003: Reflections on patients and their homes

Sarah talks with Kati about discharge scenarios and what home modifications looked like for their patients.

003: Reflections on patients and their homes
Good Fit Poor Fit

 
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Welcome to another episode of Good Fit Poor Fit. Today I have with me Kati Richardson, she is an OT student with our organization until April of this year. 

Kati: Yes, hello everyone! 

[00:00:42] Sarah: I’m glad she’s on this episode today. We are actually going to talk about my clinical experience and her experience as a fieldwork student and what discharge looked like for the patients she saw and how home modifications played a part in that, even if it did or if it was just recommending equipment, that type of thing. So I might have Kati share first of her experiences from fieldwork. 

[00:01:09] Kati: Sure. So let me start by telling you guys kind of what fieldwork is. Part of my OT program is to go to two, level two fieldwork experiences and each one is 12 weeks long and I’m supervised by an occupational therapist, and that’s where I learned all my hands-on clinical skills,  I apply what I learned in school to real-life practice, and I basically get to treat all the patients on my own, but I am supervised the whole time. So I’m not quite yet an OT, but working as one. I have already completed both of my level two fieldworks. One of them was at a skilled nursing facility and the other one was at an inpatient rehab facility.

[00:01:51] At both of these settings, I saw a lot of individuals who were older adults. A lot of them had unfortunately had a fall that caused them to break a hip or maybe they need a knee replacement or spinal surgery. So there were a lot of orthopedic conditions that I helped treat, as well as neuro conditions like strokes and Parkinson’s disease, and MS multiple sclerosis. I saw quite a wide range of different conditions and different people. In both of these settings, one of the first things that you’d want to do when evaluating your patient is figure out where they’re going to be discharging, if that’s going to be home if they’re going to be living with a family member if they’re going to be going to like a longterm care facility.  It’s important to know these so that when we’re working on things in therapy, we know exactly what it is we need to focus on. If they have stairs in their home, we need to work on that. If they have a tub shower, we need to work on getting in and out of the shower. That’s kind of just a real brief rundown of where I did my fieldworks and the reason why discharge planning is so important.

[00:03:01] Sarah: My first job was actually an inpatient rehab. And it sounds very similar to your experience. My team actually was a spinal cord injury team, but we also treated people who had hip replacements, a lot of back surgeries, some spinal cord injuries. We also did have people who may have had a heart attack, people that were hospitalized because of cancer. And so our team kind of got a lot of, of different diagnoses, but, we did the same thing. We evaluated right upfront to determine where they were headed, and it was very rarely that we actually got to go out to people’s homes to do an evaluation. I loved when we did because I really got to see that person in that environment and learn exactly what they needed to do so we could practice on the steps that, you know, they needed to go into or see how they got into their tub-shower. When in the clinic, you can mimic what might be there.

[00:03:54] When I worked in North Carolina, there were some people that were going home and went to an outhouse, they didn’t actually have a bathroom in their home. And so,  there’s just a lot of different living situations out there. I also have another, OT who was in my class who works up in DC and she’s discharging a lot of patients that are homeless. So how do you work on a  discharge plan in that regard? The evaluations were not that common because we just didn’t have the staff to go out and do the, those evaluations. It took time out of our day. We have to treat as many patients as we can. I really wish we had the time to go out and do that a lot more to see people  in their actual home environment. 

[00:04:36] Kati: Yeah. I think it’s so beneficial to be able to immerse the patient in their natural environment to see what they actually can do and to see if they are independent in their ADLs or their IADLs, which are activities of daily living and then instrumental activities of daily living. So all of these different tasks include getting dressed, taking a shower, getting on and off the toilet, cooking meals for yourself, being able to clean up around the house. So yes, like Sarah was saying, we can mimic these things and we can set them up in the therapy gym and kind of recreate their natural environment, but it’s still not the same.

[00:05:15] And, yeah, I did not see home evals a lot during my level two fieldworks. I was lucky enough to go on two when I was at the skilled nursing facility, and it was for two ladies who were in their nineties and one was in their late seventies and these women were amazing. They both still lived alone. So I was first of all taken back by that cause I was like, wow, you are almost 94 and you’re still living alone. Wow. And so we went on a home eval with them and we’re able to see, you know, can you reach your microwave to put something in there? Can you get in and out of your bed? Because their bed was a lot higher than the bed at the hospital and the bed of the hospital, it’s controlled with a remote. So it’s like you can adjust if you wanted to get out of bed, but you can’t at home. So it was really cool to see them actually function in their natural environment. 

[00:06:16] And another thing I just thought of was one of my level one fieldworks was with a therapy company that basically does house calls. So similar to home health, but the insurance reimbursement was from Medicare part B, so it was considered outpatient on wheels. 

[00:06:36] Sarah: How cool. 

[00:06:37] Kati: Yeah, it was really cool because the therapists were able to go straight into the house and work on all these activities that they needed to be able to do in the home, and it just made it so much more special to the client too, because they’re doing something that’s meaningful and in their own space. 

