Occupational therapy home health evaluation

1. Stay Informed

Home health occupational therapy services take place in the context of heavy regulations and a daunting set of rules. It is your responsibility to learn and know the rules, policies and regulations that govern home health services. Be sure to bookmark the Medicare, Centers for Medicaid and Medicare Services (CMS) and AOTA websites on your computer so you can stay abreast of all the changes that affect you, your role and the clients you serve.

2. Be HIPPA-Compliant

Adhere to the HIPPA privacy rules and safeguard your client’s privacy. For example, don’t leave your notes out and in the open while you’re getting gas or grabbing food. Don’t post information or photos of your client on social media or any internet site. Make time to call your client instead of communicating via text, as you can’t be certain who is receiving your texts. In everything you do, always consider what you must do (or not do) in order to protect your client’s privacy and confidentiality.

3. Infection Control

Learn to incorporate proper bag technique. It’s worth spending some time to understand proper bag technique to protect yourself and your clients from the spread of infection.

If you’re worried about offending your clients, you can always explain your rationale during setup:

“I want you to know that you and your family’s health and safety is top priority for me. As you can see from what I’m doing here, I take the highest precautions and safety measures during every home visit to make sure that we are keeping you, as well as all my other clients safe and protected. I appreciate your patience while I get set up here.”

Table of Contents

ADDITIONAL SAFETY TIPS

Don’t just sit on any surface, especially on any fabric furniture. If your client offers you to sit, either use your step stool or decline politely: “I’ve been sitting in the car all day and prefer to stand, but thank you.“
Never place your bag on the floor without a barrier. You can use a step stool, paper towels, newspapers, plastic or other disposable barrier between your bag and a hard surface.
Keep an extra change of clothes, shoes and hand sanitizer in your car.

4. Know How Your Productivity is Measured

With increasing demand and expectations to improve productivity, more and more home health therapists are experiencing burnout, ethical dilemmas and decreased job satisfaction. It is not uncommon for home care therapists to work off-the-clock for hours on end to meet unrealistic productivity standards and this is a common cause of therapy burnout.

In this environment, it is important that you know your rights as well as your responsibilities. First, understand how your productivity is measured. Are you given the necessary time by your employer or agency to complete paperwork and documentation between all the driving and patient visits? How about the time spent calling other team members and scheduling with your clients? If you sat down and really thought about everything you do between visits, you’ll realize how much work you’re doing that cannot be counted as “skilled” or “billable.” Now considering all this, ask yourself, “are these productivity standards fair or reasonable?”

ADVOCATE FOR A BALANCED CASELOAD

If you feel that you are not given a reasonable or accurate productivity standard, set up a meeting with your supervisor to find out how your productivity is being measured and seek his/her advice on what can be done or changed so that you can continue to perform ethically and efficiently without sacrificing quality care. Analyze your caseload and see how much time you’re spending on driving, documentation, evals, etc. If you’re having to do an overwhelming number of evals week after week, which can be time intensive, advocate for a more balanced and diverse caseload. Also, if you find that the majority of your cases require 100% supervision, request a more diverse caseload that is not so heavy with low-level clients so that you can incorporate Point-of-Service Documentation during some of your sessions. Otherwise, you may end up spending hours at home catching up on documentation. Bottom line: Don’t be afraid to speak up and advocate for yourself through an open and respectful dialogue.

5. Stay Organized

HAVE A SYSTEM IN PLACE

Keep your schedule and weekly planner easily accessible and editable. This may be your Google Calendar synced through your phone or a weekly planner you take with you in hard copy.

KEEP A LIST OF IMPORTANT CONTACTS

Be sure to keep a list of important contacts, including your client’s immediate healthcare team as well as numbers you can call in case of emergency. Consider keeping these contacts saved in your phone as well as having a hard copy in your folder as a backup.

TRACK YOUR MILEAGE

This is especially important if you are a 1099 employee. There are a few mileage tracking apps that make this process easy. MileIQ is one of the most popular and frequently used apps among home health therapists. In addition to your mileage, I would encourage you to find out which of the expenses are tax deductible.

Note: Since tax laws and rules are subject to change, it may be a worthwhile investment to hire a tax accountant to find out early what records you need to keep to get maximum deductions.

TRACK YOUR TIME

Learn to set boundaries with your client and their family. While family and caregiver education is an important component of home health, you must be able to draw clear boundaries on these family conversations to ensure you manage your time and productivity. You might even consider using a stopwatch to make sure you don’t go over the allotted time. Most clients will understand that you have a schedule you need to keep, so be sure to communicate your schedule clearly and politely inform them that you have “X” amount of time to do the session.

EXPECT THE UNEXPECTED

Keep an emergency kit in your car: Phone charger, jumper cables, tire-changing tools, portable air compressor, GPS, snacks, water and anything else you think you may need.

6. Get Familiar with OASIS

While some agencies may provide formal OASIS training, many clinicians get little support in developing good data collecting skills. Don’t be afraid to seek guidance and speak with your supervisor or team members if you need support. You can also utilize online resources from CMS and the OASIS Guidance Manual.

