Benefits of Patient-Centered Care: The Human Element is Key to Successful Discharge

By Megan Stokes, MS, OTR/L

Occupational Therapist

A referral is received and the initial evaluation is scheduled. What should be on the evaluating clinician’s mind? Discharge. But not just any discharge: A successful discharge. The discharge date may be two weeks, a month, or six months but it should still be on your mind.

You may be questioning, “What is a successful discharge?”

A successful discharge is when the goals of the patient and/or caregiver have been met. A successful discharge is when the patient has returned to their prior level of function. A successful discharge is when all educational resources and training have been provided to allow the patient to live their life to the fullest!

You may also be asking yourself, “How is a successful discharge achieved?”

Allow me to provide you with an example, using a case study of one of my former patients. This patient instantly stood out to me because of the excitement on her face when she realized she could do something again that she thought was going to be impossible. Through her success and her accomplishment, I felt successful as a clinician.

ESTABLISH patient-CENTERED GOALS

Find out what is most important to your patients. Use subjective comments or the Patient Specific Functional Scale to help.

My patient once told me, “I have trouble using the bathtub.” She rated her ability to perform bathing using her tub as 0/10.0 as a result of her current issue when her prior level of function was independent.

This patient had anxiety, depression, and a history of falls, a cerebrovascular accident, and lung cancer. She was also experiencing benign paroxysmal positional vertigo (BPPV) at the time, which was causing her difficulty transferring in and out of her bathtub by stepping over the edge. Bathing in her tub was more than a simple luxury. It was a way to improve her quality of life by providing a time of relaxation during her day in order to manage some of the symptoms she often experienced due to her diagnoses of anxiety and depression, such as decreased mood and increased stress levels. It also provided a safe alternative to bathing in standing in order to decrease her risk of falls as she was working to manage the signs and symptoms of BPPV.

The Arm Curl Test goal was established in order to address this patient’s upper body strength which would assist her with getting in and out of her bathtub. She scored a 14 on her right upper extremity and a 15 on her left upper extremity, which was below the normative range for her age and gender. Based on her occupational therapy evaluation, this patient was presenting with balance, endurance, and strength deficits.

I established her plan of care to focus on her specific goals of grooming for completing hair care, toileting with use of a toileting schedule to decrease episodes of incontinence, and upper body strengthening with the establishment of a home exercise program in order to place emphasis on using her tub for bathing.

THERAPEUTIC USE OF SELF

Use it.

What is it?

Therapeutic use of self is a way to use yourself, your personality, your experience, and your tact to engage patients in the skilled interventions required to meet their goals. It is a way to determine what is clinically appropriate for your patient.

Each patient is different. Treat them individually. Determine the best approach to treatment for each patient: rehabilitative, adaptive, and/or compensatory. It is easy to engage patients in the rehabilitative interventions, which are often the more typical treatment sessions, like exercises, balance training, cardiovascular training, walking, standing. To patients, this type of therapy is performing to return to their “normal.”

What is more difficult is introducing the adaptive and compensatory interventions and techniques they now may require to reach their prior level of function. This is because it may not be their “normal” way of performing the task but rather “modified.” Therapeutic use of self is an important tool to encourage your patient along their journey toward their individual goals.

REHABILITATIVE VS. ADAPTIVE VS. COMPENSATORY

My patient’s plan of care began as a collaboration of all three: rehabilitative, adaptive, and compensatory. I used blocked practice to perform mechanical transfers in and out of her bathtub. She physically engaged in sit-to-stand transfers on the edge of the tub and maneuvered down to the floor of the tub, using adaptive techniques– the use of a balance pad for knee comfort. Based on performance, I recommended an additional grab bar as well as another pad, namely a round swim tube to improve comfort when transitioning from her knees into the sitting position.

But did this seem to be the best technique for my patient? No. To complete the transfer into her bathtub using this technique, she required max assistance and was at an increased risk for falls. Based on her situation at the time and her history of falls, an alternative was introduced: a bath lift. This was a purely adaptive technique for using her tub for bathing. We did a simulation of a mechanical transfer into the bathtub by using a kitchen chair acting as the bath lift at the same height as the bathtub.

This led my patient to engage in further research, stating, “I know everything about the lift!” She became encouraged and excited again and proceeded to order the lift for her personal use. My patient accepted the education provided and followed through with the recommendation.

THE MEANING OF A SUCCESSFUL DISCHARGE FROM OCCUPATIONAL THERAPY

For the patient, the lift represented achievement, independence, fall prevention, and improved quality of life.

Despite her comorbidities, she was able to transfer in and out of her tub with standby assistance and bathe independently once again, completing a sit to stand from the lift with independence. Her score on the Arm Curl Test improved to 23 on her right upper extremity and 24 on her left upper extremity.

She reached independence with her home exercise program, maintaining her independence with functional transfers and decreasing her risk of falls.

In addition, the patient’s score on the Patient Specific Functional Scale addressing the use of her tub for bathing improved to 8.0/10.0!

In just a one-month time frame, this patient became a success story. This patient could finally use her bathtub once again.

Whether it be a rehabilitative, adaptive, or compensatory approach, establish patient-centered goals, engage with the therapeutic use of self, and educate your patient on their options. After all, life is great. But occupational therapy can make it better!