Prepared Patient Goodbye, Acute Care, Hello, Rehab

Main Category: Rehabilitation / Physical Therapy
Article Date: 31 Jul 2010 - 1:00 PDT

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After a person receives acute care in a "regular" hospital for catastrophic illness, traumatic injury or a debilitating chronic condition, the next step in the process of recovery often involves a stay at an inpatient rehabilitation, or rehab, facility.

Patients often have little warning when they're quickly moved to a rehab facility from acute care. Those who envision a long, leisurely recovery in a hospital or at home may find that the abrupt transition-and new responsibilities in rehab-leaves their heads spinning.

Depending on the type and severity of the patient's injury- and the mandates of the patient's insurer or Medicare/Medicaid-recovery time in the community hospital may last only hours or days before the transition to a rehab facility takes place.

Concerns also move from whether someone is going to live-which is paramount in acute care-to how are they going to live under what may be very different circumstances.

Although the doctors and nurses at an inpatient rehab hospital will provide pain medicines and medical attention, just like an acute care hospital, the purpose of inpatient rehab is to help the patient regain functions they've lost from injury and illness.

Returning to activities of daily life such as relearning how to walk or feed oneself or talk, and handling changes in mental status and emotional health are all common challenges for patients in a rehab facility.

The change in environment also means changes in daily routines from simple basics like visiting hours, meals, learning names and roles of a new health care team and changes in responsibilities for both patients and families/loved ones.

Twenty-seven-year-old Jeff Miklaszewski entered an inpatient rehab hospital three weeks after a serious motor vehicle accident almost cost him both his legs.

For younger people like Jeff, the abrupt contrast between their prior robust good health and a new significant physical impairment is a dramatic jolt, says Dexanne Clohan, M.D., medical director of HealthSouth, a nationwide network of inpatient rehabilitative hospitals. Issues related to school, career, and sexual relations can be a big worry.

In the short term, adjusting to inpatient rehab often means dealing with roommates, noise, and a lack of personal privacy for toileting, bathing and personal care. In Jeff's case, his rehab roommate required a ventilator to breathe, and the nurses didn't always respond immediately to his roommate's request for assistance, leaving Jeff frustrated and unsure how to help.

"That struck a nerve with me. I had to share a room with this guy, and it was frustrating at times watching that happen," he says.

Intense Role Shift

In the hospital, you may have felt like you were along for the ride, with your doctors and nurses in the driver's seat of your medical care. At a rehab facility, you're definitely behind the wheel, a role change that many patients don't realize when the hospital doors close behind them.

The patient's responsibilities involve undergoing several hours of physical and occupational therapy daily, usually five days a week, while at the rehab facility.

Physiatrists -physicians who specialize in rehabilitation medicine-nurses, physical and occupational therapists, and caseworkers coordinate care at the inpatient rehab hospital, designing programs that can be physically and emotionally intense as they push patients to recover lost function and regain independence.

Depending on a patient's injury or illness, physiatrists may also recommend specialized therapies, such as speech therapy or gait training.

But a successful rehab experience depends heavily on patient participation, and the person's outlook about the process plays a critical role.

"The person who says, 'I can't do this. I'm checking out. I'm never going to get better' may have a more difficult time than the patient who says, 'This is the hand I've been dealt, and I'm going to do my best. This is not going to stop me.' Motivation is a huge factor," as is support from family, says Alain Pierre-Louis, M.D., a New York City physiatrist.

Many patients don't realize that their continuing participation in rehab is not only desirable, but necessary to stay at these types of facilities, Clohan says.

"If a patient isn't able to participate consistently in therapy, then they're really not considered eligible under Medicare law for an inpatient rehab hospital . . . it's important to match each patient to the right level of care," Clohan says.

"The whole point of being with us is to get the close level of medical supervision and the intensity of the therapy a rehab hospital provides. There may be moments when they don't feel like it or they're tired of it and need rest, but our nurses and therapists can coach them through so they can achieve the best recovery possible. It takes an intense experience to get that result," Clohan says.

At first that intensity proved overwhelming for 84-year-old retired minister Larry Gruman, who spent five weeks in a rehab hospital in 2008 after a brief hospital stay for spinal surgery.

"The workouts took all the strength out of me. I was physically exhausted and very much on edge. They kept me busy with three or four appointments each day. In between those I went back to bed," Gruman says.