7. Master Documentation (Or at least try to)

Create a realistic plan and strategy for how you will complete documentation. Not just in your head, but an actual, structured system that you can follow. Without it, you will quickly become overwhelmed and end up spending hours at home completing paperwork off-the-clock. When creating your plan for documentation, you should consider your own work style and consider what location and time would be most conducive for you to efficiently complete your documentation on time. Your plan should also include a goal for how long you will be spending on documentation, depending on whether it’s an evaluation or treatment notes. Below are some examples from therapists who work in Home Health:

“I have a rule to never leave the driveway without completing at least 50% of my notes.” -Cindy K.

“My goal is to at least start my notes during the session and finish it in my car before I see my next patient. If I save my notes for later after seeing 5-6 patients, I’ll just forget everything.” -Sarah B.

“I typically spend the first and last 5 minutes of each session to do my notes. This definitely takes practice, but in time, it gets much easier and you’ll save yourself from going crazy at night trying to finish your paperwork.” -Kimberly R.

As you can see, some therapists choose to incorporate Point-of-Service (POS) Documentation, which means that you’re documenting at the same time you’re treating the client. It may not be appropriate for every client, but if done properly, POS documentation can help to improve the quality of your documentation, while also alleviating your burden to work off-the-clock to meet productivity standards. Be sure to check out my Point-of-Service (POS) Documentation article to learn how you can safely and ethically incorporate POS into your session.

OT in Home Health Overview

Before we can consider occupational therapy’s significant role in home health let’s first define what home health may consist of.

What is Home Health?

Simply put – Home Health IS what it sounds like.

In its basic forms, it is medical care provided in a patient’s home. Oftentimes, the care is more convenient and less expensive than care that may be provided in a hospital or in a rehabilitation inpatient setting.

Home health from a broad standpoint can look like a variety of qualified health and medical practitioners coming into the patient’s home to provide an array of services.

Services will include skilled care from nursing which for example could include providing wound care, monitoring variable health status, and administering intravenous therapy. Other services include skilled physical, occupational and speech therapy within the home. Other important care staff may include home health aids who are typically trained certified nursing assistants who may help with reducing caregiver burden by assisting the patient in and out of the shower 2x a week so that they caregiver may give the patient sink baths on the other days. Medical social workers play a profound role in this setting, as they often will have to help families make necessary and often difficult decisions in the event that the patient is not responding well to the transition home.

Home Health practitioners will likely check in with you to provide services discipline specific while also checking in with the patient to monitor and discuss:

What the patient is eating and drinking. How are meals / foods affecting blood glucose levels?
- When you are at home vs at the inpatient hospital where the food is controlled for example geared toward a diabetic friendly diet – the ball can quite honestly be more in the patient and caregiver’s court
Monitor vitals such as blood pressure, heartrate, respiration rate, temperature
Assess competence in medication management
Assess pain levels and interview about sleep hygiene
Check for safety in the home (helllllloooooooo OT)
Help improve self-advocacy and health literacy skills

What Home Health is Not

NOT JUST FOR THOSE WHO ARE BEDRIDDEN!!!!

Large misconception – I have had this very misconception myself with my grandma (before I completed OT school) so believe you me I am with you in the fact that there is a large disparity in knowledge of who can qualify for a referral. The reality is home health is meant to help a multitude of people including those who receive a new diagnosis or new medicine, have changes in the way they perform their daily routines, experience memory loss due to dementia or age-related cognitive changes, or are “homebound”

In home health world “homebound” can mean a myriad of things such as

1) a physician advises the patient to remain in the home because leaving the home can cause changes

2) able to leave home for a small amount of time such as for doctor appointments

3) not able to leave home without the help of an assistive device

Why do people get Home Health?

Many reasons and objectives lead toward the recommendation and ultimately a referral to home health services

To prevent avoidable and unnecessary hospital readmissions
- In short this is part of the push for quality improvement purposes
To promote an easier and safer transition back to the community after hospitalization
To achieve self – sufficiency, improve or maintain independence or function
To prevent or slow further decline

What is this whole OASIS business that references Home Health?

The Outcome and ASsessment Information Set (OASIS) is essentially a data set for the home health setting (i.e in Acute Inpatient Rehab the data set is the Medicare Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI); in Skilled Nursing Facilities the data set is the Minimum Data Set (MDS))

Not an expert (note let me be very up front in saying I never so much as had a fieldwork Level 1 in this site – I am sharing the knowledge I have accrued from researching and speaking to those who do have experience in this siteJ). OASIS measures and keeps track of patient outcomes as well as provides a template that helps build a comprehensive picture of the home care patient. One of the primary purposes the OASIS tool serves is to collect data to prevent readmission to hospital within 30 days and concurrently collects data such as patient information relating to medication management, dyspnea management, pain, and functional outcomes.

Occupational Therapy Role in Home Health

{An Occupational Therapist facilitating a patient to practice her balance, safety, planning skills, functional reach, processing skills while performing her morning task of preparing breakfast. Image from google images. URL in resources.}

Home health OT just might be the most client centered and holistic settings of all. It provides the unique opportunity to work within the person’s natural and familiar environment as well as sets the scene for pretty interesting occupation-based treatments. Occupational therapists and occupational therapy assistants in home health gather comprehensive data and information about a patient’s habitual daily routines as well as invites the chance of noting spontaneous performances when participating in various occupations (activities you need or want to do).

