Practice

Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.
ROLE OF OT IN COMMUNITY RE-INTEGRATION
Reintegration into previous roles and activities in the community
is another important part of a successful discharge after an
inpatient stay. Participation, or involvement in a life situation,
can often look different and potentially be more challenging
after an injury or illness. Additionally, after an inpatient stay,
individuals often wait to continue to make gains in rehabilitation
and return to their baseline functioning before feeling like
they can assume previous roles in the community. As a result,
many individuals never become fully reintegrated back into
their community. However, because of occupational therapy’s
focus on participation, we are well suited to address community
reintegration. This begins with using performance-based
assessments with occupational histories, instead of relying
solely on assessments that measure only basic ADLs (Wolf,
Baum, & Connor, 2009). Occupational therapy practitioners in
inpatient settings need to take all of these factors into consideration
to make appropriate recommendations for additional
therapy after discharge. Community reintegration is likely to
occur in free-standing community reintegration programs (e.g.,
vocational rehabilitation), home health, outpatient therapy, or
private practice. Thus, occupational therapy practitioners have
the ability and the responsibility to advocate for appropriate services
for their clients on discharge to receive the services they
need, beyond basic ADLs.
Occupational therapy practitioners are qualified to play a
vital role in connecting patients to needed community resources
necessary for both community re-integration and discharge
planning to reduce hospital readmissions. The role of the occupational
therapist is to identify and access the needed community-based
resources, which can include AT, medical equipment
covered and not covered under insurance, services (including
homemaking or personal care attendants), home modifications,
and support groups. Completing a detailed occupational profile
can aid occupational therapists in identifying potential community
supports and resources available to client, or simply to
encourage them to use the resources available. For example, a
therapist could help a client with Parkinson’s disease access a
local chapter of the American Parkinson Disease Association’s
adaptive equipment loaner closet to get a portable ramp or adaptive
utensils. In addition, the occupational therapy practitioner
can recommend that a client pursue a local grant for home
modifications to get needed grab bars for the shower. Perhaps
the individual just had a life-altering injury and now needs to
be connected to a support group, or the spouse needs to be
connected with respite care to allow for optimal occupational
performance. By accessing these needed resources, occupational
therapy practitioners can help ensure that clients get what they
need in a timely manner to help reduce readmissions. Therefore,
it is important that practitioners, in all care settings, are
aware of the resources available to the clients they serve outside
of the basic medical equipment provided by Medicare or other
medical insurance providers.
CASE EXAMPLE
Mr. Xavier was a 68-year-old male who was readmitted to City
Hospital 20 days after his initial hospital admission because
of complications of stroke. Mr. Xavier was initially discharged
home with orders for a home health care agency to provide
nurse visits for medication preparation once a week, and a
home health aide to visit twice day for ADL and IADL assistance.
However, Mr. Xavier was readmitted to the hospital after
sustaining a left humerus fracture after falling when attempting
a toilet transfer by himself.
City Hospital, following the lead of top-performing institutions
recognized for their clinical performance and dedication
to patient-focused care, wished to consider areas in which the
initial plan of care could have addressed to avoid Mr. Xavier’s
return to the hospital. During Mr. Xavier’s second stay, the
leadership team performed an in-depth analysis of their performance,
and sought to address these points in their plan of care.
On evaluation and conversation with Mr. Xavier, the team
found out:
• Home health RN prepared medications, but Mr. Xavier
was responsible for taking them correctly and on time. The
team learned that Mr. Xavier could not independently open
his pill bottles after his stroke because of weakness and
impairment in coordination in his affected hand. He had
not received any further therapy to address this decreased
ability to use his hand or to address his difficulty taking his
medication correctly on a daily basis.
• Mr. Xavier did not receive any rehabilitation after discharge,
as he was able to complete his basic ADLs independently
in the hospital. In addition, he did not have
reliable transportation and had not attempted to drive after
his stroke, so even when outpatient therapy was initially
discussed, he was hesitant to agree as he did not think he
had a reliable way to get to therapy.
• Side effects of Mr. Xavier’s new medication post stroke
included drowsiness and increased need to urinate.
Although Mr. Xavier had been verbally educated on these
side effects, he did not remember, as he received numerous
instructions on discharges. The connection between the
side effects and Mr. Xavier’s decreased independence with
toilet transfer at home was not addressed in the home, as
he did not receive any occupational therapy in the home
post discharge. Mr. Xavier tried to wait to use the toilet
only when the aide was present to help with transfers, but
that proved to not be very feasible. Instead, he chose to
limit his water intake, which created a risk of dehydration.
• As a result of the physical changes he experienced from his
stroke, his fear of falling during daily activities increased
significantly. Thus, he severely restricted his activities in
the home, including limiting his meal preparation, getting
dressed on his own, grooming, and getting his mail. He was
too embarrassed to let his daughter know about his significant
decrease in change in activity.
AUGUST 2016 l OT PRACTICE, 21(15)
ARTICLE CODE CEA0816
CE-5