Monday, February 20, 2012

Rehab vs. Reality

I teach aging studies and have worked in home care but still find the care partner experience to be a real challenge. This is the first of a three-part "rant and request" series that was originally written as a lesson to the students in my Interdisciplinary Perspectives on Aging course, but I think can be useful to anyone working as a formal or informal caregiver to older adults.

My 82-year old mother fell and broke her hip and elbow a few weeks ago. She had hip replacement surgery and her arm placed in a cast. Both injuries were to her dominant right side. After four days in the hospital she was moved to a skilled rehab unit where she spent six more days that included 3 hours per day of physical and occupational therapy sessions.

My mom surprised us all (including herself) with how well she did with the recovery process and how quickly she was released.  However everyone, including my mom, underestimated how difficult it would be for her to manage once she was back at home. If she did not have the day-to-day support of family it is likely that she would have had to go back to the rehab center.

“Rant & Request:” Make rehab activities realistic to properly prepare the person for their version of reality they will have to deal with when they return home.

It is great to ask an older adult if they THINK they are ready to go home and function on their own because they are adults with life experience and deserve their autonomy. However post-illness or surgery (especially when anesthesia and pain pills are involved), the senior is not any more capable than you or I to make a judgment call about self-ability in an environment that is 10 times more difficult to navigate alone than a safe, controlled rehab environment. In the rehab center, patients are monitored, supported and encouraged by a squad of extremely skilled and competent technicians.

Both motivation and confidence diminish without the attention and encouragement from the rehab center staff. At home on their own, seniors often find themselves lacking self-confidence and struggling with tasks that don’t match what they practiced in therapy sessions. This can lead to defeat and possible re-admission at a much greater cost.

PLEASE do a thorough screening process to determine if the older adult is truly capable of self-management before discharge. Don't run them through an easy and generic simulated "home" environment and think it will be fine in their own house. 

Conduct therapy sessions that are set up like the reality of life. Create obstacles and challenges to see how they cope and help them make the adjustments they need to adapt. There are so many unfortunate incidences of secondary morbidity and additional falls due to premature discharge. Transitions of care, coordinated care information, and communication are absolutely essential for long-term success. We do a disservice to seniors and to ourselves when we work so hard to help someone recover from an illness or injury, only to send them home to suffer and fail (or worse).

My mom chuckles as she describes how in the simulation kitchen, she was asked to move dishes from the counter top to a dining table that was right next to the counter and then return the dishes to the sink. In practicality, this is humorous because her dining table is not next to the kitchen counter – it is in the dining room and that means carrying a glass or plate with drink and food to another location in the house. The trouble is that she has a cast on her right arm and needs her left arm for using her cane.  What’s missing in this picture? You guessed it, the third arm that carries the dishes!

There was also less-than-realistic practice in rehab doing the laundry. The therapist told my mom to use the mechanical “reach and grab” tool they provided to take the clothes out of the washer and move them into the dryer. Then she had to remove the items from the dryer, again using the tool, and fold them. That was a practical activity and it made my mom feel confident she could do her laundry on her own.

When she tried this routine at home, she discovered a flaw in how the exercise was conducted at the rehab center. All of the clothes she took out of the washer in rehab were dry and light enough to pick up with her reach and grab tool in her left hand. However the clothes she was taking out of her washing machine at home were, uh well, washed…and therefore wet and heavy. She did not have the strength in her non-dominant left hand to accomplish the task, leaving her feeling defeated and discouraged.

My mom really is doing quite well in spite of some setbacks and I am very proud of her. I am also extremely grateful for the conscientious and dedicated staff at the rehab center and the home health professionals that have helped my mom regain the ability to function. The health care reimbursement system dictates how much time and what types of activities these folks can give to their patients. 

Maybe we need to rename and reframe “rehab” to “reality-have” in order to ensure that the time, expense and effort that are spent will accomplish what is intended – to help the older adult regain the ability to function safely and with independence. 

Be sure to return for “Rant and Request” Part 2: Build on what is known instead of starting over from “square one” – the segment where I share how confused people confuse other people!

Tamara Wolske, MS
Academic Program Director

1 Comment:

Anonymous said...

I'll never forget after my 70+ mom broke her right (dominant)arm. I found her at lunch time with her tray in front of her and she had told them she could manage--she didn't want to be "a bother." She had a cast on the right arm and a restraint on her left arm so she would not diable her IV. She could not even reach her tray and had been sitting there for 30 minutes. No one had noted.