Individualized occupational therapy evaluation to determine patient driven goals
Customized plan designed to improve performance of daily activities and additional engaging activities which may include home management and child rearing
Recommendations for adaptive equipment and follow up
Guidance for family members and caregivers
Reassessment via Outcome tests periodically to ensure goals are consistently being met. If not, adjustments can be made to the plan to accommodate setbacks or unexpected progression.

One of OT’s key roles is to identify possible barriers and highlight supports to evoke progress and change (as needed). Additionally, OT practitioners in home health should be competent in their clinical assessment skills in regard to monitoring vitals and contacting the physican and/or in rareish occasions call EMS due to patient’s BP being extremely extremely high or due to acute onset chest pain…etc

Back to the interesting occupations…

Picture collaborating with the patient to craft up a way to safely feed pets without bending down and tripping over dog bowls (hello IADL task, fall prevention, functional reach, self-determination, planning, care of pet, list goes on)…

Or perhaps you facilitate the patient to bring out those Christmas decorations after a few years of being too fearful of taking a potential tumble when hanging up ornaments or adorning the tree with a beloved angel or star to truly encompass the client factor of spirituality as well as address and specifically target dynamic standing balance, sequencing, motor planning, etc…

Safety Tips

HIPPA HIPPA HIPPA!!! When you are traveling from patient home to patient home, think twice about leaving your notes out in the passenger seat of your car while you run in and inhale a sandwich at Subway on your lunch break. Think twice about texting your patients; you never know who will read the text. Calling puts the ball more in the patient’s court.
INFECTION CONTROL: There’s this pretty decent youtube video on how to properly manage your “bag” when you go from home to home. There is a lot to learn about taking the extra step to place a barrier between your bag and the floor as well as for what you need to do if you have a patient on any type of precautions https://www.youtube.com/watch?v=Hhi-o5IgKDk
WATCH WHERE YOU SIT: note to self – never will I ever sit on fabric furniture (#itsanofromme). PRO tip also useful in the hospital setting: do yourself a solid and keep an extra pair of clothes / scrubs in your car
CARS FAIL US SOMETIMES: Perhaps what makes me the most leery of this setting is that you have to spend periods of your day driving. Location will (rural vs suburban communities) typically determine the amount of miles and time one will log in their cars. I am not one of those persons who enjoys long drives nor am I good with paper directions and so in the event that my Maps App fails me I would feel like a lost puppy…
TRUST YOUR GUT: Be on alert. Quite simply, you will not have the support of an inpatient setting in the event your patient shows signs of medical distress. You will have to make quick and important clinical decisions. In addition, if you get the heebie jeebies feeling when walking into the house, assess your surroundings, do not neglect your safety, and make the decision whether or not you feel that you need to leave and contact your company.

Before we dive in further let's think about HOME HEALTH aspart of the many COMMUNITY settings occupational therapyserves an invaluable role in:COMMUNITY therapy services typically occur within the contextof a person's or family member's home or community in which the personreceives services in that area. Some specific settings within thecommunity category that will be explained in this andfuture blog posts includes the following:-HOME HEALTH-Schools-based-Early Intervention-Community / Paratransit

DISCLAIMER: The above-mentioned list is not all inclusive.

This article should not be used as medical advice and paints

a subjective picture portrayed through different perspectives

from occupational therapy practitioners. Each setting may

look entirely different than what will be shared through

the following interview portions based on region,

economics, and more.

Questions and Answers:

OT in Home Health by OT practitioners

#inthefield

The following section of this blog article stems from information collected via online interviewing. Answers reviewed and edited with permission from the intervees by me (Shannen). To respect the privacy of the contributors, I have provided underneath each interview answer their desired form of identification. Let me just say these OTs are awesome and really disclose the need for OT in this setting!!

Q: Describe your setting. Do you work in a rural or suburban area? What other healthcare practitioners do you work with?

A: I work in home health care for seniors with the average age being 80+. The company I work for services the entire Greater Birmingham area (all of Jefferson county, Alabama) and is expanding into the next county fairly soon. We service inner city all the way out to back road areas. We have a team with multiple Nurses, OTs, PTs, and PTAs, as well as one COTA and one SLP that go out to visit patients in their home. There are other Home Health companies in our area, but we just contracted with St. Vincents as a preferred provider for their ortho patients. Our company is also affiliated with Senior Living Facility for IL/AL as well a company specific SNF facility. -Kacey (home health)

A: Being in a variation of home health, my setting ranges from inner city to rural. My company is pretty new and small so I am the first full time OT. They have a part time OT who works in the school system during the day. It’s tough, being a new grad, but it is a population I have always loved and an opportunity I just couldn’t pass up. There are two other providers in my area that service clients on the TBI waiver. All of them have multiple OTs along with other typical specialties. I know that not all states currently have a TBI waiver, but it’s not uncommon either.– Ashleigh (home health with TBI waiver)

A: I work at ATECH Services in Concord, NH. As this is a one of kind setting, we travel to people’s homes all throughout the state to provide assistive technology (AT) Services. Our team includes 3 OTs, 1 PT, and 2 SLP’s. We evaluate for seating and mobility, computer access, AAC devices, transfer equipment, home modifications, and so much more! -Lilly (assistive technology/home health)

A: Our setting is a supported living facility for those who have been involved in an automobile accident and have experienced a traumatic brain injury, spinal cord injury, or both. OT provides services in a variety of settings; clinic based, home setting and in the community – based on the client’s needs and goals. We work collaboratively with other OT’s, SLP’s, psychologists, program managers and program directors. –Rebekah (home health, community based TBI/SCI)

A: I work for a home health company in an urban environment. We actually cover the entire state of Rhode Island along side several other agencies providing similar services. Our company partners with a community of Assisted and Independent Living facilities and several day centers. Within our company we employ OT/PT/ST/RN, geriatric case managers, and HHAs. RI in general actually has a great number of resources for older adults and the state as a whole has a large elderly population. -Nicole (home health)

Q: Who benefits from OT services in your setting? What population or specific diagnoses do you typically work with? Who qualifies?