But Gruman credits the grueling workouts for helping him get back on his feet. Today he stays physically active, swimming regularly and staying mobile with the help of crutches and a scooter.

"I pushed myself always at the edge . . . I believe I progressed because of that determination to advance each day," Gruman says.

( Note: Larry Gruman is the father of Jessie Gruman, Ph.D., president of the Center for Advancing Health, of which the Health Behavior News Service is a part.)

Down the Road

Inpatient rehab stays generally aren't long, says Keith Robinson, M.D., a physiatrist based at Philadelphia's University of Pennsylvania. In fact, even for patients with severe trauma, such as spinal cord injuries, the average rehab stay is only 38 days.

That's a short span of time for people to make major, long-term adjustments.

A large study on medical rehab trends found that of the five major impairment groups -stroke, brain, spinal cord dysfunction, other neurological conditions and orthopedic conditions, like hip replacement-about 60 percent of patients are female and the average is about 68 years.

For patients of any age, the transition to rehab compels them to come face-to-face with fears and concerns about future disability.

"Any sudden decline in function is never an easy thing to adjust to. We can address issues such as worry, guilt, depression, concerns about their ability to provide for their family. No one is ever prepared to have a stroke. No one's ever really prepared to lose a limb or go through a trauma or suffer a spinal cord injury," says Alain Pierre-Louis, M.D., a New York City physiatrist.

The accidents or conditions that lead to a stay in a rehab facility have an impact far wider than just the patient. Family, friends and loved ones may all be called upon to make adjustments in their expectations, provide support and participate in therapeutic goals. The role these family members or caregivers play is a critical component of a successful inpatient rehab experience, especially when it comes to making the transition home.

While the patient is at rehab, caregivers may be expected to fetch comfortable clothing for the patient from home and launder it later. They may need to attend team meetings to assess and monitor their family member's progress. The health care team also involves caregivers when setting goals for the rehab patient. For example, the patient, health care team, and caregiver may set goals for walking, toileting without assistance and returning to home or work, if possible. If there are neurological problems with the patient, the caregiver may need to make decisions about care along with the doctors.

And for many patients in rehab, caregivers serve as a link to the community and the outside world. "There are times that if you don't have that connection to outside world, it can be lonely, despite the fact that there are patients you become friends with in rehab,"Jeff says.

Homeward Bound

Once the patient is discharged home, the caregiver's role expands even more, providing transportation to medical and therapy appointments, picking up and administering prescription medications, helping the patient bathe and toilet, fixing meals and encouraging adherence to the family member's at-home exercise schedule. Dealing with the complex financial issues associated with rehab-and dealing with insurers- also typically fall to a patient's family member during the recovery period.

However, family members and friends aren't patients' only support system. In addition to the medical team members, case managers at the rehab facility offer assistance with the transition home by helping patients and families manage outpatient therapy appointments, administer medications, and use medical equipment.

Case managers also talk extensively with patients and families about the home environment and how to arrange it so the patient can move about easily after returning home. In Gruman's case, a caseworker visited his home to offer counseling on exercise and recreational activities, using a catheter and climbing steps.

Paving the Way to Recovery

As part of discharge planning, which starts at admission, "we ask a lot of questions about what's your house like, what's your bathroom like, do you have steps, is your bedroom upstairs? We customize our therapy to help an individual patient live as independently and safely as possible. One size doesn't fit all," Clohan says.

However, as in all areas of health care, some rehab patients will have less access than others to such thorough, customized discharge planning.

A successful transition from acute care to rehab, and eventually home, means hard work and the realization that you're learning a new way of living as a disabled person, Robinson says. In many cases, even if there's a complete recovery, as in the case of a hip or knee replacement, it's important to keep in mind it doesn't happen immediately.

For many recovering patients, though, inpatient rehab helps cement their desire to regain as much independence and function as possible.

Thanks to his motivation in rehab and several orthopedic surgeries to repair the bones in his legs, today Miklaszewski is back on his feet with the help of a cane.

"The best thing about being at a rehab facility is that you're surrounded by people who are in the same spot you are. You can talk to people every day about their progress. You can see them, in the course of a few weeks, go from a wheelchair to a walker to getting their coordination back," Miklaszewski says. "That in itself is inspiring."

Source: Health Behavior News Service

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