • Transfer skills to and from a car
  • Transfer to home bathing shower and/or tub set-up.

Secondly, in order to prevent functional declines therapists must review use of all adaptive equipment to be used in discharge environment. When appropriate, they should create a home exercise program to maintain strides achieved during skilled rehab care. 

Methods to ensure understanding of completion by the patient should take into account layout of HEP, patient's visual acuity for written tasks and memory abilities to recall specifics related to use of adaptive equipment and exercises. Clinicians may consider use of pictures or videos completing exercise tasks or using adaptive equipment in order to promote understanding.

Finally, the rehabilitation team needs to work in conjunction with facility discharge planners and family. The resident should be evaluated to determine continued need for home health or outpatient services upon transition back home. 

Home assessment, prior to final discharge, should be completed in order to assist with determining these needs. It may include specific breakdowns for functional activities. This may include:

  • Mobility needs for entering and exiting the home including assessment of driveway, walkway, stairs and entry ways
  • Layout and design of bedroom and living area as differs from SNF setting, including ability to transfer to and from bed, chair and couch
  • Ability to make bed and reach into drawers
  • Bed mobility skills in home bed, such as reaching skills for turning off and on light switches and lamps
  • Bathroom assessment including ability to maneuver freely and navigate wheelchair or walker as needed
  • Ability to transfer to and from toilet and tub/shower and ability to reach counter and complete am and pm/reverse ADL self-care routines
  • Kitchen assessment including needs for reaching into cabinets, counter-height and ability to prepare items
  • Entry way into kitchen and size of area needed for wheelchair and walker use
  • Reaching abilities into refrigerator, microwave and stove
  • Safety awareness during meal preparation. 

Following completion of assessment, therapists will be able to make clinical determinations on the individuals' ability to move about the home freely and adjust or remove any limitations which may impede return to prior functional environment.

Renee Kinder, MS, CCC-SLP RAC-CT, is a clinical specialist at Evergreen Rehabilitation.

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