A: One of the best parts about this job is that people of all ages, with all diagnoses can benefit from assistive technology, so I get to work with a wide range of individuals. Since I specialize in seating and mobility and computer access, the most common diagnoses I see are Cerebral Palsy and learning disabilities . We also see clients with Parkinson’s Disease TBI, CVA, Muscular Dystrophy – the list goes on! Typically, they are referred to us by case managers through their area agency or school district. -Lilly (assistive technology/home health)

A: My clients have had a traumatic brain injury. Currently, I only work with individuals who are 18 or older, however, next year, the state that I work in is expanding their waiver to cover children as well. Clients also have to have a decline in function that is related to symptoms associated with a TBI. To qualify for free services on the TBI waiver, the client must also qualify for Medicaid. If they do not, they have the option to “buy-in” and pay for services, however the amount each client has to pay is variable. – Ashleigh (home health with TBI waiver)

A: We mainly work with the older adult population. Patients must be home bound qualified to be approved for home health care. Patients have to require assistance to leave the home whether it be verbal or physical cues/assist for safety, and leaving the home must be taxing to their body and health (which must be documented/justified). I see a lot of general debility due to aging, but I also see a range of diagnoses including, but not limited to, traumatic fx with or without joint replacement, elective joint replacement, SVA, TBI, dementia/Alzheimer’s, Parkinson’s, OA, OH, cancer, primary HTN. We have Home Health Coordinators (HHCs) who gather our referrals from the local hospitals/SNFs and we receive the patient’s referral information from them. –Kacey (home health)

A: Those who have experienced a TBI, SCI or both from an automobile accident. They are referred to our facility primarily through their case managers. –Rebekah (home health, community based TBI/SCI)

A: Primarily, home health provides services to the older adult as they re-enter their community residence following hospitalization or rehab, but it can also include patients referred to services by their primary physician without need for an acute injury. The home health population that I serve is primarily older adults or middle aged persons. Homecare in itself can serve people across the lifespan. A patient is most often referred to homecare services if they are being discharged from a rehabilitation center or hospital and the referring source has determined the person has not yet regained enough safe independence to return to their prior level of function. In order to qualify for homecare services under Medicare (who is the primary payor) a patient must have written doctors orders and be considered “homebound” (qualifying factors which make it difficult for the person to routinely leave their home/enter the community without significant effort or with the aide of another person/assistive devices). Patients receiving homecare can be short term (s/p joint replacement, brief hospitalization for deconditioning, other surgery, temporary change in mental status requiring increased care) or long term (chronic condition management/teaching, decline in safety or function). The most common diagnoses treated are: joint replacement, hospital acquired deconditioning and post-surgical care. -Nicole (home health)

Q: What value does OT bring to your setting and what ways do you make occupational therapy salient to the patient?

A: Occupational therapists are very client centered and functional in this setting. Most of the sessions occur in the home and community, so it is easy to apply learned techniques and strategies. Treatment and intervention is always goal driven. –Rebekah (home health, community based TBI/SCI)

A: It is so empowering to be an occupational therapist in this setting because we are the only discipline that has a role in all areas of service. Whether it be a wheelchair evaluation, AAC trial, computer access training or a home safety assessment, OT’s always have a role and something to contribute. In assistive technology, the way OT’s think outside of the box is essential because there is almost never a “textbook” answer. I think it’s important for OT’s to be in this setting because we are able to look at the equipment, technology, device, etc. and really evaluate and assess how it will be incorporated into their daily life to assist them with their occupations. –Lilly (assistive technology/home health)

A: Home health and occupational therapy go hand in hand. As a HH OT, I get to go into patient’s home and do a first hand home assessment and can help trouble shoot and brainstorm ways to adapt patients’ homes. I get to help patients in the comfortability of their own home. We can work on real-life scenarios in their home that will help increase each patient’s safety and independence within their own homes. Also, I feel as though the whole premise of being an OT is possing some level of creativity for engagement in desired activities. Within HH, creativity is a must. I have a patient who fell off his camper (nearly 12 foot fall) and acquired a TBI as well and traumatic hip fx with THA. Patient loved to fish before his accident, but is not able to do it currently. I purchased a small fishing rod and we work on casting, reeling, and aiming for targets (fish) during our therapy sessions to work on eye-hand coordination, BIL coordination, UE strengthening, ROM, and sequencing (we’ll progress to completing activity while standing to challenge balance soon). -Kacey (home health)

A: To me,

home care encompasses everything that OT is about. Occupational Therapy focuses on meaningful participation in everyday living tasks. As OTs we are trained in assessing the person the environment and the occupation. What better setting to complete that in than at home?”

