ABC’s of OT: how to address COMMUNITY Re-Integration in the SNF setting

In the SNF (skilled nursing facility) we generally have two categories of patients: those who are admitted for short-term skilled rehab, and those who are admitted for permanent, long-term care. Which means we have two categories of community: community within the facility, and community outside the facility. As an OT, we can assist with re-integration to both.

As far as skilled patients are concerned, they are usually desperate to get back to their normal routines. By the time we work with them, they have been in the hospital for anywhere from a few days to a few months. So at this point their routine has usually (but not always) transformed into laying in bed all day except for the occasional therapy session or bathroom break.

For many of our long-term residents, the temptation to stay in bed all day can be strong and just as limiting.

I don’t necessarily have science to site here to back up my point, but the way I see it, this kind of routine can make patients extremely susceptible to depression and/or self-isolation.

This is why it is so important for us as the occupational therapist to identify both what is meaningful for the patient and how we can incorporate those meaningful tasks into a functional routine and therapy plan of care.

The right questions are critical. If the patient is admitted under a skilled, short-term stay we want to ask questions like:

Do you work?

Do you live with anyone?

What kinds of things are you responsible for around the house?

What do you like to do for fun?

How often do you get out of the house each week?

Are you involved in any community groups, like church, book clubs, gym memberships, coffee hours, or Veteran’s associations?

From there we can work with the patient to identify strategies to re-integrate into these tasks. So for example: let’s say our patient wants to regularly attend church after discharge home. Great!

But wait a minute. He has been in the hospital for about 2 weeks with the flu, he is very de-conditioned, and is only able to walk about 20 feet before requiring a seated rest break. So that’s okay; he has the option to sit for the duration of the church service.

But hold on. There are about 5 steps with no railings to get into the front door of the church. And normally our patient would walk to the bus stop at the end of his street to hop on the public transit to get to church.

So now we know that in order to get to church, our patient needs to be able to get himself washed and dressed. Then he needs to be able to safely walk to the bus stop, get in and out of the bus, climb 5 steps, and then transition into the sanctuary to sit down for service.

Which means we need to work on bathing, dressing, strength, endurance, distance ambulation, safety awareness, problem solving, sequencing, direction following, and energy conservation.

See what I mean? By identifying that one leisure/community task, we identified a whole list of therapeutic performance areas that we need to address in our care plan.

Now, what about residents living in the long-term care units. The process is very similar but often a little less complex.

Let’s say we have a patient who was recently admitted to the dementia unit. She is able to ambulate independently and demonstrates normal ROM and fair strength. Biomechanically she is doing pretty well. But cognitively her progressed dementia has resulted in significant wandering, emotional distress, and inability to attend to task for more than a minute.

Just as with the skilled patient, we want to ask the right questions (except this time we’ll ask the patient’s family):

What did she do for work?

What kinds of hobbies did she enjoy? Does she still enjoy them?

Does she have a favorite snack?

Does she like music?

What sorts of roles did she hold throughout her life?

In this scenario, we’ll say that our patient used to be an avid baker. Great! That’s something we can work with. We find some plastic cookie cutters, recipe cards with large photos, or even simple box cake mixes and we engage our patient in a tabletop task that allows her to sit out in the community area for 10-15 minutes at a time while engaging in something meaningful.

Maybe there are a few other residents who also loved to bake throughout their lives. Set those few people up at a table with those recipe cards and you’ve got a meaningful group activity that can appropriately engage each patient based on his or her cognitive level.

Are you starting to see how it all comes together?

By identifying one meaningful task, we can facilitate return to that task within the facility community or the greater community. We provided successful, appropriately graded therapeutic intervention tailored specifically to the interests of the patient.

This is what makes OT so special; our ability to relate strength and endurance training to the bigger, human picture.

What are some activities that you have helped patients re-integrate into?

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