Re-entry program makes full use of community
Patients visit museums, aquariums
For a little more than a year, stroke and neurology inpatients at Spaulding Rehabilitation Hospital in Boston have been able to plan outings to Boston destinations of their choice as part of the rehab facility’s community re-entry program.
"We wanted to be able to offer patients a chance to carry out their newly learned skills in the greater community," says Megan Austin, MS, CCC, SLP, speech pathologist practice leader of the stroke unit.
Families are encouraged to accompany patients and therapists on the outings, which provides a wonderful opportunity for education and training for both patients and families, Austin says.
"Patients love the program," Austin notes. "They talk about the program, and we take pictures at the outings and give them the pictures."
The re-entry program is billed by therapists as group therapy, and therapists document skills and exercises used during the outings, Austin says.
"The documentation is carried out in the weekly note," Austin says. "Therapists write that patients went on a community outing and write a narrative about what treatment they did."
Here’s how the program works:
• Doctor referral: Physicians write orders to send particular rehab inpatients on the community re-entry outing. The patients selected are those who typically have completed several weeks of inpatient treatment. The 30-day length of stay usually involves evaluations on the first week, individual therapies in the second week, and re-entry outing planning in the third week. The actual outing takes place in the fourth week, Austin says.
"The outing usually is done simultaneously with discharge planning, and it helps us to make overall recommendations about what supervision a patient needs when they leave and to make recommendations for the next level of care," Austin says.
Referred patients have one opportunity for an outing, and staff attend the outings 24 times a year.
• Planning session: Patients who have been approved for the outing meet the Friday prior to the trip to decide where they will go. The outings are from 10 a.m. to 1 p.m. on Fridays, so the destinations must be in the Boston area and must not involve a lengthy visit, such as going to see a feature film.
"Patients often report they want to go to the movies, but we don’t go to the movies because it takes too long," Austin says. "We can’t afford to have therapists out of the hospital all afternoon."
Also, more passive activities like viewing movies would deprive patients of some therapeutic experiences, Austin notes.
"So we’d rather have patients in motion than watching a long movie," she says.
Groups choose specific exhibits to visit
The time constraints also mean that if a group of patients decide they would like to visit the local art or history museum, they will have to decide on a particular exhibit. For example, one group decided to visit the musical instrument room in the Museum of Fine Arts, Austin says.
"It was nice because they had to look at the museum map and navigate their way to the music room," Austin adds. In this way, the time constraint means patients have to use more of their cognitive planning skills than if they were to simply go into a museum and begin to view exhibits in the very first room available.
Patients previously have selected outings to these Boston locations: Fleet Center Sports Museum, the Prudential building skywalk,
the North End’s Italian community where Paul Revere lived, the Cambridge Side Galleria Mall, the 360-degree Omni theater in the round, the Boston Aquarium, and the Museum of Science. There also have been trips to family-style restaurants and bakeries.
Patients are transported in the rehab facility’s wheelchair vans, and they are asked to bring $10 with them to pay for any admission fees or lunch they may purchase. However, the museums and other destinations often will reduce or waive entry fees for patients and/or staff. When patients have no money for the fee, the staff use the chaplain’s fund to pay for it. Staff’s fees are paid out of a $1,500 allocation for the program, Austin says.
• Staffing outings: The community re-entry team includes two physical therapists, one occupational therapist, two speech pathologists, and a therapeutic recreation specialist. There are also volunteers who assist. The outings groups are kept small with four to five patients, and the staff typically accompany them in a ratio of one staffer to two patients, Austin says.
All of the therapists, except the therapeutic recreation specialist, bill for their services during the outing.
Therapists often will carry clipboards with sheets for the patients on the outing. These also include notes about patients’ special needs, such as whether a particular patient needs to take medications at a certain time. The staff have cell phones in case of emergencies.
• Therapies employed: The physical therapists assess patients’ wheelchair mobility and ambulation, as well as their level of independence. They note whether patients are able to ambulate on uneven surfaces, such as where there’s a change from gravel or concrete to grass, and they monitor patients’ ability to use stairs.
Physical therapists also assess patients’ endurance with mobility issues during the long outing, and they note their transfer status: "Can the patient transfer from the wheelchair to the car alone, or how much assistance does the patient need?" Austin says. "Patients have the chance to direct their own care, and we teach them to say how much assistance they need."
For instance, patients are told to tell their families whether they need help with applying wheelchair brakes, or whether they need some other assistance in transferring.
The occupational therapist looks at patients’ ability to do money management in the community, and the OT assesses patients’ ability to dress themselves appropriately, manage toilet needs, and feed themselves during the outing.
Speech pathologists assess the patient’s language and cognitive ability during the outing. "Can the patient express basic needs, understand what’s being said, and read exit signs and women’s or men’s bathroom signs?" Austin says.
Everyone monitors the patient’s ability to cross streets safely and remember daily routines and appointments, Austin says.
"Patients might have jaywalked before their stroke because they could ambulate quickly across the street," Austin says. "But now they have to go to a crosswalk and wait for the light to change because they don’t have the speed they used to have."
In another example, a patient who has a left hemisphere impairment might use a communication device on the outing, giving both the patient and staff an opportunity to see how well the patient uses the device in a community setting, Austin says.
Also, when patients eat out at a restaurant, they may bring adaptive silverware to use.
So far the program has been successful with both patients and staff, Austin says.
"Therapists love it," Austin says. "It’s a lot of work to plan the outings, but the staff enjoy planning it and seeing patients become successful in the community."
Need More Information?- Megan Austin, MS, CCC, SLP, Speech Pathologist Practice Leader of the Stroke Unit, Spaulding Rehabilitation Hospital, 125 Nashua St., Boston, MA 02114. Telephone: (617) 573-2452.
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