While a patient may have the individual skills to complete a transfer in a rehab environment, do they have a home set up with a sturdy, comfortable chair with arm rest and a clear pathway to access it? They may be able to take the pills handed to them, but do they have adequate family support to assist them with administration, or a reminder system in place to ensure they are taken at the right time? Identifying the disconnect or overlap between skills in the home setting is a unique perspective that OTs bring to ensuring that the patient is successful in their chosen occupations.

Salient occupations are everything at home. Home health goes BEYOND treating the deficit. Typical sessions in OT at home involve demonstrating that the skills they learned can be carried over into chosen functional tasks. Your patient gained 10 degrees of shoulder flexion or improved by one balance grade by completing their home exercise program? Great! OT today can include practicing emptying the dishwasher and putting your dishes away in the cabinet like you have been unable to do since returning home. -Nicole (home health)

A: As an OT, I work a lot more with helping my clients do the things that they need to do. I love home health in that it’s like living the dream, I’m with individuals in their natural environments doing the things they want/need to do! We work a lot with paying bills, memory compensation strategies, remembering and being available for appointments (OT/PT/SLP/PCP/etc). Sometimes it’s tough because we are working mostly with cognitive functions and so does SLP, cognitive therapy, and behavioral therapy. However, my focus is always on the client being functional in daily life and fulfilling their roles. – Ashleigh (home health with TBI waiver)

Q: What does occupational therapy look like in your setting? What is the duration, frequency, etc of treatment? What is a patient’s typical length of stay and where do they go after discharge -do they transition to another follow up setting….? What theories or frames of reference do you incorporate into treatment planning?

A: Occupational therapy definitely looks different in this setting. Typically, for wheelchair evaluations there will be one 2-hour (though I’ve been in evaluations up to 9 hours…) session to determine equipment with a DME provider, then a fitting when the chair is delivered in 3-4 months. For Computer Access and AAC, there is typically 3 evaluation sessions with training after equipment is purchased. A home evaluation is usually 2+ hours long with a follow-up session if needed. I love that this model allows us to treat so many clients, but it’s disappointing that we rarely get to build a therapeutic relationship with our clients. -Lilly (assistive technology/home health)

A: I actually see clients for between four and six hours a week, usually for about 2 hours at a time. I don’t like to make it longer because it can be very fatiguing. The primary theories I use are MOHO, EHP, and PEO. I would love to explain how each applies, but I don’t want to write you a novel. I get the question, “What is OT?” all the time. I try to explain that I work with individuals to do what they want to do. In time, we also work on what they need to do (it’s all about that motivation). I ask them, “what is giving you a hard time?” Then I tell them about how I could help them do that thing. It’s hard getting them to really understand that I am coming to them do actually do things (they think we need to sit down and “do therapy”) but, in time, they get understand. – Ashleigh (home health with TBI waiver)

A: Occupational Therapy in homecare can last anywhere from a single visit to several months in duration. At times, an eval visit only is appropriate, other times for patients with a complex heath condition or slow recovery there is an ever long list of things that can be addressed by the OT practitioner. On average, most patients are seen 1-3x/wk for a 3-4 week duration. Typical sessions last 30-60 minutes. A homecare certification period is set for 60 days according to current Medicare guidelines but can be extended if needed. Most homecare patients are discharged to “home”, patients who need increased care after homecare may transition to assisted living environments, joint replacement patients typically transition to outpt after they are no longer considered homebound.

In my own experience I typically rely most on the P-E-O-P frame of reference but I also heavily use the compensatory frame of reference. Both or these are based on the theory that all parts of the whole must be in “good fit” in order for a person to be successful. By adapting the environment, utilizing equipment or strategies and teaching the person skills to compensate for deficits there is the greatest opportunity for successful performance. In the home setting assessments typically include the Barthel Index or Modified Barthel Index (coming initially from rehab I have a tendency to FIM everything also, even if we don’t use that assessment). I complete the Functional Reach assessment frequently, and often a cognitive screen such as the Mini Mental, SLUMS, MOCA. I have also used Allen cognitive levels and Dementia staging to drive my intervention planning.

Most simply, when a patient asks me what OT can do for them, I ask them to provide an example of ‘something they would like to do, but have not attempted/not been successful at since returning home” and after providing education on how OT can address that, other areas of occupation seem to be “opened up”.

-Nicole (home health)

A: Following an initial evaluation of cognitive and physical skillset (using a myriad of functional assessments), the frequency of treatment is determined. Immediately following a hospital stay, OT is usually recommended at a higher frequency and intensity (sometimes it occurs 2x daily for 5 days/wk). Those who present as higher functioning, their frequency varies from 2-3x/wk and range from 1-3 hour sessions, depending on the focus. The length of stay can vary depending on how severe the injury is. Some of our clients have been in our program for 5-10 years. Outcome measures are functional, so demonstrating more and more independence in a certain task (ie. Cooking) is measured and tracked over time. OT in this setting has a large focus on IADL and community re-integration, but depending on the injury and how recent it is, self-care, safety, functional transfers and functional ambulation is addressed. –Rebekah (home health, community based TBI/SCI)

Q: Why do you like this setting? (What do you like about it? How does it help you grow? Describe a moment in which you felt like you facilitated a positive change in your patient’s life or trajectory of functional recovery? What positive changes have occurred in yourself in this setting?)