[00:06:53] Sarah: Yeah, definitely when you went on your home evals were you able to recommend any type of actual modification to the space? Like widening doors or, I mean, I know lots of people probably needed to make big changes to their home, but was that even possible or part of your discharge plan with them?

[00:07:11] Kati: Most of the time we were recommending equipment more often than actually recommending like a builder coming in remodel. Remodeling is quite expensive. It’s usually not realistic for these people to be able to have the money to perform these modifications. So many times we would be recommending equipment to help them, such as a tub bench. It’s a bench that you can sit inside of your bathtub and it extends past the ledge so that all you have to do is sit on the end of it and kind of swing your legs up and over the edge of the tub then we would recommend like handheld showerheads to be installed. So I guess that is kind of a bit of a remodel cause we have to install that, but, 

[00:07:58] Sarah: But much, much simpler than like widening doors or changing the layout of something.

[00:08:05] Yeah. I think the only time I went on a home eval and like actually got to really dig into what they were doing in the construction phase was really cool. It was a young kid and he had a spinal cord injury but had also injured his other arm in the accident he was in and so he really only had one working arm. And so the family and community around him rallied together and they were able to do some modifications, and so they had an addition to the home that included a bedroom and a bathroom for him. 

[00:08:37] It would be great if it was like that for every patient, but finances and working in the hospital, you don’t have connections to builders; that’s just not part of our job. I know a lot of the PTs would just be able to hand out like a handout on a ramp, you know,  here’s how to do it, but you have to find your own resources and manpower to do it.

[00:08:57] And people really do have to make compromises in these situations.  The biggest things that we were trying to figure out on discharge is: Can they get into their home? Can they get to a bathroom? And can they sleep?

[00:09:08] And so, maybe they were the person that did the laundry before, but it’s in the basement. Maybe that, that won’t be their task for a while or until they progress and get better, or maybe somebody else is going to have to do that in the future. So,  I just feel like when homes aren’t designed well from the start and there is an accident or injury that occurs, then compromises have to occur and that really impacts people’s health. 

[00:09:33] Kati: Oh, totally. Some of the most common compromises that people had to make were,  if their bathroom was upstairs and they couldn’t get there, they would have to do a sponge bath. For example, my grandpa, he had a stroke and at the time of the stroke he was living with my grandma in a two-bedroom apartment, but the stroke had some lasting effects and they recommended that he needed 24-hour supervision. He came and lived with us and he wasn’t able to get upstairs so for a long time he was doing sponge baths in the kitchen and then was sleeping in a recliner in our living room until we could afford to get a stairlift installed. And then he rode the stair lift up to the full bathroom upstairs. So a lot of compromises and money that we had to put into our own home for his sake.  

[00:10:25] Sarah: Yeah. I did have one patient who came in and I was asking about stuff for discharge and asking about showering and he said, “Oh we rent a hotel room every once in a while so I can get a shower.” And I thought, wow,  that’s tough when you know, you just have to go down the street to a hotel or maybe get a gym membership to use the shower. 

[00:10:45] Kati: I think one of my patients would go to the gym to shower because it was accessible. 

[00:10:50] Sarah: Yeah. 

[00:10:50] Kati: And it was a big enough shower that she could use it. 

[00:10:52] Sarah: And most of the showers at the gym are walk-in showers and some of them, sometimes they provide a bench. I know the one here has a bench so. That’s true. Get a gym membership and be able to use the shower. It just unfortunate and money. Yeah, it is. And gym memberships are definitely not cheap.

[00:11:09] I think this is pretty common. I think a lot of the OTs that I talked to, I mean, are coming out with these same issues when they’re treating their clients. And so,  if houses were built more functionally from the start, then, people would be able to go home and be a little more independent than they are now. 

[00:11:26] Kati: Not being able to go and do a home evaluation is something that’s usually at the, it’s like the structure of the organization you’re working for. So you might not be able to go out and do a home eval because of productivity or whatever the case may be. So you have to be more proactive upfront and you have to start asking the patient to send you pictures of their home or getting the family involved so that they can describe what the home looks like and so just trying to, as best you can,  model the home in the therapy environment.  But on the other hand, if we were able to go into the home and do a home eval and experience how the person is functioning in their own space that would allow for more time for us to work on other things while we’re in therapy.   I think we definitely need more home evals and more opportunities to go into the client’s home when we’re working in settings like inpatient rehab, skilled nursing hospitals and stuff like that but we’re limited. 

[00:12:20] Sarah: Well, and I think we’d even have more time for different types of treatment for strength and stuff like that if housing was more functional, then we could work on more of those things versus that one sticking point for them to go home independently is they have to get into that tub or they have to maneuver these stairs or that type of thing. If that’s what you have to work on to get home safely, I mean, there’s a lot of other things that you can’t work on. It makes a big difference when the design is a poor fit for that person who’s trying to go home.

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