A: I didn’t think I would like the setting. I originally accepted this job because I really needed the job at the time. I have an affinity for pediatrics, but that type of position was not available at the time in my area. I took a leap of faith because I was a “new grad” going in to home health (we were warned many times to try to avoid this during OT school). However, I feel like this has been THE BEST choice I could have made. I don’t think I see myself staying in home health for the rest of my career, but I also do not see me leaving home health any time soon. Being a home health OT requires me to think on my feet and to be creative with what patients have on hand in their homes. Sometimes everyday items turn into crucial therapy components that the patient would not have otherwise thought of.

The anecdotal story I spoke of above about the fishing honestly was a great morale boost for myself. This patient has been down about his injuries, and me showing him he can still participate in his favorite pass time was a liberating moment not only for the patient, but for me as well. We go into the field wanting to help others, but sometimes it’s the patients who help us. Not too long ago, I had a patient who prayed for me at the end of every visit and gave me a prayer card the day I discharged him that I keep in my wallet. I was having a tough time, and that patient reminded me why I love doing what I am doing. –Kacey (home health)

A: This setting allows clinicians to be creative and gives us an outlet to be as functional as we can by providing treatment in the home and community. It allows us to apply various techniques and skills so they are able to generalize new skills in a real life situation and/or in their own environment. We see patients on a long term basis (I have seen a lot of clients for 3 years). This allows us to see progress over the span of a long period of time, which is rewarding. -Rebekah (home health, community based TBI/SCI)

A: I love that the skills I am learning in this setting are unique and will transfer to other, more traditional settings when and if I choose to move on. The skills I am learning now will be able to grow with me as a therapist. This setting, especially as my first OT job, as forced me out of a box and enabled me to be confident in myself. When you are at a client’s home with no direct support from your main office, it empowers you to trust your instincts (and education!). I was able to see the power of assistive technology during a computer access evaluation with an older gentleman, diagnosed with Parkinson’s Disease.

He had been an editor, but due to the tremors in his hands he is now unable to type legibly. I provided him with an adaptive keyboard and the first time he tried it he made only 2 mistakes. It was one of those “this is why I do this” moments!-Lilly (assistive technology/home health)

A: There are so many things I love about this setting. I love that I have autonomy to pick my own hours and meeting times (working with the client’s schedule, of course). I love my clients and I love working in the realm of neuro rehab. They always keep me on my toes. And, I get to work with them in their natural environment, which is always a HUGE plus! –Ashleigh (home health with TBI waiver)

A: Home health is flexible and rewarding. Patients are typically happy to see you (unlike the look of dread that spreads across their faces sometimes when you approach them in acute care or wake them up in rehab for a 7am ADL). Home care allows you the opportunity to dedicate the time needed to addressing patients chosen tasks and there are opportunities to focus on the occupation with realistic barriers/environmental support/resources.

I recently had a patient say to me “I never knew OTs were little miracle workers”. (I had placed a piece of nonslip shelf liner under her chair cushion to prevent it from sliding forward when she attempted to stand.) I have taught myself to appreciate the ability to make small changes which result in big differences in performance. Another thing that home health has given me is an appreciation for family and friend support. Often times in homecare for persons living alone, their therapists/nurses are the only people they have advocating for them and providing needed assistance or even companionship. Sometimes a quick phone call, a visit from a friend, or having someone who can stop by the store for you is a novelty that goes under appreciated until you find yourself to be the one alone. As a homecare OT I have been “that person” for many patients and I have gained appreciation for the family/friends/caregivers that play a role in a patients recovery that can easily be overlooked. -Nicole (home health)

Q: What things do you not like (or wish you could change) about this setting? (What are the barriers to therapy, progress, success?…)

A: It can be tough building up a client base. So, I’m three months in and still only have a handful of clients. And if a client cancels their session, I don’t get paid. And for some of my clients, motivation is something we’re working on, so meeting them regularly is really tough. – Ashleigh (home health with TBI waiver)

A: The biggest aspect of this job that I do not like is the fact that we currently do not implement any type of outcome measures in our work. Essentially we tell clients “call us if you have any problems!” and hope for the best. How do we know that what we are doing is working? How do we know that our clients are actually gaining functional skills and improving qualify of life? We don’t. Since I’ve come on board, this as been one of my goals. By talking with our senior therapists, I have found out that they used to use the COPM, but for some reason it didn’t work. We have so many clients come back to us years later for us to only find out the technology wasn’t accepted. If anyone has any outcome measure ideas, let me know! –Lilly (assistive technology/home health)

A: Patient motivation, stagnancy, etc. TBI is a long road to recovery – sometimes years. A lot of the time the patient will need services lifelong. This is discouraging and can cause a lot of anxiety and possibly depression. –Rebekah (home health, community based TBI/SCI)

A: A lot of homecare is reliant on patient carryover of recommendations outside of sessions, completion of HEP, purchasing of equipment etc. Unlike inpatient settings, there is a lot riding on patients or their families continuing outside of therapy sessions. One hour twice a week is not often enough to make a change, patients have to be willing and able to put in the time/effort when you’re not around. -Nicole (home health)

A: Like most settings, insurance red tape is a huge barrier. Insurance limits visits, which in turn limits the patients rehab potential. Documentation is also a BEAST. When I first started, I stayed up till midnight almost every night for a month documenting. I have since become more efficient in documenting, but there will be an occasion where I have to stay up late. –Kacey (home health)

Q: How did you “get your foot in the door” to work in this setting?

A: I think a common misconception is that only older therapists with a lot of experience can work in homecare. I don’t think that is true at all. In order to be a successful homecare therapist you just have to be autonomous and resourceful enough that when you don’t know the answer/think your patient needs something you take the initiative to see that it is addressed. You don’t need 10 years of treating under your belt, or a specialty certification. –Nicole (home health)

A: I had a level II in another setting similar and fell in love with the concept. I applied right after taking my boards. –Rebekah (home health, community based TBI/SCI)

A: I completed one of my Level 2 rotations in SNF setting, which gave me experience with the older adult population. I also took the leap of faith and applied as soon as this position came open, because I was not expecting to even be called for an interview. The home health director and director of clinical director admired my honesty about experience and after a lengthy discussion on how my SNF clinical experience would help guide my home health practice, they felt as though I was a good fit and the right addition to their team. –Kacey (home health)

A: I actually was a student at ATECH for one of my level II fieldwork experiences. I had returned for a visit to connect a classmate with ATECH and they mentioned that they were hiring another OT. I made a joke about how they should wait for me to pass my NBCOT – and they did! -Lilly (assistive technology/home health)

A: Honestly, I just went in for an interview. It was so easy!– Ashleigh (home health with TBI waiver)

Q: Where do you see yourself in 5 years? 10 years? How does working in this setting help you reach your personal professional goals?

A: On a personal level, I can see myself continuing with homecare for many years to come. It is sustainable, the population is always again and the need for homecare services is growing with shorter hospitalizations/rehab stays. Once I can no longer perform the physical job duties needed/want to travel less/work less hours I would like to consider transitioning into a community environment setting such as assisting patients to find needed resources – therapy services, transportation, equipment etc. And I think homecare provides a great set -up to being able to do that. I could also see myself opening a LSVT clinic in the future because I am passionate about the value of this program and the underserved number of people who have a Parkinson’s diagnosis. –Nicole (home health)

A: I want to have my own practice one day although I’m not sure what that will look like just yet. I have always loved the neuro population and plan to continue serving them as I move forward. – Ashleigh (home health with TBI waiver)

A: Working at ATECH definitely has a direct impact on where I see myself in the future. Short term, I plan on receiving my ATP with ATECH to better hone in on my skills. In the future, I would love to see AT integrated in other practice settings more. While it’s part of our scope of practice, most school-based OT’s are unaware of the computer access treatments they see me do and most SNF-based OT’s are unaware of all the capabilities and options for a wheelchair. -Lilly (assistive technology/home health)

A: This setting allows me to set myself up for success as it has allowed me to build my skill set. In 5-10 years, I would love to open my own business and continue to work with those with TBI/SCI. –Rebekah (home health, community based TBI/SCI)

Q: What specific “special skills” (like things you aren’t prepared from entry level OTA/OT skills) do you need to be successful in your setting?

A: Flexibility, creativity, time management, organization –Rebekah (home health, community based TBI/SCI)

A: Hmm… I’m not sure about this one. I know you need patience, flexible thinking, empathy, and work ethic. Working in the cognitive realm is unique, you are working with adults who sometimes lack what it is that we consider makes an adult. You have to help these individuals as adults, hold them accountable, but understand that they have difficulties. –Ashleigh (home health with TBI waiver)

A: Honestly, there was A LOT I was unprepared for coming into this setting as a new grad. I can’t speak for all programs, but my grad class had 1 class session on how to complete a wheelchair evaluation, a PowerPoint on a few computer access programs and a worksheet on things to look for during a home safety evaluation. THIS WAS NOT ENOUGH. I definitely learned (and am continung to learn) how to take initiative for my own competence as a new grad – this is such an important skill, no matter the setting! -Lilly (assistive technology/home health)

Q: if applicable to your setting How do you deal with grief, illness, sadness, loss, caregiver burden…etc in your setting? (What psychosocial interventions…who do you refer your patients to….how do your prevent burnout and maximize your own self care and occupational balance??)

A: My clients do deal with a sense of loss over their skills and abilities. It’s interesting because they are so far out from their initial injury, but I see it from time to time as they have difficulty doing things that they think should be easier. Just listening, I found, is helpful. Everyone needs time to just vent and then get back up and try again. The resilience I’ve seen thus far amazes me. – Ashleigh (home health with TBI waiver)

A: I think grief and loss is a widely unaddressed component of OT services. OTs are taught to treat the whole person, which includes their psychological factors as well as their physical ones. Patients who have a loss of independence or skills are bound to experience some of those psychological factors. Older adults have often lost significant others, siblings and friends. Social isolation and depression are common in homebound patients and as OTs finding meaningful, valued occupations that your patients desire to participate in is a great way to help reduce those. Addressing and reducing caregiver burden is a valuable skill that OT is trained to incorporate into the POC. By working with your patients to recover lost skills, increase their independence or reduce that need for caregiver assistance you can simultaneously address the psychological factors that have caused them to feel sad or alone. –Nicole (home health)

A: Provide active listening, feedback if needed, provide community and local resources -Rebekah (home health, community based TBI/SCI)

Q: Advice you would give to someone thinking about / wanting to work in your setting? What do you wish you knew about this setting x years ago?

A: One of the biggest things I heard pre-grad was that it is very hard for new grads to go into home health – don’t let this scare you away!! It also helps you be independently competent and confident in yourself. It allows you to think for yourself and not just “copy” other therapist’s interventions. -Lilly (assistive technology/home health)

A: Be prepared to be challenged every single day. Not one day is the same! –Rebekah (home health, community based TBI/SCI)

A: It requires patience to build up a client base and out of the box thinking. If you haven’t had much experience with cognitive rehab, it’s important to think about how learning takes place and to really understand the nuances of executive functions such as attention, motivation, self-awareness, planning, and initiating/ending tasks. – Ashleigh (home health with TBI waiver)

A:Be prepared to MacGyver everything! Next to zero OT equipment is covered by insurance but when it comes down to it, OTs care trained to adapt and you can make almost anything needed with household supplies/some resourceful shopping. –Nicole (home health)

Q: Anything else your heart desires to tell the OT world about …? ☺

A: Patience is key. Always. It can be frustrating when dealing with individuals who lack motivation, are emotionally labile, lack self-awareness, and lack other functions we expect out of adults. However, this is their need. They don’t need condescension, they need empathy, patience, and a willingness to hold them accountable! (Hope that makes sense!) –Ashleigh (home health with TBI waiver)

A: I think its easy to get discouraged sometimes, you lose sight of the value of what makes OT so great. I’ve heard so many people say “yeah, its like PT” or they downplay their role because they feel like a “jack of all trades” instead of a specialist with a skill. But regardless of the setting, OT provides a distinct role and we should all own it, because OT rocks! –Nicole (home health)

In summary: Occupational therapy services in the acute care setting are imperative to promoting improved future functional outcomes. This fast paced setting filled with often medically complex patients presents with many trials, but one objective rises above: Occupational therapy within the medical model environment acknowledges the totality of the whole patient and strive to break down barriers to facilitate one to reestablish previously meaningful roles, habits, and routines on their journey toward reclaimed health and wellness.

About the contributors:

Nicole Dufresne, MS, OTR/L (IG: @nicole_dufresne)

“Nicole graduated from American International College in Springfield Massachusetts in 2015. She developed a passion for working with the older adult population during school, and took her first job in an acute rehab unit of a hospital where she worked for her first two years of practice. She also worked (and still does) in the acute setting of multiple hospitals. After relocating geographically, she took a job in home care and has been there full time ever since. She is LSVT BIG certified and is also a certified kinesiotape practitioner. Nicole is passionate about providing older adults the opportunity to safely “age in place”, and loves the fact that home care provides the circumstances to allow that to happen. “

Lilly Hamlin, MS, OTR/L (IG: @lillybugg32)

Lilly graduated from the University of New Hampshire combined bachelors/masters program in December of 2017. She began working for ATECH Services in April of 2018, where she completed her Level II fieldwork the previous year. Unfortunately, ATECH Services has since closed due to lack of funding, so Lilly is out looking for her next adventure. She hopes to continue in the field of assistive technology and to pursue her ATP certification. Additionally, she works per diem at a Skilled Nursing Facility in Kittery, ME where she is able to explore her passion of the geriatric population.

Ashleigh Heldstab, MOT, OTR/L (IG: @bluebird_ot)

Ashleigh graduated with a Master of Occupational Therapy from the University of Kansas in May 2018. She currently works in home health with individuals on the Traumatic Brain Injury (TBI) Waiver. Her passions include running, pugs, yoga, coloring, succulents, and overall wellness. She aspires to make health and wellness attainable for all of her clients. Ashleigh lives with her husband and fur-baby in Kansas City.

Rebekah Mohney, MOT, OTR/L, CBIS (IG: @rmohney3)

Rebekah graduated with her masters degree from Wayne State University in Detroit, Michigan in 2015. She works with clients who have sustained a traumatic brain injury and/or spinal cord injury from a vehicle accident. She works in a facility that supports independent living following a hospital and subacute stay. She became certified as a brain injury specialist shortly after landing this job, and helps people every achieve their goals in their home and community. Her passions lie in advocating for her clients and helping them achieve things they didn’t think they were capable of. As a full-time working mom, Rebekah values spending time with her family.

Kacey Slagle, OTR/L (IG: @k_slagle21)

Kacey is an occupational therapist that graduated from the MSOT program at the University of Alabama at Birmingham in 2017. Kacey has many valuable occupational roles, one which being the role of mother. She chose to take time off to spend with her two kids prior to starting her OT career in November 2018, with home health being her first job post-graduation. Kacey is also very interested in pediatrics.

Thanks for reading!! Love to hear from our readers, comment below where you work!! Next up COMMUNITY SETTINGS: OCCUPATIONAL THERAPY IN SCHOOLS!

Resources

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68,S1–S48. https://doi.org/10.5014/ajot.2014.682006

https://www.ahhqi.org/images/pdf/what-is-hhc-data-readmissions.pdf

Images:

https://www.cstcenter.com/project/home-health-care

http://www.kalksteinfamilychiropractic.com/kalkstein-chiropractic-explains-the-value-of-health/

Support At Home: Needs Assessment and Service Coordination

http://susihomes.com/home-inspection/home-stethoscope/

https://www.etsy.com/market/occupational_therapy_ornament

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